Chapter Ins 100 Organizational Rules

Part Ins 101 Definitions

N.H. Code Admin. R. Ann. Ins 101.01 Commissioner {#sec-ins-101.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 101.01}

“Commissioner” means “commissioner” as set forth in RSA 400-A:3.

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #6967, eff 3-26-99; ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20

N.H. Code Admin. R. Ann. Ins 101.02 Department {#sec-ins-101.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 101.02}

“Department” means the New Hampshire insurance department.

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #6967, eff 3-26-99; ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20

Part Ins 102 Description of Department

N.H. Code Admin. R. Ann. Ins 102.01 Commissioner; Administration Division {#sec-ins-102.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 102.01}

(a) The department is under the direction of the commissioner.

(b) The commissioner, as head of the department, implements the policies and programs of the department, submits the budget, and has a grant of authority pursuant to RSA 400-A:3.

(c) Pursuant to RSA 400-A:6, II, the deputy commissioner performs the duties and exercises the power of the commissioner as authorized by the commissioner. In the vacancy or incapacity of the commissioner, the deputy commissioner becomes the acting commissioner.

(d) Pursuant to RSA 400-A:6, III-a, the assistant commissioner performs the duties and exercises the power of the commissioner as authorized by the commissioner. In the vacancy or incapacity of the commissioner and the deputy commissioner, the assistant commissioner becomes the acting commissioner.

(e) The administration division is responsible for the general oversight and operational needs of the department, including personnel management and the supervision of the department’s various divisions which are herein described.

(f) The department may be contacted by telephone directly, 603-271-2261, TDD access relay 800-735-2964, by email at requests@ins.nh.gov, by facsimile 603-271-1406, or by writing to the insurance commissioner at:

The New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301.

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #6967, eff 3-26-99; ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20

N.H. Code Admin. R. Ann. Ins 102.02 Business Operations Division {#sec-ins-102.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 102.02}

(a) The business unit is responsible for general office matters, which include:

(1) Federal grants accounting;

(2) Project management;

(3) Health reform coordination;

(4) Requisitioning of supplies and equipment;

(5) Agency budget preparation;

(6) Information technology initiatives;

(7) Facilities management;

(8) Journalizing and depositing all monies received and disbursed;

(9) Accounts payable; and

(10) Accounts receivable.

(b) The producer licensing unit has responsibility for the collection of fees and the licensing and examination of producers and adjusters, both resident and non-resident, in accordance with RSA 402-B, RSA 402-D, and RSA 402-J. The producer licensing unit may be contacted directly by telephone, (603) 271-0203, TDD access relay 800-735-2964, by facsimile 603-271-7029, by email at producerquestions@ins.nh.gov, or by writing to the insurance commissioner, to the attention of the producer licensing unit, at:

The New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301.

(1) Collecting and auditing the premium tax returns in accordance with RSA 400-A, RSA 405, RSA 405-A, RSA 405-B, and RSA 406-B;

(2) Calculating, invoicing, and collecting assessments for the department’s administration fund in accordance with RSA 400-A:39; and

(3) Assisting in the development of projections for general fund revenues received by the department, and monitoring and reporting variances between the actual general fund revenue and estimated revenue.

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss and moved by #6967, eff 3-26-99 (from Ins 102.05); ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20

N.H. Code Admin. R. Ann. Ins 102.03 Legal Division {#sec-ins-102.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 102.03}

(a) The legal division is comprised of the legal counsel unit, the enforcement unit, and the fraud unit, under the direction and supervision of the general counsel. Pursuant to RSA 400-A:6, VII, the general counsel performs the duties and exercises the power of the commissioner as authorized by the commissioner.

(b) The legal counsel unit interprets existing laws and rules pertaining to insurance regulation, conducts research to develop departmental policy, and participates in the department’s legislative and rulemaking process.

(c) The enforcement unit assists the department in meeting its mission of promoting and protecting the public good by ensuring the existence of a safe and competitive insurance marketplace through the equitable enforcement of New Hampshire’s insurance laws and rules. The compliance and enforcement counsel manages the unit in accordance with RSA 400-A:6, VII.

(d) The fraud unit conducts criminal investigations and collaborates with other law enforcement agencies to prevent insurance fraud and other insurance-related crimes pursuant to RSA 417:23. The fraud unit may be contacted directly by telephone, 603-271-2261 or 1-800-852-3416, TDD access relay 800-735-2964, by facsimile, 603-271-1406, by email nhfraud@ins.nh.gov, or by written communication addressed to the insurance commissioner, to the attention of the fraud unit, at:

The New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss and moved by #6967, eff 3-26-99 (from Ins 102.07); ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20; renumbered by #13218 (formerly Ins 102.04)

N.H. Code Admin. R. Ann. Ins 102.04 Life and Health Division {#sec-ins-102.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 102.04}

(a) The life and health division is comprised of the life and health market conduct examinations unit, the life and health form examinations unit, the life and health rates unit, and the health data analytics unit.

(b) The life and health market conduct examinations unit is described as follows:

(1) The market conduct examinations unit performs on-site market conduct examinations, desk reviews, investigations, surveys, market analyses, and other steps to determine whether licensees of the department are performing in the marketplace following the laws and rules of this state;

(2) This unit has primary responsibility to regulate and oversee the marketplace operations of insurance department licensees and any other entities regulated by the department;

(3) The market conduct examinations unit addresses market conduct problems using a variety of approaches including proactive outreach, department communications, licensee interviews, information gathering, licensee policies and procedures reviews, interrogatories, voluntary compliance programs, investigations, examinations, compliance programs, and enforcement actions; and

(4) The market conduct examinations unit shares and coordinates its results and certain activities with other states through participation in resources developed by the National Association of Insurance Commissioners (NAIC).

(c) The life and health forms examinations unit examines the rates and forms for all life and accident and health policies, riders, endorsements, and applications submitted to the section for approval prior to use to ensure conformity to the laws and rules of the state of New Hampshire.

(d) The life and health rates unit is responsible for:

(1) Reviewing actuarial aspects of policy form and rate filings to determine that premium rates are not excessive, inadequate, or unfairly discriminatory and that premium rates conform to statutory requirements; and

(2) Assisting the commissioner with setting regulatory policy and providing actuarial expertise on life and health matters.

(e) The health data analytics unit is responsible for:

(1) Supervising the collection and use of data in support of department health care costs and health insurance market transparency efforts; and

(2) Providing health finance and policy expertise on related matters as requested by the commissioner.

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss and moved by #6967, eff 3-26-99 (from Ins 102.08); ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20; ss by #13219, eff 6-28-21 (formerly Ins 102.05)

N.H. Code Admin. R. Ann. Ins 102.05 Financial Regulation Division {#sec-ins-102.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 102.05}

(a) The financial regulation division is responsible for ensuring company solvency, conducting financial examinations, financial analysis, and licensing and registering all domestic and foreign companies and all other regulated entities. The director of financial regulation manages the division in accordance with RSA 400-A:6, VII.

(b) The financial regulation division is comprised of 2 units as follows:

(1) The financial examinations unit conducts the on-site financial examination of domestic or foreign insurance companies located throughout the United States. The chief financial examiner manages the unit in accordance with RSA 400-A:6, VII; and

(2) The financial analysis and company licensing unit:

a. Reviews financial records filed with the department by all licensed insurance companies;

b. Grants, suspends, and revokes company licenses based on financial condition or other changes in a company’s business affairs; and

c. Has primary responsibility for the regulation of surplus lines or excess insurance as defined in RSA 405:24 through RSA 405:31.

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss and moved by #6967, eff 3-26-99 (formerly Ins 102.09); ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20; renumbered by #13218 (formerly Ins 102.06)

N.H. Code Admin. R. Ann. Ins 102.06 Property and Casualty Division {#sec-ins-102.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 102.06}

(a) The property and casualty division is comprised of the property and casualty market conduct examinations unit, the property and casualty forms examinations unit, and the property and casualty actuarial unit.

(b) The property and casualty market conduct examinations unit is described as follows:

(1) The property and casualty market conduct examinations unit performs on-site market conduct examinations, desk reviews, investigations, surveys, market analyses, and other steps to determine whether licensees of the department are performing in the marketplace following the laws and rules of this state;

(2) This unit has primary responsibility to regulate and oversee the marketplace operations of insurance department licensees and any other entities regulated by the department;

(3) The unit addresses market conduct problems using a variety of approaches including proactive outreach, department communications, licensee interviews, information gathering, licensee policies and procedures reviews, interrogatories, voluntary compliance programs, investigations, examinations, compliance programs, and enforcement actions; and

(4) The unit shares and coordinates its results and certain activities with other states through participation in resources developed by the NAIC.

(c) The property and casualty forms examinations unit examines rates and forms for casualty and property insurance contracts submitted to the division to ensure conformity to the laws and rules of the state of New Hampshire.

(d) The property and casualty actuarial unit is responsible for:

(1) Reviewing actuarial aspects of policy form, rule, and rate filings to determine that premium

rates and rating plans are not excessive, inadequate, or unfairly discriminatory and that premium rates conform to statutory requirements; and

(2) Assisting the commissioner with setting regulatory policy and providing actuarial expertise

on property and casualty matters.

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss and moved by #6967, eff 3-26-99 (formerly Ins 102.11); ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20; ss by #13218, eff 6-28-21 (formerly Ins 102.07)

N.H. Code Admin. R. Ann. Ins 102.07 Consumer Services Division {#sec-ins-102.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 102.07}

(a) The consumer services division investigates complaints and responds to inquiries received relating to any entity subject to the regulatory authority of the commissioner in accordance with RSA 400-A:15-e.

(b) The consumer services division refers matters to other divisions, law enforcement, or other agencies in this state or any other jurisdiction when further investigation or examination is necessary.

(1) Property and casualty disputes; and

(2) Life and health disputes.

(d) The consumer services division may be contacted directly by calling toll-free 1-800-852-3416, TDD access relay 800-735-2964, by facsimile 603-271-1406, or by email at consumerservices@ins.nh.gov. Written communications shall be addressed to the insurance commissioner, to the attention of the consumer services division, at:

The New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301

Online complaints may be submitted through the department’s website at https://www.nh.gov/insurance/complaints/index.htm.

History

#2336, eff 4-8-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #6967, eff 3-26-99; ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20; ss by #13218, eff 6-21-21 (formerly Ins 102.08)

Part Ins 103 Requests for Department Documents or Records

N.H. Code Admin. R. Ann. Ins 103.01 Document Requests {#sec-ins-103.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 103.01}

(a) Requests for copies of department documents or records shall be made pursuant to RSA 91-A.

(b) All requests for copies of department documents or records shall be in a manner that would give the department notice of exactly what records the requestor is seeking, including the period of time from which the records are sought.

(1) By U.S. mail to:

The New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301;

(2) By email to requests@ins.nh.gov;

(3) By facsimile transmission to 603-271-1402;

(4) By telephone at 603-271-2261; or

(5) In person.

History

#6967, eff 3-26-9999; ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20

N.H. Code Admin. R. Ann. Ins 103.02 Department Response {#sec-ins-103.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 103.02}

(a) The department shall respond to all requests for records as soon as practicable and in accordance with RSA 91-A.

(b) When inspection of publicly available records is not immediately feasible, the requesting party and the department shall agree upon a mutually convenient time for such.

(c) By agreement between the requesting party and the department, copies shall be electronically sent to a valid email address provided by the requesting party.

(d) If copies are requested, the requesting party shall be charged a fee for the actual cost of the paper or electronic copies as assessed by the department.

APPENDIX

RULE NUMBER

STATE STATUTE IMPLEMENTED

Ins 101.01

RSA 400-A:15, I; RSA 400-A:3; RSA 541-A:16, I(a)

Ins 101.02

RSA 400-A:15, I; RSA 400-A:3; RSA 541-A:16, I(a)

Ins 102.01

RSA 400-A:15, I; RSA 400-A:1; RSA 400-A:3; RSA 400-A:9;

RSA 400-A:10; RSA 400-A:6; RSA 541-A:16, I(a)

Ins 102.02

RSA 400-A:15, I; RSA 400-A:9; RSA 400-A:10; RSA 541-A:16, I(a)

Ins 102.04

RSA 400-A:15, I; RSA 400-A:9; RSA 400-A:10; RSA 400-A:6,VII;

RSA 541-A:16, I(a)

Ins 102.05

RSA 400-A:15, I; RSA 400-A:9; RSA 400-A:10; RSA 400-A:6, VII;

RSA 541-A:16, I(a)

Ins 102.06

RSA 400-A:15, I; RSA 400-A:9; RSA 400-A:10; RSA 541-A:16, I(a)

Ins 102.07

RSA 400-A:15, I RSA 400-A:9; RSA 400-A:10; RSA 400-A:15-e;

RSA 541-A:16, I(a)

Ins 102.09

RSA 400-A:15, RSA 400-A:9 and RSA 400-A:10

Ins 102.10

RSA 400-A:15, RSA 400-A:9 and RSA 400-A:10

Ins 102.11

RSA 400-A:15, RSA 400-A:9, RSA 400-A:10 and RSA 417:23

Ins 103.01

RSA 400-A:15, I; RSA 91-A:4; RSA 541-A:16, I(a)

Ins 103.02

RSA 400-A:15, I; RSA 91-A:4; RSA 541-A:16, I(a)

History

#6967, eff 3-26-9999; ss by #7984, eff 11-10-03; ss by #12983, eff 2-1-20 (formerly Ins 103.03)

Chapter Ins 200 Practices and Procedures

Part Ins 201 General Information

N.H. Code Admin. R. Ann. Ins 201.01 Scope {#sec-ins-201.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 201.01}

The rules in this chapter shall govern all proceedings before the department.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 202 Definitions

N.H. Code Admin. R. Ann. Ins 202.01 Definitions {#sec-ins-202.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 202.01}

(a) "Adjudicative proceeding" means the procedure to be followed in contested cases, as set forth in RSA 541-A.

(b) "Commissioner" means the insurance commissioner.

(d) “Confidential document” means a document that is confidential in its entirety because it contains confidential information, and there is no practicable means of filing a redacted version of the document.

(e) “Confidential information” means:

(1) Information that is not public pursuant to state or federal statute, administrative or court rule, a prior court order placing the information under seal, or case law; or

(2) Information which the hearing officer finds, if publicly disclosed, would substantially impair:

a. The privacy interests of an individual; or

b. The business, financial, or commercial interests of an individual or entity.

(f) "Contested case" means "contested case" as defined in RSA 541-A:1 IV.

(g) "Declaratory ruling" means "declaratory ruling" as defined in RSA 541-A:1, V.

(h) "Department" means the insurance department.

(i) "Ex parte communications" means the transmittal of data or argument concerning the merits of the subject matter of any adjudicative proceeding to or from the hearing officer, commissioner, or any assistant or advisor to the hearing officer or commissioner without notice to all parties to the adjudicative proceeding.

(j) "Hearing" means the formal or informal receipt by the department of data or argument, or both, from persons.

(k) "Hearing officer" means the commissioner or if the commissioner is unavailable or unable to preside, the deputy commissioner or any natural person whom the commissioner has designated to preside over a hearing.

(l) "License" means “license” as defined in RSA 541-A:1, VIII.

(m) "Licensing" means "licensing" as defined in RSA 541-A:1, X.

(n) "Motion" means any application by a party to a proceeding for an order relating to the proceeding.

(o) "Order" means "order" as defined in RSA 541-A:1, XI.

(p) "Party" means "party" as defined in RSA 541-A:1, XII.

(q) "Person" means "person" as defined in RSA 541-A:1, XIII.

(r) “Probation” means holding in abeyance the imposition of a license revocation or suspension, the payment of a monetary fine, or other penalty or punishment imposed by order, for a specific period of time, provided certain conditions are satisfied.

(s) "Proceeding" means any investigation, examination, hearing, or adjudication in which the legal rights, duties, or privileges of a person as set forth by statute or rule are determined by the department after opportunity for a hearing.

(t) “Remote hearing” means a hearing conducted via telephone, computer, or other electronic means.

(u) "Rule" means "rule" as defined in RSA 541-A:1, XV.

(v) “Staff advocate” means any person designated by the commissioner to act as the advocate for the department in an adjudicative proceeding.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 203 Hearing Officer

N.H. Code Admin. R. Ann. Ins 203.01 Hearing Officer; Appointment; Authority {#sec-ins-203.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 203.01}

(a) All hearings shall be conducted by a hearing officer.

(b) The commissioner or deputy commissioner shall act as hearing officer in any summary suspension hearing pursuant to Ins 206.04. For all other hearings, the commissioner or deputy commissioner shall act as hearing officer or the commissioner shall appoint a natural person to act as hearing officer.

(c) If neither the commissioner nor deputy commissioner acts as hearing officer, the commissioner shall appoint a hearing officer who shall receive evidence and who shall be charged with preparing a proposed written decision and proposed order with recommendations for the final disposition of the case or for any dispositive motion, as set forth in Ins 207.04.

(d) A hearing officer shall, as necessary:

(1) Regulate and control the course of a hearing;

(2) Facilitate an informal resolution of an appeal;

(3) Administer oaths and affirmations;

(4) Receive relevant evidence and exclude irrelevant, immaterial, or unduly repetitious evidence;

(5) Rule on procedural requests, including adjournments or postponements, at the request of a party or on the hearing officer’s own motion;

(6) Question any person who testifies;

(7) Cause a complete record of any hearing to be made, as specified in RSA 541-A:31, VI;

(8) Communicate with all parties to an adjudicative proceeding regarding scheduling or procedural matters in writing, in person, by fax, electronic mail, or by telephone, in compliance with Ins 204.07; and

(9) Take any other action consistent with applicable statutes and rules necessary to conduct the hearing and complete the record in a fair and timely manner.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 203.02 Withdrawal of Hearing Officer {#sec-ins-203.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 203.02}

(a) Upon the hearing officer's own initiative or upon the motion or request of any party, a hearing officer shall, for good cause, withdraw from any appeal.

(b) Good cause shall exist if a hearing officer has a direct interest in the outcome of the hearing or any connection with the parties that would be likely to improperly influence his or her judgment.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 203.03 Inquiry by Hearing Officer {#sec-ins-203.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 203.03}

The hearing officer in an adjudicative proceeding shall question witnesses and make such inquiry of witnesses, parties, or counsel as the hearing officer believes appropriate to promote the fair, accurate, and efficient resolution of issues pending before the department.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 204 Appearances Before the Department

N.H. Code Admin. R. Ann. Ins 204.01 Who May Appear {#sec-ins-204.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 204.01}

(a) Any party may appear in a proceeding either in person, by a representative, or both.

(b) Each party shall file an appearance in the proceeding indicating an intention to appear on the date of the hearing.

(d) Appearances by the party and any representative shall be filed at the earliest date practical, but no later than 3 days before the scheduled hearing.

(e) Any person seeking to intervene in a proceeding shall file a petition for intervention in accordance with RSA 541-A:32. Unless granted permission to intervene, such persons shall have no role in the proceeding.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 204.02 Representatives {#sec-ins-204.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 204.02}

(a) A representative shall be either an attorney-at-law, licensed in New Hampshire, or an officer or employee designated to represent a business entity.

(b) Designation of an attorney-at-law or other representative shall:

(1) Be in writing; and

(2) Contain the following information:

a. Name, address, and telephone number of designee;

b. Title or name of matter pending before the department; and

c. Duration of designation.

(d) An attorney from another jurisdiction shall be permitted to participate in the proceedings if the attorney files a motion for leave to appear providing proof the attorney is in good standing in his or her home jurisdiction.

(e) Nothing in this rule shall be interpreted as permitting the unauthorized practice of law, nor shall this rule be construed to restrict or limit the right of any person to conduct his or her own business with the department.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 204.03 Right to Counsel {#sec-ins-204.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 204.03}

Any party in a proceeding may be represented by counsel. Parties shall retain counsel at their own expense and requests for appointment of counsel shall not be granted.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 204.04 Prohibited Conduct and Representation {#sec-ins-204.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 204.04}

(a) “Misconduct” means any act or non-act which would constitute misconduct of an attorney-at law as defined in the New Hampshire supreme court rules of professional conduct.

(b) The department shall, after notice and opportunity for hearing, upon a finding of misconduct as defined in this section, prohibit an individual from acting as representative for any and all pending or future matters, or any combination thereof, before the department.

(c) Upon a finding of misconduct by any attorney admitted to practice in New Hampshire, the matter shall be referred to the New Hampshire supreme court, committee on professional conduct, for such determination as they find appropriate.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 204.05 Staff of Department {#sec-ins-204.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 204.05}

(a) Staff members of the department shall only participate in a proceeding as witnesses, technical assistants, technical advisors, or as otherwise provided in this chapter.

(b) The staff advocate shall be that person authorized to represent the department in an adjudicative proceeding.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 204.06 Role of Complainants in Enforcement or Disciplinary Hearings {#sec-ins-204.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 204.06}

Unless called as witnesses or granted intervenor status, a complainant shall have no role during enforcement or disciplinary hearings beyond the role of witness or intervenor.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 204.07 Ex Parte Communications, Adjudicative Proceedings {#sec-ins-204.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 204.07}

(a) Once an adjudicative proceeding has commenced, unless required for the disposition of ex parte matters authorized by law or exempt herein, no party shall communicate, directly or indirectly, with the commissioner, the hearing officer, or any assistant or advisor to the hearing officer concerning the merits of the case, except upon notice and opportunity for all parties to participate.

(b) The notice and opportunity to participate requirement imposed pursuant to paragraph (a) shall not apply:

(1) When a hearing officer has been appointed to receive evidence pursuant to Ins 203.01(c) and communications between or among the commissioner and department staff are required for the proper administration of the business of the department;

(2) To ex parte communications between or among the hearing officer and any assistant or advisor designated by the commissioner to assist the hearing officer; or

(3) To ex parte communications with staff participating in the preparation of the final order after the commissioner has received, reviewed and determined whether to accept, reject or otherwise modify a proposed decision pursuant to Ins 207.04.

(c) When the commissioner has appointed a hearing officer to receive evidence and enter a proposed decision pursuant to Ins 203.01(c), there shall be no ex parte communications directly or indirectly between the hearing officer and the commissioner concerning the merits of the case.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 205 Filing and Service of Documents

N.H. Code Admin. R. Ann. Ins 205.01 Date of Issuance or Filing of Documents {#sec-ins-205.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 205.01}

(a) All decisions, orders, notices, or other written correspondence or documents issued by or at the direction of the department shall be refutably presumed to have been issued on the date noted on the document.

(b) All written documents governed by these rules shall be deemed to have been filed with or received by the department on the actual date of receipt by the department, as evidenced by a date stamp placed on the document by the department in the normal course of business.

(c) A decision, order, notice, or other written correspondence or document issued by the department shall be deemed to have been received on the day it is:

(1) Delivered to a party or left at the physical address of that person, if delivery is by personal delivery;

(2) Deposited in a depository of the United States Postal Service, if delivery is by first class mail; or

(3) Faxed or sent electronically, if delivery is by electronic mail.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 205.02 Format and Filing of Documents {#sec-ins-205.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 205.02}

(a) All correspondence, pleadings, motions, or other documents filed under these rules shall:

(1) Include the title and docket number of the proceeding, if known;

(2) Be clearly printed on durable paper, 8½ by 11 inches in size;

(3) Be signed by the party or proponent of the document or, if the party appears by a representative, by the representative; and

(4) Include a statement certifying that a copy of the document has been delivered to all parties to the proceeding in compliance with Ins 205.03.

(b) The signature on a document filed with the department shall constitute certification that:

(1) The signer has read the document;

(2) The signer is authorized to file it;

(3) To the best of the signer’s knowledge, information, and belief there are good and sufficient grounds to support it; and

(4) The document has not been filed for purposes of delay.

Hearings Clerk

New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301

(d) All petitions, motions, exhibits, memoranda, or other documents filed in connection with adjudicative proceeding shall be filed with an original and 3 copies, unless otherwise directed by the department.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 205.03 Delivery of Documents {#sec-ins-205.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 205.03}

(a) Copies of all petitions, motions, exhibits, memoranda, or other documents filed by any party to a proceeding governed by this rule shall be delivered by that party to all other parties to the proceeding.

(b) All proposed and final notices, orders, decisions, or other documents issued by the hearing officer or the commissioner pursuant to this rule shall be delivered to all parties to the proceeding.

(c) Delivery of all documents relating to a proceeding shall be made by personal delivery or by depositing a copy of the document, by first class mail, postage prepaid, in the United States mail, addressed to the party at the last address given to the department by the party. Unless otherwise prohibited by this chapter or by law, upon the consent of any party, delivery may be by fax or electronic mail, in lieu of delivery by first class mail.

(d) Notwithstanding paragraphs (a) through (c) above, when a party appears by a representative, delivery shall be upon the representative at the address stated on the appearance filed by the representative.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 205.04 Computation of Time {#sec-ins-205.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 205.04}

(a) Unless otherwise specified, all time periods referenced in this chapter shall be calendar days.

(b) Computation of any period of time referred to in this chapter shall begin with the day after the action which sets the time period in motion and shall include the last day of the period so computed.

(c) If the last day of the period so computed falls on a Saturday, Sunday, or legal holiday, then the time period shall be extended to include the first business day following the Saturday, Sunday, or legal holiday.

(d) Except where the time has been fixed by statute, the hearing officer shall for good cause, upon request or upon the hearing officer's own initiative, lengthen or shorten the time provided for the filing of any document. Good cause shall include the unavailability of information, parties, witnesses, or attorneys necessary for the filing of the document, the likelihood that the filing will not be necessary because the parties anticipate a settlement, or any other circumstances that demonstrate that a postponement would assist in resolving the case fairly.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 205.05 Motions and Response Thereto {#sec-ins-205.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 205.05}

(a) Unless presented during an oral session of a proceeding, motions and all replies thereto shall be in written form and filed with the hearing officer, unless made in response to a matter asserted for the first time at the hearing or on the basis of information which was not received in time to prepare a written motion.

(b) Oral motions and any oral objection to such motions shall be recorded in full in the record of the hearing. If the hearing officer finds that the motion requires additional information in order to be fully and fairly considered, the hearing officer shall direct the moving party to submit the motion in writing, with supporting information, before any deadline established by the hearing officer.

(1) The purpose of the motion;

(2) The relief sought by the motion;

(3) The statues, rules, orders, or other authority sanctioning the relief sought by the motion; and

(4) The facts claimed to constitute grounds for the relief requested by the motion.

(d) Replies to motions shall state:

(1) The defense of the party filing the reply;

(2) The action which the party filing the reply wishes the department to take on the motion;

(3) The statutes, rules, orders, or other authority relied upon in defense of the motion; and

(4) Any facts which are additional to or different from the facts stated in the motion.

(e) Motions shall be decided upon the writings submitted. Repetitious motions shall not be accepted.

(f) Replies to motions shall be filed within 10 days after the filing of the motion. Failure to reply to a motion within the time allowed shall constitute a waiver of objection to the motion but shall not in and of itself constitute grounds for granting the motion.

(g) The hearing officer shall rule upon a motion after full consideration of all objections and other factors relevant to the motion in accordance with this chapter.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 205.06 Confidential Documents and Confidential Information {#sec-ins-205.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 205.06}

(a) Except as otherwise provided by statute or rule, all pleadings, attachments to pleadings, and exhibits submitted at hearings shall be available for public inspection.

(b) A confidential document shall not be accepted in a pleading if it is neither required for filing nor material to the proceeding.

(c) If a confidential document is required or is material to the proceeding, the party shall file the confidential document in the manner prescribed by paragraph (d) below.

(d) When a party files a document, the party shall omit or redact confidential information from the filing when the information is not required to be included for filing and is not material to the proceeding; and

(1) If none of the confidential information is required or material to the proceeding, the party shall file only the version of the document from which the omissions or redactions have been made; and

(2) At the time the document is submitted to the hearing clerk, the party shall clearly indicate on the document that the document has been redacted or information has been omitted pursuant to Ins 205.06.

(e) It is the responsibility of the filing party to ensure that confidential information is omitted or

redacted from a document before the document is filed.

(f) If confidential information is required for filing or is material to the proceeding and must be included in the document, the filer shall file:

(1) A motion to seal as provided in paragraph (g);

(2) For inclusion in the public file, the document with the confidential information redacted by blocking out the text or using some other method to clearly delineate the redactions; and

(3) An unredacted version of the document clearly marked as confidential.

(g) A motion to seal a confidential document or a document containing confidential information shall state the authority for the confidentiality or circumstance that requires confidentiality. An agreement of the parties that a document is confidential or contains confidential information shall not be sufficient basis alone to seal the record but must be ruled so, pursuant to paragraph (h) below.

(h) The hearing officer shall:

(1) Review the motion to seal and any objection to the motion to seal that may have been filed and determine whether the unredacted version of the document shall be confidential; and

(2) Issue an order setting forth the hearing officer’s ruling on the motion to seal, which order shall include the duration that the confidential document or document containing confidential information shall remain under seal, and the reasons for the ruling.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 206 Adjudicative Proceedings

N.H. Code Admin. R. Ann. Ins 206.01 Adjudicative Proceedings {#sec-ins-206.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.01}

(a) In any adjudicative proceeding before the department, all motions, requests, and actions shall be conducted pursuant to RSA 541-A:31 through 38.

(b) Hearings shall be conducted with the respondent, the department, and any witnesses physically present before the hearing officer. A remote hearing shall be conducted upon motion of any party if the hearing officer determines that:

(1) There is good cause as set forth in paragraph (c), below; and

(2) Conducting the hearing with one or more parties participating remotely would not violate any law or rule or constitutional protections, and would promote the fair, accurate, and efficient resolution of issues pending before the department.

(1) Excessive distance to the hearing location;

(2) Physical disability or impairment of the respondent;

(3) Transportation difficulties;

(4) The physical presence of the respondent would threaten the health or safety of the respondent or any other individual; or

(5) Other circumstance that would prevent the respondent or other parties from being able to appear and participate in person at the hearing.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.02 Waiver of Procedural Rules {#sec-ins-206.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.02}

The hearing officer, upon the hearing officer's own initiative or upon the motion or petition of any interested person, shall waive any requirement or limitation imposed by this chapter not otherwise contrary to law, upon reasonable notice to affected persons, when the proposed waiver appears to be lawful and would be more likely to promote the fair, accurate, and efficient resolution of issues pending before the department than would adherence to a particular rule or procedure.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.03 Effect of Failure to Comply with the Rules or Attend the Hearing {#sec-ins-206.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.03}

(a) Failure to comply with the rules in this chapter shall result in the denial of any petition or motion so failing to comply, or the rejection of any document so failing to comply, or the issuance of an order adverse to the person so failing to comply.

(b) If any party, to whom notice has been properly given in accordance with RSA 400-A:18, fails to attend a hearing, the hearing officer shall declare that party to be default and shall either:

(1) Dismiss the case, if the party with the burden of proof fails to appear; or

(2) Hear the testimony and receive the evidence offered by a party, if that party has the burden of proof.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.04 Summary Suspension of Department Issued Licenses {#sec-ins-206.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.04}

In the case of summary suspensions, the following general provisions shall apply:

(a) When the commissioner finds that public health, safety, or welfare requires emergency action, and incorporates a finding to that effect in such order, summary suspension of a license shall be ordered, effective on the date specified in such order, pending proceedings for revocation or other action;

(b) An order of summary suspension shall be served prior to, simultaneously with, or after the commencement of an adjudicative proceeding seeking the suspension or revocation of a license; and

(c) The order of summary suspension shall be served upon the holder of a license, either by personal service, by certified mail, return receipt requested, electronic delivery, or by some other means for the purpose of directly informing the holder and shall become effective upon delivery to the licensee.

(d) The hearing shall be scheduled to commence within 10 business days of the effective date of the order of license suspension.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.05 Burden and Standard of Proof {#sec-ins-206.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.05}

(a) For purposes of this section, “proof by a preponderance of the evidence" means what is sought to be proved is more probable than not.

(b) In a hearing held to determine whether a certification, license, permit, or other approval that has already been issued should be suspended or revoked, the department shall, unless otherwise required by statute, present a prima facie case supporting its action in order to meet its burden of going forward with evidence of the violation, after which the opposing party shall bear the burden of persuasion to present evidence to convince the hearing officer that the department’s position should not be upheld.

(c) The standards for meeting the department's burden of going forward with evidence of the violation and the respondent's burden of persuasion shall be by a preponderance of the evidence.

(d) In a hearing held to determine whether an administrative fine should be imposed, the department shall bear the overall burden of proof by a preponderance of the evidence.

(e) In any hearing held pursuant to RSA 400-A:17, II(b) to review a department decision, the burden of proof shall be on the person seeking to overturn the decision.

(f) The party asserting a proposition shall bear the burden of proving the truth of the proposition by a preponderance of the evidence.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.06 Continuances {#sec-ins-206.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.06}

(a) The hearing officer shall for good cause, upon request or upon the hearing officer's own initiative, advance or postpone the time and date set for any hearing.

(b) If a postponement is requested by a party to the hearing, it shall be granted if the hearing officer determines that good cause has been demonstrated.

(c) Good cause shall include the unavailability of information, parties, witnesses, or attorneys necessary to conduct the hearing, the likelihood that the hearing will not be necessary because the parties anticipate settlement, or any other circumstances that demonstrate that a postponement would assist in resolving the case fairly.

(d) If the date, time, and place of the continued hearing are known, the date, time, and place shall be stated on the record. If the date, time, and place of the continued hearing are not known, the hearing officer shall issue a written scheduling order stating the date, time, and place of the postponed hearing as soon as possible.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.07 Prehearing Conferences {#sec-ins-206.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.07}

(a) At any time following the notice of hearing of an adjudicatory proceeding, the hearing officer, upon motion or upon his or her own initiative, shall direct all interested parties to attend one or more prehearing conferences to aid in the disposition of the proceeding.

(b) The following may be considered at a prehearing conference:

(1) Opportunities and procedures for settlement;

(2) Opportunities and procedures for simplification of the issues;

(3) Possible amendments to the pleadings;

(4) Possible admissions of fact and of documents to avoid unnecessary proof;

(5) Possible limitations on the number of witnesses;

(6) Possible changes to the standard procedures which would otherwise govern the proceedings;

(7) The distribution of written testimony, if any, and exhibits to the parties;

(8) Possible consolidation of the examination of witnesses by the parties; and

(9) Any other matters which might contribute to the prompt and orderly conduct of the proceeding.

(c) The department shall cause prehearing conferences to be recorded unless all parties wish to discuss possible settlement off the record or the hearing officer determines that the prehearing process is best served by conducting discussions and conferences off the record. Matters decided at a prehearing conference shall be reflected in an appropriate order.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.08 Discovery and Disclosure {#sec-ins-206.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.08}

(a) Any party wishing discovery against another party shall, by motion, seek leave to do so and shall identify the exact type of discovery requested.

(b) Discovery shall be permitted when:

(1) It appears that the parties cannot adequately address the factual issues at the time fixed for the presentation of evidence without an opportunity to acquire data pursuant to discovery;

(2) The requested method of discovery is reasonable and will not cause material unfairness or unreasonable expenses to any party; and

(3) The requested discovery will not unreasonably delay the proceeding.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.09 Subpoenas {#sec-ins-206.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.09}

(a) Subpoenas for the attendance of witnesses at or the production of evidence in adjudicatory proceedings shall be issued only upon the order of the commissioner or pursuant to authority delegated by the commissioner. Subpoenas shall be issued in response to a motion when the commissioner determines that a subpoena is necessary for a full and fair presentation of evidence at the hearing and the information is not otherwise available to the moving party. A party requesting a subpoena shall attach a copy of the proposed subpoena to its motion. The requesting party shall be responsible for the service of the subpoena and payment of any witness fee and mileage expenses which may be required.

(b) The person to whom the subpoena is directed may, within 10 days after service of the subpoena or before the date specified in the subpoena for compliance therewith, whichever is earlier, file a motion to quash or modify the subpoena. The filing of a motion to quash or modify shall toll the time period within which the person named in the subpoena is directed to comply with the subpoena. However, if the commissioner denies the motion to quash or modify, in whole or in part, the tolling of the time period for compliance shall end and the person to whom the subpoena is directed shall comply with the subpoena, or any modification thereof, within the balance of time remaining as provided in the subpoena. The commissioner shall grant additional time to comply with the subpoena if the commissioner determines the motion to quash or modify was made in good faith and granting such additional time will not cause material unfairness to any party and will not unreasonably delay the proceeding.

(c) A subpoena shall be served by any person who is 18 years of age or older and in the manner authorized for service of subpoenas in the New Hampshire Superior Court. The fact of service shall be written on the reverse of the original copy of the subpoena by the person making service. The original copy shall be immediately returned to the commissioner, or commissioner’s designee who authorized the subpoena, by the person making service.

(d) Should any person fail to comply with a subpoena issued pursuant to this section, the commissioner shall employ any remedy authorized by this title or the law of New Hampshire or shall direct an interested party to seek judicial enforcement.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.10 Evidence {#sec-ins-206.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.10}

(a) Receipt of evidence shall be governed by RSA 541-A:33.

(b) All documents, materials, and objects offered as exhibits shall be admitted into evidence unless excluded by the presiding officer as irrelevant, immaterial, unduly repetitious, or legally privileged.

(d) Transcripts of testimony and documents or other materials admitted into evidence shall be public records unless the presiding officer determines that all or part of a transcript or document is exempt from disclosure under RSA 91-A:5 or applicable case law.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.11 Proposed Findings of Fact and Conclusions of Law {#sec-ins-206.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.11}

(a) Any party may submit proposed findings of fact and conclusions of law to the presiding officer prior to or at the hearing.

(b) Upon request of any party, or if the presiding officer determines that proposed findings of fact and conclusions of law would serve to clarify the issues presented at the hearing, the presiding officer shall specify a date for the submission of proposed findings of fact and conclusions of law.

(c) In any case where proposed findings of fact and conclusions of law are submitted, the decision shall include rulings on the proposals.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.12 Transcripts {#sec-ins-206.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.12}

The entirety of all oral proceedings shall be recorded verbatim. Upon the written request to the commissioner by any party, or upon the department's own initiative, such record shall be transcribed and the requesting party shall pay all reasonable costs for such transcription.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.13 Record {#sec-ins-206.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.13}

The record in a contested case shall include all of the following that are applicable in that case:

(a) Any prehearing order;

(b) All pleadings, motions, objections, and rulings;

(d) A statement of matters officially noticed;

(e) Proposed findings and exceptions;

(f) Any decision, opinion, or report by the officer presiding at the hearing;

(g) The tape recording or stenographic notes or symbols prepared for the hearing officer, together with any transcript of all or part of the hearing considered before final disposition of the adjudicative proceeding;

(h) Staff memoranda or data submitted to the hearing officer, except advisory memoranda prepared and submitted to the hearing officer by staff of the department or others designated by the commissioner to act as advisor or assistant to the hearing officer; and

(i) Matters placed on the record after an ex parte communication.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.14 Consolidation {#sec-ins-206.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.14}

Upon motion or the hearing officer’s own initiative, if 2 or more proceedings involve common questions of law or fact, and the hearing officer determines consolidation is fair and efficient, the hearing officer shall consolidate those proceedings for hearing, decision, or both, after providing the parties notice and an opportunity for hearing on the proposed consolidation.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.15 Severance {#sec-ins-206.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.15}

Whenever it shall appear to the department, upon motion or its own initiative, that injury to the substantial rights of a party or undue delay might be thereby avoided, the department shall, as fairness and efficiency permit, sever one or more issues from a proceeding and dispose of those issues in another proceeding, after providing the parties notice and an opportunity for hearing on the proposed severance.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 206.16 Limiting Number of Witnesses {#sec-ins-206.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 206.16}

To avoid unnecessary cumulative evidence in any proceeding, the hearing officer may limit the number of witnesses or the time for testimony upon a particular issue in the course of any hearing.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 207 Settlement, Decisions, and Rehearing

N.H. Code Admin. R. Ann. Ins 207.01 Settlement {#sec-ins-207.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 207.01}

(a) Settlements between the parties shall be encouraged in accordance with RSA 541-A:38.

Parties shall attempt to settle a matter before it is scheduled for a hearing and may settle a matter at any stage of the proceedings.

(b) All settlement agreements shall:

(1) Be in writing, describing the agreement's material terms; and

(2) Be signed by both parties and their attorneys or agents.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 207.02 Voluntary Surrender of License {#sec-ins-207.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 207.02}

(a) Any licensee may voluntarily surrender his or her license by returning it to the department, accompanied by a signed letter stating that the licensee intends to surrender his or her license.

(b) A licensee who reapplies for licensure in New Hampshire after a voluntary surrender shall meet all of the requirements then in effect for new applicants.

(1) Investigate violations of insurance laws or the rules by a person licensed at the time the alleged violation occurred; or

(2) Impose disciplinary sanctions for violations that occurred while the person was licensed.

(d) Nothing in this section shall prohibit the department and a licensee from entering into a settlement agreement or a consent decree relative to any alleged violation.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 207.03 Reopening the Record {#sec-ins-207.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 207.03}

(a) At any time prior to the issuance of the decision on the merits, the hearing officer, on the hearing officer’s own motion or on the motion of any party, shall reopen the record to receive relevant, material, and non-duplicative testimony, evidence, arguments, or exhibits not previously received.

(b) Requests to reopen the record made after one or more parties have left the hearing shall be made in writing.

(c) The hearing officer shall give written notice of such further proceedings if the parties are no longer present. The hearing officer shall also specify a date by which other parties shall respond to or rebut the newly received evidence.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 207.04 Findings and Orders {#sec-ins-207.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 207.04}

(a) If, pursuant to Ins 203.01 (c), the commissioner has appointed a natural person other than the deputy commissioner to preside at a hearing as hearing officer, the following procedures shall apply:

(1) The hearing officer shall submit to the commissioner, within 35 days after the termination of a hearing, a proposed decision and order including a proposed decision and order on any dispositive motion. Any such proposed decision and order shall be delivered to all parties;

(2) The parties may file exceptions and supporting memoranda of law for review by the commissioner within 20 days from the date the proposed decision and order is delivered pursuant to (a)(1) above. Replies to exceptions and legal memoranda may be filed within 10 days from the date of the filing of the document prompting the reply;

(3) Requests for oral argument on exceptions to the proposed order shall be filed with the commissioner within 20 days from the date the proposed decision and order is delivered, and the commissioner shall issue an order granting or denying such request within 10 days;

(4) The commissioner shall, based upon the record, determine whether the respective parties have met their burdens of proof set forth in Ins 206.05 and shall accordingly issue a final decision and order accepting, rejecting, or modifying the proposed decision and order. Any such order shall be subject to reconsideration of any final order pursuant to Ins 207.05 and Ins 207.06;

(5) If the commissioner issues a final decision and order that rejects or otherwise modifies the proposed decision and order:

a. The commissioner's factual determinations in any final order shall be based upon a review of the record;

b. The record shall provide a reasonable basis supporting the rejection or modification of the findings and rulings of the hearing officer;

c. The final decision shall adequately explain the grounds for the commissioner's decision; and

d. The commissioner shall review all evidence in the record and resolve any evidentiary conflicts by applying the commissioner's own expertise and technical judgment; and

(6) The final order shall comply with all requirements set forth in (c) of this section.

(b) If the commissioner or deputy commissioner has presided over the hearing, the commissioner or deputy commissioner, as appropriate, shall issue a final decision and order consistent with the requirement of (c) of this section.

(1) Be issued within 90 days of the termination of the hearing, pursuant to RSA 400-A:23, II;

(2) Be made on the basis of the evidence of record presented at the hearing and rationally supportable by such evidence;

(3) Be in writing or stated in the record;

(4) Include findings of fact and conclusions of law, separately stated; and

(5) Be the final action of the department, subject to the reconsideration of any final order pursuant to Ins 207.05 and Ins 207.06.

(d) No factual information received or known that is not evidence of record shall be considered in any final decision and order.

(e) Request for rehearings and appeals from a final action shall be made in writing and shall be made pursuant to RSA 541.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 207.05 Reconsideration on the Commissioner’s Own Motion {#sec-ins-207.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 207.05}

Within 30 days of any final order, the commissioner, based upon the existing record, may reconsider, revise, or reverse any final action on the commissioner's own motion. If reconsideration is based upon the existing record, prior notice shall not be given to the parties. If the commissioner believes further argument or data should be considered, an appropriate order providing the parties with notice and an opportunity to be heard shall be issued before any revision shall be made in the department’s previous action.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 207.06 Motion for Reconsideration {#sec-ins-207.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 207.06}

(a) A motion for reconsideration shall be filed within 30 days of the final decision.

(b) A motion for reconsideration shall:

(1) Identify each error of fact, error of reasoning, or error of law which the moving party wishes to have reconsidered;

(2) Describe how each error causes the final decision to be unlawful, unjust, unreasonable, or illegal in respect to jurisdiction, authority, or observance of the law, an abuse of discretion, or is arbitrary, unreasonable, or capricious;

(3) State concisely the factual findings, reasoning, or legal conclusion proposed by the moving party; and

(4) Include any argument or memorandum of law the moving party wishes to file.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 207.07 Stay of Department Orders {#sec-ins-207.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 207.07}

(a) A stay of department action shall be specifically requested. The mere filing of a motion for reconsideration shall not operate as a stay of any order, but a motion for stay may be combined with a motion for reconsideration.

(b) If the commissioner, acting on the commissioner's own motion, stays the effect of any final order, the commissioner shall do so with or without a corresponding order to reconsider or reopen the proceeding.

(c) Consent agreements shall be encouraged and shall provide a legitimate conclusion to the hearing process. When the consent agreement is issued, the signatories to it shall thereby waive their right to a motion to reconsider. Intervenors shall have no standing to contest the consent agreement.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 207.08 Record Retention {#sec-ins-207.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 207.08}

The department shall keep a decision or order on file in its records for at least 6 years following the date of the final decision or the date of the decision on any appeal, unless the director of the division of records management and archives of the department of state sets a different retention period pursuant to rules adopted under RSA 541:31.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 208 Proceedings to Determine Commercial Reasonableness of Health Care Fees

N.H. Code Admin. R. Ann. Ins 208.01 Scope {#sec-ins-208.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 208.01}

(a) Ins 208 contains requirements for proceedings before the department under RSA 420-J:8-e to determine whether a fee charged for health care services submitted to an insurance carrier for payment represents a commercially reasonable value, based on payments for similar services from New Hampshire insurance carriers to New Hampshire health care providers.

(b) The requirements of Ins 208 shall be in addition to the hearing standards under Ins 201, Ins 202, Ins 203, Ins 204, Ins 205, Ins 206, and Ins 207, which shall be applicable unless specifically provided herein.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 208.02 Petition for Hearing {#sec-ins-208.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 208.02}

(a) In the event of a dispute between a health care provider and an insurance carrier relative to the reasonable value of a service under RSA 329:31-b, either the provider or the insurance carrier may petition for a hearing under RSA 400-A:17 and Ins 208.

(b) The petitioner shall file an original and 2 copies of the petition, and the petition shall set forth the following information:

(1) The rate the petitioning party believes is commercially reasonable;

(2) The evidence and methodology for asserting that the fee is reasonable;

(3) The relevant facts relating to the billing code used;

(4) The efforts made by the parties to resolve the dispute prior to petitioning the commissioner for review, including a statement of whether the parties have engaged in mediation; and

(5) A certification that the other party and the data analytics division of the Insurance Department has been served with the petition.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 208.03 Response to the Petition {#sec-ins-208.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 208.03}

(a) Within 10 days of the filing of the petition for a hearing, the responding party shall file a response to the petition.

(b) The respondent shall file an original and 2 copies of the response, and the response shall set forth the following information:

(1) The rate the responding party believes is commercially reasonable;

(2) The evidence and methodology for asserting that the fee is reasonable;

(3) Any facts which are additional to or different from the facts stated in the petition; and

(4) A certification that the other party and the data analytics division of the insurance department has been served with the petition;

(c) Failure to file a response to the petition shall result in a default finding that the petitioning parties proposed rate is commercially reasonable.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 208.04 Prehearing Conference {#sec-ins-208.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 208.04}

An order scheduling a prehearing conference shall be issued within 10 days of the filing of the response to the petition.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 208.05 Prehearing Statements {#sec-ins-208.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 208.05}

(a) At least 7 days before the prehearing conference, all parties shall file with the hearing clerk and serve on the other parties prehearing statements.

(b) Prehearing statements shall include, by numbered paragraphs, a detailed, comprehensive, and good faith statement, setting forth the following:

(1) Statement of the facts;

(2) Disputed issues of fact;

(3) Applicable law;

(4) The rate the party believes is commercially reasonable;

(5) A detailed description of the party’s methodology for calculating the rate;

(6) A list of all exhibits to be offered in the direct case of each party;

(7) A copy of each document or exhibit;

(8) A list of all witnesses to be called at the hearing, together with a brief summary of their testimony; and

(9) The status of settlement negotiations.

(c) Except for good cause shown, only witnesses listed in the prehearing statement shall be allowed to testify and only exhibits, so listed, shall be received in evidence.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 208.06 Intervention by the Department {#sec-ins-208.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 208.06}

(a) At any time prior to the issuance of the decision on the merits, the department may file a motion to intervene as a party. Such motion shall be in writing and served upon the parties.

(b) If the department is allowed to intervene after the close of the record, the hearing officer shall reopen the record to receive relevant, material, and non-duplicative testimony, evidence, arguments, or exhibits not previously received.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 209 Petition for Declaratory Ruling

N.H. Code Admin. R. Ann. Ins 209.01 Petitions {#sec-ins-209.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 209.01}

(a) Any person may request a declaratory ruling from the department on matters within its jurisdiction by filing an original and 4 copies of the petition, and the petition for declaratory ruling shall set forth the following information:

(1) The exact ruling being requested, including any rule or statute implicated;

(2) The statutory and factual basis for the ruling, including any supporting affidavits or memoranda of law; and

(3) A statement as to how the language of the rule or statute applies to the circumstances of the petitioner's case.

(b) Any petition for declaratory ruling which does not contain the information required in (a) above shall be inadequate.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 209.02 Action on Petitions {#sec-ins-209.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 209.02}

(a) If examination of a petition for declaratory ruling reveals that other persons would be substantially affected by the proposed ruling, the department shall require service of the petition on such persons and advise them that they may file a reply.

(b) The petitioner and any persons served with notice of the petition shall provide such further information or participate in such evidentiary or other proceedings as the department may direct after reviewing the petition and any replies received.

(1) Issue a written ruling within 30 days after receipt of all information or the conclusion of any evidentiary or other proceeding; or

(2) Reject the petition if:

a. It is inadequate;

b. It involves a hypothetical situation or otherwise seeks advice as to how the commissioner would decide a future case;

c. It does not implicate the legal rights or responsibilities of the petitioner;

d. It is beyond the scope of the commissioner's statutory authority;

e. There is pending legislation or rulemaking, a pending administrative or judicial proceeding, or a pending investigation or examination that will address the petition; or

f. Other procedural options are available to the interested parties or the department.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 210 Rulemaking

N.H. Code Admin. R. Ann. Ins 210.01 How Adopted {#sec-ins-210.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 210.01}

A rule of the department or any amendment or repeal thereof shall be adopted by the commissioner after notice and opportunity for hearing in accordance with RSA 541-A. Rules may be proposed by any person pursuant to RSA 541-A:4 or by the agency.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 210.02 Manner for Adoption {#sec-ins-210.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 210.02}

(a) The department shall commence rulemaking by drafting a proposed rule or by accepting as a proposed rule the draft of a rule proposed by any person pursuant to Ins 209 and Ins 210.03.

(b) With respect to any proposed rule, the department shall conduct rulemaking and adoption proceedings pursuant to RSA 541-A.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 210.03 Petitions to Department for Rulemaking {#sec-ins-210.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 210.03}

Petitions from interested persons requesting adoption, amendment, or repeal of a rule shall be received and disposed of in the following manner:

(a) Petitions shall be submitted to the commissioner by letter;

(b) Petitions shall contain the following:

(1) The date of the petitioning;

(2) The petitioner's name, address, and telephone number; and

(3) The name and address of any other person or organization petitioner represents;

(d) The petitions shall be typed or printed in a legible fashion;

(e) If possible, petitioner shall cite the rule and its provisions and specify any changes desired, if repeal or amendment is sought, and shall provide the text or approximate text of the proposed rule, if promulgation is sought;

(f) The petitioner shall include a detailed and complete statement of the petitioner's reasons in support of the requested action;

(g) If the commissioner determines that any petition is deficient in any respect, the commissioner shall, within 10 working days of receipt of said petition, notify the petitioner, in writing, of the specific deficiencies and allow the petitioner to amend the petition; and

(h) Within 30 days of receipt of a petition or amended petition for rulemaking that meets the requirements of (a)-(g), the commissioner shall grant the petition and initiate rulemaking proceedings in accordance with RSA 541-A:4, if the commissioner determines that the department has authority to take the proposed action and the proposed action is:

(1) Consistent with state and federal law and policy; and

(2) Necessary to the efficient and effective implementation of the rules that are within the jurisdiction of the department.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 210.04 Public Hearings {#sec-ins-210.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 210.04}

(a) Pursuant to the provisions of RSA 541-A, the department shall conduct a public hearing on all proposed rules.

(b) The public hearing shall afford all interested persons opportunity to testify.

(c) The presiding officer at a public hearing in a rulemaking proceeding shall be the commissioner, deputy commissioner, or an individual designated by the commissioner to preside at the hearing.

(d) Notice of the date, time, and place or remote access information of the public hearing for a rulemaking proceeding held pursuant to RSA 541-A shall be given by publication in the rulemaking register pursuant to RSA 541-A.

(e) A record of the public hearing shall be kept by electronic recording or other method that shall provide a verbatim record.

(f) Any individual wishing to submit exhibits or written testimony at a public hearing shall submit such exhibits or testimony to the presiding officer, provided the individual signs and dates such testimony or exhibits.

(g) Any individual wishing to testify at a public hearing shall submit in writing to the presiding officer their name, address, and whom the individual represents, if anyone. The presiding officer shall call each individual to present their testimony. The presiding officer shall encourage individuals who testify orally to place their testimony in writing and to submit such written testimony to the presiding officer prior to the close of the record.

(h) Any comments, questions, or discussions that the presiding offer determines as not to be relevant to the subject of the public hearing shall be ruled out of order by the presiding officer.

(i) When the presiding officer determines that no person has further questions or comments that are relevant to the subject of the hearing, the presiding officer shall close the hearing.

(j) Pursuant to RSA 541-A, the department shall provide a period of at least 5 days after the hearing to afford all interested persons the opportunity to submit data, views, or arguments in writing or electronic format.

(k) A continuance of a public hearing on a proposed rule shall be granted in accordance with RSA 541-A.

(l) If a public hearing is continued, and the later date, time, and place are known at the time of the hearing that is being continued, the presiding officer shall state the date, time, and place on the record in accordance with RSA 541-A. If such later date, time, and place are not known at the time of the hearing that is being continued, the presiding officer shall state how notice shall be given of the date, time, and place of the continued hearing in accordance with RSA 541-A.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 210.05 Request for Notice of Intended Department Rulemaking Action {#sec-ins-210.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 210.05}

(a) Pursuant to the provisions of RSA 541-A, the department shall maintain a current listing of all persons having made a request for advance notice of the rulemaking proceedings.

(b) The department shall charge a fee of $.25 per page as the copy fee for providing proposed department rules in a paper format.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

N.H. Code Admin. R. Ann. Ins 210.06 Explanation of the Rule {#sec-ins-210.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 210.06}

The department shall provide, if requested by any person at any time before 30 days after the final adoption of the rule, an explanation of the rule, including:

(a) A concise statement of the principal reasons for and against the adoption of the rule in its final form; and

(b) An explanation of why the department overruled the arguments and considerations against the rule, if any.

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Part Ins 211 Waiver of Rules

N.H. Code Admin. R. Ann. Ins 211.01 Waiver of Rules {#sec-ins-211.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 211.01}

(a) The commissioner, upon the commissioner’s own initiative or upon request by an insurer, shall waive any requirement of this chapter if such waiver does not contradict the objective or intent of the rule and:

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX

Rule

Specific State Statute the Rule Implements

Ins 201.01

RSA 400-A:15, I; RSA 400-A:17-24; RSA 417:6-16; RSA 541; RSA 541-A:30-a

Ins 202.01

RSA 400-A:15, I; RSA 541-A:1; RSA 541-A:36;

Ins 203.01

RSA 400-A:13; RSA 400-A:15, I; RSA 400-A:17; RSA 400-A:19; RSA 417:7;

RSA 541-A:30-a;

Ins 203.02

RSA 400-A:15, I; RSA 541-A:30-a

Ins 203.03

RSA 400-A:15, I; RSA 400-A:19; RSA 417:7; RSA 541-A:31

Ins 204.01

RSA 400-A:15, I; RSA 400-A:19; RSA 400-A:20; RSA 417:7 and 8; RSA 541-A:31

Ins 204.02

RSA 400-A:15, I; RSA 400-A:20; RSA 417:7 and 8; RSA 541-A:31

Ins 204.03

RSA 400-A:15, I; RSA 400-A:19; RSA 400-A:20; RSA 400-A:21; RSA 417:7 and 8;

RSA 541-A:31

Ins 204.04

RSA 400-A:15, I; RSA 417:7; RSA 541-A:30-a; RSA 541-A:31

Ins 204.05

RSA 400-A:10; RSA 400-A:15, I; RSA 417:7; RSA 541-A:30-a; RSA 541-A:31;

RSA 541-A:33

Ins 204.06

RSA 400-A:15, I; RSA 400-A:19; RSA 417:12; RSA 417:18; RSA 417:20;

RSA 541-A:30-a; RSA 541-A:32; RSA 541-A:38;

Ins 204.07

RSA 400-A:15, I; RSA 400-A:19, RSA 541-A:36

Ins 205.01

RSA 400-A:15, I; RSA 400-A:14,19; RSA 417:7; RSA 541-A:33; RSA 541-A:30-a

Ins 205.02

RSA 400-A:15, I; RSA 541-A:30-a; 541-A:31

Ins 205.03

RSA 400-A:14; RSA 400-A:15, I; RSA 400-A:19; RSA 541-A:30-a; RSA 541-A:31;

RSA 541-A:36

Ins 205.04

RSA 400-A:14; RSA 400-A:15, I; RSA 400-A:19; RSA 541-A:33; RSA 541-A:30-a

Ins 205.05

RSA 400-A:15, I; RSA 541-A:31

Ins 205.06

RSA 400-A:15, I; RSA 400-A:25

Ins 206.01

RSA 400-A:15, I; RSA 400-A:19; RSA 417:7; RSA 541-A:31 – 38;

Ins 206.02

RSA 400-A:15, I; RSA 417:7; RSA 541-A:30-a; RSA 541-A:37

Ins 206.03

RSA 400-A:15, I; RSA 400-A:21; RSA 541-A:30-a

Ins 206.04

RSA 400-A:15, I; RSA 541-A:30

Ins 206.05

RSA 400-A:15, I; RSA 400-A:19-23; RSA 417:12; RSA 541-A:30-a

Ins 206.06

RSA 400-A:14; RSA 400-A:15, I; RSA 400-A:19; RSA 417:7; RSA 541-A:30-a

Ins 206.07

RSA 400-A:15, I; RSA 400-A:19; RSA 417:7; RSA 541-A:31

Ins 206.08

RSA 400-A:15, I; RSA 400-A:19; RSA 400-A:21 and 22; RSA 417:7,8;

RSA 541-A:30-a; RSA 541-A:33

Ins 206.09

RSA 400-A:15, I; RSA 400-A:19 and 20; RSA 400-A:22; RSA 417:7; RSA 417:15;

RSA 541-A:30-a

Ins 206.10

RSA 400-A:15, I; RSA 541-A:33

Ins 206.11

RSA 400-A:15, I; RSA 400-A:23; RSA 417:7; RSA 541-A:31; RSA 541-A:34 and 35

Ins 206.12

RSA 400-A:15, I; RSA 400-A:19; RSA 541-A:31

Ins 206.13

RSA 400-A:15, I; RSA 400-A:19; RSA 541-A:31

Ins 206.14

RSA 400-A:15, I; RSA 400-A:17 and 19; RSA 417:7; RSA 541-A;31

Ins 206.15

RSA 400-A:15, I; RSA 400-A:17 and 19; RSA 417:7; RA 541-A:31

Ins 206.16

RSA 400-A:15, I; RSA 400-A:14; RSA 400-A:19 and 20; RSA 541-A:31

Ins 207.01

RSA 400-A:15, I; RSA 541-A:38

Ins 207.02

RSA 400-A:15, I; RSA 402-J; RSA 541-A:38

Ins 207.03

RSA 400-A:15, I; RSA 400-A:17, 19,20; RSA 417:11; RSA 541-A:30-a

Ins 207.04

RSA 400-A:15, I; RSA 400-A:23; RSA 417:12 and 13; RSA 541-A:34 and 35

Ins 207.05

RSA 400-A:15, I; RSA 400-A:24; RSA 417: 11 and 12; RSA 541-A:30-a

Ins 207.06

RSA 400-A:15, I; RSA 541-A:30-a

Ins 207.07

RSA 400-A:15, I; RSA 400-A:17; RSA 417:7; RSA 541:18

Ins 207.08

RSA 400-A:15, I; RSA 400-A:25

Ins 208.01

RSA 400-A:15, I; RSA 420-J:8-e; RSA 541-A:31-38

Ins 208.02

RSA 329:31-b; RSA 400-A:15, I; RSA 400-A:17

Ins 208.02

RSA 400-A:15, I; RSA 400-A:17; RSA 420-J:8-e; RSA 541-A:31-38

Ins 208.04

RSA 400-A:19; RSA 417:7; RSA 541-A:31

Ins 208.05

RSA 400-A:19; RSA 541-A:31

Ins 208.06

RSA 400-A:19; RSA 541-A:31

Ins 209.01

RSA 400-A:15, I; RSA 400-A:17; RSA 417:11; RSA 541-A:4; RSA 541-A:16, I(d)

Ins 209.02

RSA 400-A:15, I; RSA 400-A:17; RSA 541-A:16, I(d)

Ins 210.01

RSA 400-A:15, I; RSA 541-A:3

Ins 210.02

RSA 400-A:15, I; RSA 541-A

Ins 210.03

RSA 400-A:15, I; RSA 541-A:4; RSA 541-A:16, I(c)

Ins 210.04

RSA 400-A:15, I; RSA 400-A:17; RSA 541-A:16, I(b)(3)

Ins 210.05

RSA 400-A:15, I; RSA 541-A:6

Ins 210.06

RSA 400-A:15, I; RSA 400-A:17; RSA 541-A:16, I.; RSA 541-A:11, VII

Ins 211.01

RSA 400-A:15, I; RSA 541-A:22, IV

History

(See Revision Note at chapter heading for Ins 200) #13073-A, eff 7-27-20

Chapter Ins 300 Life Insurance

Part Ins 301 Life Insurance Solicitation

N.H. Code Admin. R. Ann. Ins 301.01 Purpose {#sec-ins-301.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.01}

(a) The purpose of this part is to require insurers to deliver to purchasers of life insurance, information that will improve the buyer's ability to select the most appropriate plan of life insurance for the buyer’s needs and improve the buyer's understanding of the basic features of the policy that has been purchased or is under consideration.

(b) This part does not prohibit the use of additional material that is not a violation of this part or any other New Hampshire statute or rule.

History

#5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#9651, eff 2-5-10; ss by #12423, eff 2-5-18; ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.02 Scope {#sec-ins-301.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.02}

(a) Except as hereafter exempted, this part shall apply to any solicitation, negotiation, or procurement of life insurance occurring within this state. This part shall apply to any issuer of life insurance contracts including fraternal benefit societies.

(b) This part shall not apply to:

(1) Individual and group annuity contracts;

(2) Credit life insurance;

(3) Group life insurance, except for disclosures relating to preneed funeral contracts or prearrangements; these disclosure requirements shall extend to the issuance or delivery of certificates as well as to the master policy; or

(4) Life insurance policies issued in connection with pension and welfare plans as defined by and which are subject to the federal Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. Section 1001 et seq. as amended.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-5-10
#9651, eff 2-5-10; ss by #12423, eff 2-5-18; ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.03 Definitions {#sec-ins-301.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.03}

For the purposes of this part, the following definitions shall apply:

(a) “Buyer’s Guide” means the National Association of Insurance Commissioner’s approved Life Insurance Buyer’s Guide, available as referenced in Appendix B;

(b) “Current scale of nonguaranteed elements” means a formula or other mechanism that produces values for an illustration as if there is no change in the basis of those values after the time of illustration;

(d) “Nonguaranteed elements” means the premiums, credited interest rates, including any bonus, benefits, values, non-interest based credits, charges, or elements of formulas used to determine any of these, that are subject to company discretion and are not guaranteed at issue. An element is considered nonguaranteed if any of the underlying nonguaranteed elements are used in its calculation;

(e) “Policy data” means a display or schedule of numerical values, both guaranteed and nonguaranteed for each policy year, or a series of designated policy years, of the following information:

(1) Illustrated annual, other periodic, and terminal dividend;

(2) Premiums;

(3) Death benefits;

(4) Cash surrender values; and

(5) Endowment benefits;

(f) "Policy summary" means a written statement describing the elements of the policy, including, but not limited to:

(1) A prominently placed title as follows: “STATEMENT OF POLICY COST AND BENEFIT INFORMATION”;

(2) The name and address of the insurance producer or, if no producer is involved, a statement of the procedure to be followed in order to receive responses to inquiries regarding the policy summary;

(3) The full name and home office or administrative office address of the company in which the life insurance policy is to be or has been written;

(4) The generic name of the basic policy and each rider;

(5) The following amounts, where applicable, for the first 5 policy years and representative policy years thereafter sufficient to clearly illustrate the premium and benefit patterns, including at least one age from 60 through 65 and policy maturity:

a. The annual premium for the basic policy;

b. The annual premium for each optional rider;

c. The amount payable upon death at the beginning of the policy year regardless of the cause of death, other than suicide or other specifically enumerated exclusions, that is provided by the basic policy and each optional rider, with benefits provided under the basic policy and each rider shown separately;

d. The total guaranteed cash surrender values at the end of the year with values shown separately for the basic policy and each rider; and

e. Any endowment amounts payable under the policy that are not included under cash surrender values above;

(6) The effective policy loan annual percentage interest rate, if the policy contains this provision, specifying whether this rate is applied in advance or in arrears. If the policy loan interest rate is adjustable, the policy summary shall also indicate that the annual percentage rate will be determined by the company in accordance with the provisions of the policy and the applicable law; and

(7) The date on which the policy summary is prepared.

(g) "Preneed funeral contract or prearrangement" means an agreement by or for an individual before that individual's death relating to the purchase or provision of specific funeral or cemetery merchandise or services.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01; amd by #7536, eff 8-1-01; paragraphs (a)-(f) EXPIRED: 2-16-09; paragraph (g) EXPIRED: 8-1-09
#9651, eff 2-5-10; ss by #12423, eff 2-5-18; ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.04 Duties of Insurers {#sec-ins-301.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.04}

(a) Requirements applicable generally shall be as follows:

(1) The insurer shall provide a Buyer’s Guide to all prospective purchasers prior to accepting the applicant's initial premium or premium deposit. Except, if the policy for which application is made contains an unconditional refund provision of at least 10 days, the Buyer’s Guide may be delivered with the policy or prior to delivery of the policy; and

(2) The insurer shall provide:

a. A policy summary to prospective purchasers where the insurer has identified the policy form as one that will not be marketed with an illustration;

b. That the policy summary shall show guarantees only;

c. That the policy summary shall consist of a separate document with all required information set out in a manner that does not minimize or render any portion of the summary obscure;

d. That any amounts that remain level for 2 or more years of the policy may be represented by a single number if it is clearly indicated what amounts are applicable for each policy year. Amounts in Ins 301.03(f)(5) shall be listed in total, not on a per thousand or per unit basis; and

e. If more than one insured is covered under one policy or rider:

Death benefits shall be displayed separately for each insured or for each class of insureds if death benefits do not differ within the class;
Zero amounts shall be displayed as a blank space; and
Delivery of the policy summary shall be consistent with the time for delivery of the Buyer’s Guide as specified in (a)(1) above;

(b) Requirements applicable to existing policies:

(1) Upon request by the policy owner, the insurer shall furnish either policy data or an in force illustration as follows:

a. For policies issued prior to the 2017 effective date of Ins 309, the insurer shall furnish policy data or, at its option, an in force illustration meeting the requirements of Ins 309;

b. For policies issued after the 2017 effective date of Ins 309 that were declared not to be used with an illustration, the insurer shall furnish policy data, limited to guaranteed values, if it has chosen not to furnish an in force illustration meeting the requirements of this rule;

c. If the policy was issued after the 2017 effective date of Ins 309 and declared to be used with an illustration, an in force illustration shall be provided;

d. Unless otherwise requested, the policy data shall be provided for 20 consecutive years beginning with the previous policy anniversary. The statement of policy data shall include nonguaranteed elements according to the current scale, the amount of outstanding policy loans, and the current policy loan interest rate. Policy values shown shall be based on the current application of nonguaranteed elements in effect at the time of the request. The insurer shall not charge a fee for the preparation of the statement;

(2) If a life insurance company changes its method of determining scales of nonguaranteed elements on existing policies, it shall, no later than when the first payment is made on the new basis, advise each affected policy owner residing in this state of this change and of its implication on affected policies. This requirement shall not apply to policies for which the amount payable upon death under the basic policy as of the date when advice would otherwise be required does not exceed $5,000; and

(3) If the insurer makes a material revision in the terms and conditions under which it will limit its right to change any nonguaranteed factor, it shall, no later than the first policy anniversary following the revision, advise each affected policy owner residing in this state.

History

#1900, eff 1-1-82; amd by #2141, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#9651, eff 2-5-10; ss by #12423, eff 2-5-18; ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.05 Preneed Funeral Contracts or Prearrangements Funded in Whole or in Part by Life Insurance {#sec-ins-301.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.05}

The following information shall be adequately disclosed at the time an application is made, prior to accepting the applicant's initial premium or deposit, for a preneed funeral contract or prearrangement that is funded or to be funded by a life insurance policy:

(a) The fact that a life insurance policy is involved or being used to fund a prearrangement;

(b) The nature of the relationship among the soliciting producer or producers, the provider of the funeral or cemetery merchandise or services, the administrator, and any other person;

(c) The relationship of the life insurance policy to the funding of the prearrangement, and the nature and existence of any guarantees relating to the prearrangement;

(d) The impact on the prearrangement:

(1) Of any changes in the life insurance policy, including but not limited to changes in the assignment, beneficiary designation, or use of the proceeds;

(2) Of any penalties to be incurred by the policyholder as a result of failure to make premium payments; and

(3) Of any penalties to be incurred or monies to be received as a result of cancellation or surrender of the life insurance policy.

(e) A list of the merchandise and services which are applied or contracted for in the prearrangement and all relevant information concerning the price of the funeral services, including an indication that the purchase price is either guaranteed at the time of purchase or to be determined at the time of need;

(f) All relevant information concerning what occurs and whether any entitlements or obligations arise if there is a difference between the proceeds of the life insurance policy and the amount actually needed to fund the prearrangement;

(g) Any penalties or restrictions, including but not limited to geographic restrictions or the inability of the provider to perform, on the delivery of merchandise, services, or the prearrangement guarantee;

(h) If so, the fact that a sales commission or other form of compensation is being paid and the identity of the individuals or entities to whom it is paid; and

(i) Additional disclosure requirements:

(1) An insurer issuing a small face amount policy, where over the term of the policy the cumulative policy premiums paid may exceed the face amount of the policy, shall clearly and prominently disclose, on or before policy delivery, the length of time until the cumulative policy premiums paid may exceed the face amount of the policy;

(2) The insurer shall clearly and prominently disclose, on or before policy delivery, available premium payment plans;

(3) Cumulative premiums shall include premiums paid for riders except, the face amount shall not include the benefit attributable to the riders;

(4) Each policy subject to the disclosure requirements of this section shall contain a provision that allows the policyholder to cancel the policy within 10 days following the delivery of the policy with full premium refund to the consumer and with no charge or penalty. The free-look period shall be clearly and prominently disclosed to the consumer; and

(5) If the policy uses graded benefits, they shall be disclosed to the applicant prior to entry into the contract. The policy shall also provide that graded death benefits life insurance policies shall pay the policy face value after 2 years of premium payments.

History

#1900, eff 1-1-82; amd by #2141, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#9651, eff 2-5-10; ss by #12423, eff 2-5-18; ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.06 Solicitation of Life Insurance General Rules {#sec-ins-301.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.06}

(a) Each insurer shall maintain at its home office or principal office a complete file containing one copy of each document authorized and used by the insurer pursuant to this part. The file shall contain one copy of each authorized form for a period of 5 years following the date of its last authorized use unless otherwise provided by Ins 301. Insurers must also comply with RSA 400-B:4 and Ins 2602.

(b) A producer shall inform the prospective purchaser, prior to commencing a life insurance sales presentation, that they are acting as a life insurance producer and inform the prospective purchaser of the full name of the insurance company which the producer is representing to the buyer. In sales situations in which a producer is not involved, the insurer shall identify its full name.

(c) An insurance producer shall not use terms such as “financial planner”, “investment advisor”, “financial consultant”, or “financial counseling” in such a way as to imply that they are primarily engaged in an advisory business in which compensation is unrelated to sales, unless that is actually the case and the producer otherwise complies with RSA 402-J:3 and RSA 405:44-a. This provision is not intended to:

(1) Preclude persons who hold some form of formally recognized financial planning or consultant designation from using this designation even when they are only selling insurance;

(2) Preclude persons who are members of a recognized trade or professional association having such terms as part of its name from citing membership, providing that a person citing membership, if authorized only to sell insurance products, shall disclose that fact; or

(3) Permit persons to charge an additional fee for services that are customarily associated with the solicitation, negotiation, or servicing of policies.

(d) Any reference to nonguaranteed elements shall include a statement that the item is not guaranteed and is based on the company's current scale of nonguaranteed elements using the appropriate special term such as "current dividend" or "current rate" scale. If a nonguaranteed element would be reduced by the existence of a policy loan, a statement to that effect shall be included in any reference to nonguaranteed elements. A presentation or depiction of a policy issued after the effective date of 2017 Ins 309 that includes nonguaranteed elements over a period of years shall be governed by Ins 301. Solicitations pertaining to nonguaranteed elements shall also comply with Ins 2602.05(o).

History

#1900, eff 1-1-82; amd by #2141, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#9651, eff 2-5-10; ss by #12423, eff 2-5-18; ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.07 Suitability of Recommendation or Sale {#sec-ins-301.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.07}

Reasonable inquiry shall be made by insurers and producers to determine the suitability of any recommendations or sales, and all replacement of life insurance policies shall comply with Ins 302.

History

#1900, eff 1-1-82; amd by #2141, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01; amd by renumbering and deleting paragraph (h) and renumbering paragraphs (l) and (m) as (k) and (l) #7536, eff 8-1-01 (formerly Ins 301.09); paragraphs (a)-(l) EXPIRED: 2-16-09
#9651, eff 2-5-10; ss by #12423, eff 2-5-18; ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.08 Failure to Comply {#sec-ins-301.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.08}

Failure of an insurer to provide or deliver a Buyer’s Guide, an in force illustration, a policy summary, and policy data as provided in Ins 301.04 shall constitute an omission which misrepresents the benefits, advantages, conditions, or terms of an insurance policy and be subject to the penalties contained in RSA 400-A:15 and RSA 417:10.

History

#9651, eff 2-5-10; ss by #12423, eff 2-5-18 (from Ins 301.07); 18; ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.09 Electronic Sales {#sec-ins-301.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.09}

Electronic sales of life insurance as described in RSA 420-Q shall be subject to the identical disclosure and record keeping requirements as non-electronic sales.

History

#12423, eff 2-5-18 (from Ins 301.08); ss by #13691, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 301.10 Waiver or Suspension of Rules {#sec-ins-301.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 301.10}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) Waivers that are granted shall be in effect for the period of time requested and approved by the commissioner.

History

#12423, eff 2-5-18; ss by #13691, eff 7-21-23

Part Ins 302 Life Insurance and Annuities Replacement

N.H. Code Admin. R. Ann. Ins 302.01 Purpose {#sec-ins-302.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.01}

(a) The purpose of this part is:

(1) To regulate the activities of insurers and producers with respect to the replacement of existing life insurance and annuities; and

(2) To protect the interests of life insurance and annuity purchasers by establishing minimum standards of conduct to be observed in replacement or financed purchase transactions. It will:

a. Assure that purchasers receive information with which a decision can be made in their own best interest;

b. Reduce the opportunity for misrepresentation and incomplete disclosure; and

c. Establish penalties for failure to comply with requirements of this part.

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.02 Scope {#sec-ins-302.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.02}

(a) Unless otherwise specifically included, this part shall not apply to transactions involving:

(1) Credit life insurance;

(2) Group life insurance or group annuities where there is no direct solicitation of individuals by an insurance producer. Direct solicitation shall not include any group meeting held by an insurance producer solely for the purpose of educating or enrolling individuals or, when initiated by an individual member of the group, assisting with the selection of investment options offered by a single insurer in connection with enrolling that individual. Group life insurance or group annuity certificates marketed through direct response solicitation shall be subject to the provisions of Ins 302.08;

(3) Group life insurance and annuities used to fund prearranged funeral contracts;

(4) An application to the existing insurer that issued the existing policy or contract when a contractual change or a conversion privilege is being exercised; or, when the existing policy or contract is being replaced by the same insurer pursuant to a program filed with and approved by the commissioner; or, when a term conversion privilege is exercised among corporate affiliates;

(5) Proposed life insurance that is to replace life insurance under a binding or conditional receipt issued by the same company;

(6) Policies or contracts used to fund:

a. An employee pension or welfare benefit plan that is covered by the Employee Retirement and Income Security Act (ERISA);

b. A plan described by Sections 401(a), 401(k) or 403(b) of the Internal Revenue Code where the plan, for purposes of ERISA, is established or maintained by an employer;

c. A governmental or church plan defined in Section 414, a governmental or church welfare benefit plan, or a deferred compensation plan of a state or local government or tax exempt organization under Section 457 of the Internal Revenue Code; or

d. A nonqualified deferred compensation arrangement established or maintained by an employer or plan sponsor;

(7) Notwithstanding subparagraph (6) above, this rule shall apply to policies or contracts used to fund any plan or arrangement that is funded solely by contributions an employee elects to make, whether on a pre-tax or after-tax basis, and where the insurer has been notified that plan participants may choose from among 2 or more insurers and there is a direct solicitation of an individual employee by an insurance producer for the purchase of a contract or policy. As used in this subsection, direct solicitation shall not include any group meeting held by an insurance producer solely for the purpose of educating individuals about the plan or arrangement or enrolling individuals in the plan or arrangement or, when initiated by an individual employee, assisting with the selection of investment options offered by a single insurer in connection with enrolling that individual employee;

(8) Where new coverage is provided under a life insurance policy or contract and the cost is borne wholly by the insured’s employer or by an association of which the insured is a member;

(9) Existing life insurance that is a non-convertible term life insurance policy that will expire in 5 years or less and cannot be renewed; or

(10) Structured settlements.

(b) Registered contracts shall be exempt from the requirements of Ins 302.06(a)(2) and Ins 302.07(a)(1) with respect to the provision of illustrations or policy summaries; however, premium or contract contribution amounts and identification of the appropriate prospectus or offering circular shall be required instead.

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.03 Definitions {#sec-ins-302.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.03}

(a) “Direct-response solicitation” means a solicitation through a sponsoring or endorsing entity or individually solely through mails, telephone, the Internet, or other mass communication media.

(b) “Existing insurer” means the insurance company whose policy or contract is or will be changed or affected in a manner described within the definition of “replacement”.

(c) “Existing policy or contract” means an individual life insurance policy or annuity contract in force, including a policy under a binding or conditional receipt or a policy or contract that is within an unconditional refund period.

(d) “Financed purchase” means the purchase of a new policy involving the actual or intended use of funds obtained by the withdrawal or surrender of, or by borrowing from values of an existing policy to pay all or part of any premium due on the new policy. For purposes of a regulatory review of an individual transaction only, if a withdrawal, surrender or borrowing involving the policy values of an existing policy is used to pay premiums on a new policy owned by the same policyholder and issued by the same company within 4 months before or 13 months after the effective date of the new policy, it will be deemed prima facie evidence of the policyholder’s intent to finance the purchase of the new policy with existing policy values. This prima facie standard is not intended to increase or decrease the monitoring obligations contained in Ins 302.05(a)(5).

(e) “Illustration” means a presentation or depiction that includes non-guaranteed elements of a policy of life insurance over a period of years as defined in Ins 309.

(f) “Policy summary” means:

(1) For policies or contracts other than universal life policies, means a written statement regarding a policy or contract which shall contain to the extent applicable, but need not be limited to, the following information:

a. Current death benefit;

b. Annual contract premium;

c. Current cash surrender value;

d. Current dividend;

e. Application of current dividend; and

f. Amount of outstanding loan;

(2) For universal life policies, means a written statement that shall contain at least the following information:

a. The beginning and end date of the current report period;

b. The policy value at the end of the previous report period and at the end of the current report period;

c. The total amounts that have been credited or debited to the policy value during the current report period, identifying each type, such as interest, mortality, expense, and riders;

d. The current death benefit at the end of the current report period on each life covered by the policy;

e. The net cash surrender value of the policy as of the end of the current report period; and

f. The amount of outstanding loans, if any, as of the end of the current report period.

(g) “Producer” shall be defined to include agents, brokers, and producers.

(h) “Replacing insurer” means the insurance company that issues or proposes to issue a new policy or contract that replaces an existing policy or contract or is a financed purchase.

(i) “Registered contract” means a variable annuity contract or variable life insurance policy subject to the prospectus delivery requirements of the Securities Act of 1933.

(j) “Replacement” means a transaction in which a new policy or contract is to be purchased, and it is known or should be known to the proposed producer, or to the proposing insurer if there is no producer, that by reason of the transaction, an existing policy or contract has been or is to be:

(1) Lapsed, forfeited, surrendered, or partially surrendered, assigned to the replacing insurer or otherwise terminated;

(2) Converted to reduced paid-up insurance, continued as extended term insurance, or otherwise reduced in value by the use of nonforfeiture benefits or other policy values;

(3) Amended so as to effect either a reduction in benefits or in the term for which coverage would otherwise remain in force or for which benefits would be paid;

(4) Reissued with any reduction in cash value; or

(5) Used in a financed purchase.

(k) “Sales material” means a sales illustration and any other written, printed, or electronically presented information created, or completed or provided by the company or producer and used in the presentation to the policy or contract owner related to the policy or contract purchased.

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.04 Duties of Producers {#sec-ins-302.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.04}

(a) A producer who initiates an application shall submit to the insurer, with or as part of the application, a statement signed by both the applicant and the producer as to whether the applicant has existing policies or contracts. If the answer is “no,” the producer’s duties with respect to replacement are complete.

(b) If the applicant answered “yes” to the question regarding existing coverage referred to in (a) above, the producer shall present and read to the applicant not later than at the time of taking the application, a notice regarding replacements in the form as described in Appendix A or other substantially similar form approved by the commissioner. However, no approval shall be required when amendments to the notice are limited to the omission of references not applicable to the product being sold or replaced. The notice shall be signed by both the applicant and the producer attesting that the notice has been read aloud by the producer or that the applicant did not wish the notice to be read aloud (in which case the producer need not have read the notice aloud) and left with the applicant.

(c) The notice shall list all life insurance policies or annuities proposed to be replaced, properly identified by name of insured, the insurer or annuitant, and policy or contract number if available; and shall include a statement as to whether each policy or contract will be replaced or whether a policy will be used as a source of financing for the new policy or contract. If a policy or contract number has not been issued by the existing insurer, alternative identification, such as an application or receipt number, shall be listed.

(d) In connection with a replacement transaction the producer shall leave with the applicant at the time an application for a new policy or contract is completed the original or a copy of all sales material. With respect to electronically presented sales material, it shall be provided to the policy or contract owner in printed form no later than at the time of policy or contract delivery.

(e) Except as provided in Ins 302.06(c), in connection with a replacement transaction, the producer shall submit to the insurer, to which an application for a policy or contract is presented, a copy of each document required by this section, a statement identifying any preprinted or electronically presented company approved sales materials used, and copies of any individualized sales materials, including any illustrations related to the specific policy or contract purchased.

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.05 Duties of Insurers that Use Producers {#sec-ins-302.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.05}

(a) Each insurer shall maintain a system of supervision and control to insure compliance with the requirements of this rule that shall include at least the following:

(1) Inform its producers of the requirements of this rule and incorporate the requirements of this rule into all relevant producer training manuals prepared by the insurer;

(2) Provide to each producer a written statement of the company’s position with respect to the acceptability of replacements providing guidance to its producer as to the appropriateness of these transactions;

(3) A system to review the appropriateness of each replacement transaction that the producer does not indicate is in accord with paragraph (2) above;

(4) Procedures to confirm that the requirements of this rule have been met; and

(5) Procedures to detect transactions that are replacements of existing policies or contracts by the existing insurer, but that have not been reported as such by the applicant or producer. Compliance with this rule may include, but shall not be limited to, systematic customer surveys, interviews, confirmation letters, or programs of internal monitoring.

(b) Each insurer shall have the capacity to monitor each producer’s life insurance policy and annuity contract replacements for that insurer, and shall produce, upon request, and make such records available to the department. The capacity to monitor shall include the ability to produce records for each producer’s:

(1) Life replacements, including financed purchases, as a percentage of the producer’s total annual sales for life insurance;

(2) Number of lapses of policies by the producer as a percentage of the producer’s total annual sales for life insurance;

(3) Annuity contract replacements as a percentage of the producer’s total annual annuity contract sales;

(4) Number of transactions that are unreported replacements of existing policies or contracts by the existing insurer detected by the company’s monitoring system as required by (a)(5) above; and

(5) Replacements, indexed by replacing producer and existing insurer.

(c) Each insurer shall require with or as a part of each application for life insurance or an annuity a signed statement by both the applicant and the producer as to whether the applicant has existing policies or contracts.

(d) Each insurer shall require with each application for life insurance or an annuity that indicates an existing policy or contract a completed notice regarding replacements as contained in Appendix A.

(e) When the applicant has existing policies or contracts, each insurer shall be able to produce copies of any sales material required by Ins 302.04(e), the basic illustration and any supplemental illustrations related to the specific policy or contract that is purchased, and the producer’s and applicant’s signed statements with respect to financing and replacement for at least 5 years after the termination or expiration of the proposed policy or contract.

(f) Each insurer shall ascertain that the sales material and illustrations required by Ins 302.04(e) of this rule meet the requirements of this rule and are complete and accurate for the proposed policy or contract.

(g) If an application does not meet the requirements of this rule, notify the producer and applicant and fulfill the outstanding requirements.

(h) Each insurer shall maintain records in paper, photograph, microprocess, magnetic, mechanical, or electronic media or by any process that accurately reproduces the actual document.

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.06 Duties of Replacing Insurers that Use Producers {#sec-ins-302.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.06}

(a) Where a replacement is involved in the transaction, the replacing insurer shall:

(1) Verify that the required forms are received and are in compliance with this rule;

(2) Notify any other existing insurer that may be affected by the proposed replacement within 5 business days of receipt of a completed application indicating replacement or when the replacement is identified, if not indicated on the application, and mail a copy of the available illustration or policy summary for the proposed policy or available disclosure document for the proposed contract within 5 business days of a request from an existing insurer;

(3) Be able to produce copies of the notification regarding replacement required in Ins 302.04(b), indexed by producer, for at least 5 years or until the next regular examination by the insurance department of a company’s state of domicile, whichever is later; and

(4) Provide to the policy or contract owner notice of the right to return the policy or contract within 30 days of the delivery of the contract and receive an unconditional full refund of all premiums or considerations paid on it, including any policy fees or charges or, in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender value provided under the policy or contract plus the fees and other charges deducted from the gross premiums or considerations imposed under such policy or contract; such notice may be included in Appendix A or C.

(b) In transactions where the replacing insurer and the existing insurer are the same or subsidiaries or affiliates under common ownership or control, allow credit for the period of time that has elapsed under the replaced policy’s or contract’s incontestability and suicide period up to the face amount of the existing policy or contract. With regard to financed purchases, the credit may be limited to the amount the face amount of the existing policy is reduced by the use of existing policy values to fund the new policy or contract.

(c) If an insurer prohibits the use of sales material other than that approved by the company, as an alternative to the requirements made of an insurer pursuant to Ins 302.04(e), the insurer may:

(1) Require with each application a statement signed by the producer that:

a. Represents that the producer used only company-approved sales material; and

b. States that copies of all sales material were left with the applicant in accordance with Ins 302.04(d);

(2) Within 10 days of the issuance of the policy or contract:

a. Notify the applicant by sending a letter or by verbal communication with the applicant by a person whose duties are separate from the marketing area of the insurer, that the producer has represented that copies of all sales material have been left with the applicant in accordance with Ins 302.04(d);

b. Provide the applicant with a toll free number to contact company personnel involved in the compliance function if such is not the case; and

c. Stress the importance of retaining copies of the sales material for future reference; and

(3) Be able to produce a copy of the letter or other verification in the policy file for at least 5 years after the termination or expiration of the policy or contract.

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.07 Duties of the Existing Insurer {#sec-ins-302.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.07}

(a) Where a replacement is involved in the transaction, the existing insurer shall:

(1) Retain and be able to produce all replacement notifications received, indexed by replacing insurer, for at least 5 years or until the conclusion of the next regular examination conducted by the insurance department of its state of domicile, whichever is later;

(2) Send a letter to the policy or contract owner of the right to receive information regarding the existing policy or contract values including, if available, an in force illustration or policy summary if an in force illustration cannot be produced within 5 business days of receipt of a notice that an existing policy or contract is being replaced. The information shall be provided within 5 business days of receipt of the request from the policy or contract owner; and

(3) Upon receipt of a request to borrow, surrender or withdraw any policy values, send a notice, advising the policy owner that the release of policy values may affect the guaranteed elements, non-guaranteed elements, face amount or surrender value of the policy from which the values are released. The notice shall be sent separate from the check if the check is sent to anyone other than the policy owner. In the case of consecutive automatic premium loans, the insurer is only required to send the notice at the time of the first loan.

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.08 Duties of Insurers with Respect to Direct Response Solicitations {#sec-ins-302.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.08}

(a) In the case of an application that is initiated as a result of a direct response solicitation, the insurer shall require, with or as part of each completed application for a policy or contract, a statement asking whether the applicant, by applying for the proposed policy or contract, intends to replace, discontinue or change an existing policy or contract. If the applicant indicates a replacement or change is not intended or if the applicant fails to respond to the statement, the insurer shall send the applicant, with the policy or contract, a notice regarding replacement in Appendix B, or other substantially similar form approved by the commissioner.

(b) If the insurer has proposed the replacement or if the applicant indicates a replacement is intended and the insurer continues with the replacement, the insurer shall:

(1) Provide to applicants or prospective applicants with the policy or contract a notice, as described in Appendix C, or other substantially similar form approved by the commissioner. In these instances the insurer may delete the references to the producer, including the producer’s signature, and references not applicable to the product being sold or replaced, without having to obtain approval of the form from the commissioner. The insurer’s obligation to obtain the applicant’s signature shall be satisfied if it can demonstrate that it has made a diligent effort to secure a signed copy of the notice referred to in this paragraph. The requirement to make a diligent effort shall be deemed satisfied if the insurer includes in the mailing a self-addressed postage prepaid envelope with instructions for the return of the signed notice referred to in this section; and

(2) Comply with the requirements of Ins 302.06(a)(2), if the applicant furnishes the names of the existing insurers, and the requirements of Ins 302.06(a)(3), Ins 302.06(a)(4), and Ins 302.06(b).

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.09 Violations and Penalties {#sec-ins-302.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.09}

(a) Any failure to comply with this rule shall be considered a violation of RSA 417:4. Examples of violations include:

(1) Any deceptive or misleading information set forth in sales material;

(2) Failing to ask the applicant in completing the application the pertinent questions regarding the possibility of financing or replacement;

(3) The intentional incorrect recording of an answer;

(4) Advising an applicant to respond negatively to any questions regarding replacement in order to prevent notice to the existing insurer; or

(5) Advising a policy or contract owner to write directly to the company in such a way as to attempt to obscure the identity of the replacing producer or company.

(b) Policy and contract owners have the right to replace existing life insurance policies or annuity contracts after indicating in or as a part of applications for new coverage that replacement is not their intention; however, patterns of such action by policy or contract owners of the same producer shall be deemed prima facie evidence of the producer’s knowledge that replacement was intended in connection with the identified transactions, and these patterns of action shall be deemed prima facie evidence of the producer’s intent to violate this rule.

(c) Where it is determined that the requirements of this rule have not been met, the replacing insurer shall provide to the policy owner an in force illustration, if available, or policy summary for the replacement policy or available disclosure document for the replacement contract and the appropriate notice regarding replacements in Appendix A or C.

(d) Any violations of these rules shall be subject to the penalties imposed by RSA 402-J:12 and RSA 417:10 or subject to such suspension or revocation of certificate of authority or license, or administrative fine not to exceed $2,500 per violation, as may be applicable under Title XXXVII.

History

#7537, eff 8-1-01; ss by #9571, eff 10-21-09; ss by #12375, eff 10-21-17

N.H. Code Admin. R. Ann. Ins 302.10 Waiver or Suspension of Rules {#sec-ins-302.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 302.10}

(a) The commissioner, upon the commissioner’s own initiative or upon request by an insurer, shall waive any requirement of Ins 302 if such waiver does not contradict the objective or intent of the rule and:

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX A

IMPORTANT NOTICE:

REPLACEMENT OF LIFE INSURANCE OR ANNUITIES

This document must be signed by the applicant and the producer, if there is one,

and a copy left with the applicant.

You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements.

A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.

A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement.

You should carefully consider whether a replacement is in your best interests. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured.

We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form.

Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? ___YES ___NO
Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? ___YES ___NO

If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing:

INSURER NAME CONTRACT OR INSURED OR REPLACED (R) OR

POLICY # ANNUITANT FINANCING (F)

Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision.

The existing policy or contract is being replaced because _____________________________________

I certify that the responses herein are, to the best of my knowledge, accurate:

Applicant’s Signature and Printed Name Date

Producer’s Signature and Printed Name Date

I do not want this notice read aloud to me.____ (Applicants must initial only if they do not want the notice read aloud.)

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense:

PREMIUMS: Are they affordable?

Could they change?

You’re older – are premiums higher for the proposed new policy?

How long will you have to pay premiums on the new policy? On the old policy?

POLICY VALUES: New policies usually take longer to build cash values and to pay dividends.

Acquisition costs for the old policy may have been paid, you will incur costs for the new one.

What surrender charges do the policies have?

What expense and sales charges will you pay on the new policy?

Does the new policy provide more insurance coverage?

INSURABILITY: If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down.

You may need a medical exam for a new policy.

Claims on most new policies for up to the first two years can be denied based

on inaccurate statements.

Suicide limitations may begin anew on the new coverage.

IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:

How are premiums for both policies being paid?

How will the premiums on your existing policy be affected?

Will a loan be deducted from death benefits?

What values from the old policy are being used to pay premiums?

IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT:

Will you pay surrender charges on your old contract?

What are the interest rate guarantees for the new contract?

Have you compared the contract charges or other policy expenses?

OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:

What are the tax consequences of buying the new policy?

Is this a tax free exchange? (See your tax advisor.)

Is there a benefit from favorable “grandfathered” treatment of the old policy under the federal tax code?

Will the existing insurer be willing to modify the old policy?

How does the quality and financial stability of the new company compare with your existing company?

APPENDIX B

NOTICE REGARDING REPLACEMENT

REPLACING YOUR LIFE INSURANCE POLICY OR ANNUITY?

Are you thinking about buying a new life insurance policy or annuity and discontinuing or changing an existing one? If you are, your decision could be a good one – or a mistake. You will not know for sure unless you make a careful comparison of your existing benefits and the proposed policy or contract’s benefits.

Make sure you understand the facts. You should ask the company or agent that sold you your existing policy or contract to give you information about it.

Hear both sides before you decide. This way you can be sure you are making a decision that is in your best interest.

APPENDIX C

IMPORTANT NOTICE:

REPLACEMENT OF LIFE INSURANCE OR ANNUITIES

We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form.

Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? ___YES ___NO
Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? ___YES ___NO

INSURER NAME CONTRACT OR INSURED OR REPLACED (R) OR

POLICY # ANNUITANT FINANCING (F)

I certify that the responses herein are, to the best of my knowledge, accurate:

Applicant’s Signature and Printed Name Date

PREMIUMS: Are they affordable?

Could they change?

You’re older – are premiums higher for the proposed new policy?

How long will you have to pay premiums on the new policy? On the old policy?

POLICY VALUES: New policies usually take longer to build cash values and to pay dividends.

Acquisition costs for the old policy may have been paid, you will incur costs for the new one.

What surrender charges do the policies have?

What expense and sales charges will you pay on the new policy?

Does the new policy provide more insurance coverage?

INSURABILITY: If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down.

You may need a medical exam for a new policy.

Claims on most new policies for up to the first two years can be denied based on inaccurate statements.

Suicide limitations may begin anew on the new coverage.

IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:

How are premiums for both policies being paid?

How will the premiums on your existing policy be affected?

Will a loan be deducted from death benefits?

What values from the old policy are being used to pay premiums?

IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT:

Will you pay surrender charges on your old contract?

What are the interest rate guarantees for the new contract?

Have you compared the contract charges or other policy expenses?

OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:

What are the tax consequences of buying the new policy?

Is this a tax free exchange? (See your tax advisor.)

Is there a benefit from favorable “grandfathered” treatment of the old policy under the federal tax code?

Will the existing insurer be willing to modify the old policy?

How does the quality and financial stability of the new company compare with your existing company?

History

#12375, eff 10-21-17

Part Ins 303 Deposit Term Life Insurance

N.H. Code Admin. R. Ann. Ins 303.01 Purpose {#sec-ins-303.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 303.01}

The purpose of this part is to require insurance companies and agents to disclose certain information to purchasers of deposit term life insurance products prior to the consummation of the sale in order to guarantee that deposit term life insurance products are properly sold by the agent and fully explained to the buyer.

History

#7450, eff 2-16-01

N.H. Code Admin. R. Ann. Ins 303.02 Scope {#sec-ins-303.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 303.02}

(a) This part shall apply to all policies or plans of life insurance defined in Ins 303.03(a) as deposit term life insurance.

(b) This part does not prohibit the use of additional material which is not in violation of this part or any other statute or part.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01

N.H. Code Admin. R. Ann. Ins 303.03 Definitions {#sec-ins-303.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 303.03}

(a) "Commissioner" means the insurance commissioner of the state of New Hampshire.

(b) "Deposit term life insurance" means those policies or plans which provide that an additional first year premium shall be paid in order that certain values and options will be available at the end of the initial term period or upon a specific policy anniversary and which additional first year premium is typically forfeited, in whole or in part, if the policy terminates for any reason in its early years other than for death of the insured deposit term life insurance includes term insurance, modified premium term insurance and modified premium whole life insurance.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01

N.H. Code Admin. R. Ann. Ins 303.04 Advertising and Solicitation Requirements {#sec-ins-303.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 303.04}

(a) No insurer, agent, broker or any such person shall make any statement in any form in any sales presentation or advertisement for a deposit term life insurance policy which:

(1) Indicates or implies that the additional first year premium is or resembles a form of interest-bearing savings or investment;

(2) Indicates or implies that the pure endowment benefit of any such policy is or resembles a return of the additional first year premium together with an accumulation of interest;

(3) Describes the additional first year premium as a deposit; or

(4) Depicts a deposit term policy as a low cost policy or as a policy that will enable the purchaser to save money unless actual premiums or cost indexes are shown or presented in conjunction with that statement.

(b) Any written material presented in conjunction with a sales presentation or proposal coupling a deposit term life insurance policy with any form of side investment, including but not limited to deferred annuity contract, retirement deposit fund rider, and mutual funds, and which shows figures illustrating the premiums payable, the cash values and the death benefits shall show the figures for the deposit term life

insurance policy and the side investment in separate and distinct columns. Where the above figures are shown in separate and distinct columns, it shall be permissible to include columns combining these figures.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01

N.H. Code Admin. R. Ann. Ins 303.05 Disclosure Requirements {#sec-ins-303.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 303.05}

(a) Prior to taking an application for a deposit term life insurance policy, the insurer, agent, broker or any other such person shall present to the applicant a completed Disclosure Statement for Policy with an Additional First Year Premium, the substance and format of which shall be substantially the same as that shown in Table 303-1. One copy of this statement, signed by the agent, shall be left with the applicant for the applicant’s records. Another copy of this statement shall be signed by the applicant as an acknowledgement of receipt and submitted with the application to the insurer.

(b) The Disclosure Statement for Policy with an Additional First Year Premium shown in Table 303-1 shall be used with the modified premium whole life type of deposit term policy on the market at the time this part became effective. It shall be appropriately altered to adapt it to other types of deposit term policies.

(1) Comply with the intent and spirit of this part; and

(2) Include a full disclosure of the following items:

a. With respect to the additional first year premium, its amount, forfeiture details, guaranteed values and ultimate disposition;

b. Face amount and premium information for at least the first 20 years;

c. Representative cash value information for the first 20 years; and

d. A complete description of each option existing under the policy at the maturity date of the pure endowment, typically, the end of the 10th policy year, to include a designation of the automatic option, if any.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01

N.H. Code Admin. R. Ann. Ins 303.06 Penalty {#sec-ins-303.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 303.06}

(a) Failure of an insurer or agent to comply with any of the requirements contained in Ins 303.04 or Ins 303.05 of this part shall be a violation of the part, subject to the penalties provided in RSA 400-A:15, subject to the requirements therein, in addition to any other penalties provided by the laws of this state.

(b) After appropriate notice and hearing, an administrative fine of $2,500 shall be levied for each finding of violation of RSA 400-A:15, III if the penalty of suspension or revocation as specified below is not appropriate.

(c) The insurer or agent may request at hearing a reduced fine or no fine imposed under (b) above through successful demonstration that:

(1) There is no or minimal damage or costs to consumers, the State or other insurance entities as a result of the violation; and

(2) The insurer or agent has not committed multiple or repeated violations.

(d) Insurers and agents shall be subject to suspension pursuant to RSA 400-A:15,III if one of the following occurs:

(1) The violation is continuing; or

(2) There is a high probability the violation will be repeated, based on findings of record; and

(3) Imposition of a penalty other than suspension, such as a fine, will not be a sufficient deterrent.

(e) Insurers and agents shall be subject to revocation pursuant to RSA 400-A:15, III if:

(1) The violative act or omission was intentional or committed in bad faith; or

(2) There was significant damage or cost to consumers, the State or other insurance entities as a result of the violation.

(f) Repeated or multiple violations of this part shall constitute separate violations subject to penalty.

Table 303-1 Disclosure Statement for Policy with an

Additional First Year Premium

You are invited to determine if your needs for a life insurance program can be adequately served by the (insert policy description) life policy being proposed. Note that this policy is designed to provide individuals with an incentive to maintain the policy in force for at least 10 full years. Conversely, it may be said that the policy design includes disincentives or penalties for individuals who lapse the policy prior to the 10 anniversary.

The premium payable in the first year is $ , and the premium payable in years two through ten is $ .

The difference between these amounts, $ , is the additional first year premium.

The cash values payable at the end of policy years one through ten under this policy are:

Policy Year Cash Value

1 $ _________________

2 $ _________________

3 $ _________________

4 $ _________________

5 $ _________________

6 $ _________________

7 $ _________________

8 $ _________________

9 $ _________________

10 $ _________________

If you choose to terminate this policy, only the cash value, less any policy loans, will be paid to you.

*Optional Benefits Included:

Premium Years Payable

Waiver of Premium $ _________ __________

Accidental Death Indemnity $ _________ __________

$ _________ __________

Policy options at the end of the 10th policy year are:

(a) Continue in 11th year as whole life policy

(b) Renew MPWL for second ten years

If the person insured or policyowner does not elect an option, the terms of the policy designate option no. ______ above as the automatic option.

The following is a brief outline of each option listed above:

Option 1. Continue as whole life insurance $ __________ face amount.

Premiums 11th year and thereafter $ __________

Cash values

10th year $ _________

15th year $ _________

20th year $ _________

Age 65 $ _________

Interest adjusted surrender cost ______%

10 years _____ 20 years _____

Disposition of pure endowment _____

Or tenth year cash value __________

Option 2. ** Renew MPWL for another 10 year $ __________

period for face amount.

Premiums per year 11th through 20th year $ _________

** Additional first year premium 11th year $ _________

only

Ten year total premiums $ _________

Guaranteed cash value after 10 years $ _________

Interest adjusted surrender cost _________%

10 years ________ 20 years _________

Disposition of pure endowment or tenth

year cash value: $ _________

*Includes rider benefits

**Death benefit is increased by additional first year premium

Option 3. Convert to decreasing term to age $ _________

100 for face amount.

Level premiums $ _________

Additional 11th year premium $ _________

Interest adjusted surrender cost %

10 years _________ 20 years _________

Disposition of pure endowment or tenth

year cash value: $ _________

You will have ten days from the day the (insert policy description) life policy is delivered to you to return it for cancellation. Should you elect to cancel, all premiums paid by you will be returned.

Insurance Company

(Insert Name)

Address:

Telephone No.

Agent's Signature

I acknowledge that I received a copy of this disclosure statement for policy with an additional first year premium on the date indicated below.

Applicant's Signature

Date

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01

Part Ins 304 Financing of Life Insurance Premiums

N.H. Code Admin. R. Ann. Ins 304.01 Premium Financing Requirements {#sec-ins-304.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 304.01}

(a) If a note is taken to finance less than the full first year premium, the balance shall be paid by the applicant at the time the application is taken.

(b) If a note is taken to finance all or part of the first year's premium, said note may be sold or otherwise negotiated or transferred by the payee with recourse only.

(c) One who becomes a payee of the note, whether that is the premium finance company, or any affiliate thereof, note purchaser, or any assignee of the note, shall notify the notemaker, the insured, and all co-makers of the note about the purchase or transfer of the note. In providing such notification, the life insurance policy, which is used as collateral for the note, shall be identified by policy number, named insured, and life insurance company.

(d) The giving of a promissory note in connection with the first premium shall be set out in the application over the applicant's signature, showing the amount of the note, the true annual rate of interest, and the amount of any downpayment made to the agent at the time of sale and, if applicable, the fact that the note becomes due and payable in full upon any default in premium payment.

(e) Any note may contain an acceleration clause to become operable not less than 31 days after default in the payment of any renewal premium. The obligation evidenced by a promissory note may be satisfied in advance of the maturity date without penalty. Where the applicant is an undergraduate college student, the maturity date of any promissory note payable in one lump sum at maturity, or the maturity date of any installment type note which provides for a balloon payment, shall not be less than 90 days after the anticipated graduation date from college of the applicant.

(f) Any downpayment shall be paid by the applicant, and any payment or reimbursement to or for the benefit of the applicant in connection with the sale, directly or indirectly, shall be presumed to be a rebate or an improper inducement.

(g) Any premium financing arrangement shall be fully set forth and described in the policy or policy rider, and a copy of any promissory note executed by the insured and any assignment thereof shall be attached to the policy.

(h) Upon delivery of the policy to the insured, a receipt or acceptance form shall be executed which recites that:

(1) The policy has been issued as represented; and

(2) The insured acknowledges and understands the obligation of the premium financing arrangement and the financial indebtedness that they have incurred.

(i) The premium finance company shall request the insured to sign and return the policy receipt or acceptance form to the company within 14 days of receipt by the insured. Such receipt or acceptance form outlined in Ins 304.01(h) shall be identified by number with the corresponding life insurance policy number and kept with other policy records of the insured in the company’s principal place of business.

(j) The blank receipts or acceptance forms referred to in Ins 304.01(h) shall not be made available to field representatives, agents, or producers but shall be furnished by the company only in transmittal of the policy to the writing agent.

(k) Until the executed policy receipt or acceptance form has been received and filed with the company, no promissory note executed by the insured shall be sold or otherwise transferred or assigned, and no commission on such sale shall be paid to any agent or producer.

(l) The maximum amount of any such premium financing arrangement which may be entered into in connection with the purchase of the policy shall be in accordance with reasonable and sound underwriting practices as determined by the company.

(m) Producers and companies shall comply with Ins 302 as to any partial or total replacement of an existing life policy that is associated with a premium finance arrangement.

(n) Producers of the company who are licensed by this state to represent the company as licensed life producers shall not represent, refer to, or hold themselves out to the public under any special title or as representatives of any special policy or company division unless otherwise identified as a licensed producer of the company for which they hold a license.

(o) In the case of a request being made by an insured expressing a desire to cancel such a policy and premium financing arrangement, the company, its agents, and its producers shall cooperate with the insured to work towards a satisfactory resolution of the matter. If such matter cannot be resolved in a timely manner, the premium finance company shall provide a notice to the insured that the insured may contact the consumer services division of the New Hampshire insurance department for assistance. Consumer services may be reached by phone at (800) 852-3416 or by email at consumerservices@ins.nh.gov.

(p) If, at the time the receipt or acceptance form is presented with the policy to the applicant for signature, the applicant decides not to proceed with the premium finance arrangement, the policy shall be returned to the company with the applicant’s signed request for release. The policy and note shall then be cancelled and the applicant released from any liability relative to the application and a refund made of any downpayment.

(q) If it is determined that the company or producer has violated this part, or if it is determined that there has been a material misrepresentation of the contract, then the policy shall be returned to the company with a signed request for release. The policy and note shall then be cancelled and the applicant released from any liability and refund made of any downpayment.

(r) Any cash value of the life insurance policy shown at the time of presentation of the premium finance arrangement shall be based upon the face amount of the policy being offered. For example, if a $10,000 policy is being sold, the value for this $10,000 policy, and not the values for a $50,000 or $75,000 policy, shall be given. If a sales presentation was made for an amount of insurance greater than what the applicant decided to purchase, an appropriate summary shall be given to the applicant for the correct cash value of the policy sold not later than the time that the applicant signs the application for the note.

(s) Companies shall notify their agents and producers of the requirements set forth in this part.

History

#7450, eff 2-16-01, EXPIRED: 2-16-09
#12399, eff 9-30-17

N.H. Code Admin. R. Ann. Ins 304.02 Exemption. {#sec-ins-304.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 304.02}

Premium financing plans requiring the delivery of the prospectus filed with the Securities and Exchange Commission under the Securities Act of 1933 shall be exempt from the provisions and requirements of this part.

History

#1942, eff 2-1-82; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12399, eff 9-30-17

N.H. Code Admin. R. Ann. Ins 304.03 Waiver or Suspension of Rules {#sec-ins-304.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 304.03}

(a) The commissioner, upon the commissioner’s own initiative or upon request by an insurer, shall waive any requirement of this part if such waiver does not contradict the objective or intent of the rule and:

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

History

#12399, eff 9-30-17

Part Ins 305 Suitability in Annuity Transactions

N.H. Code Admin. R. Ann. Ins 305.01 Purpose {#sec-ins-305.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.01}

(a) The purpose of this rule is to require producers, as defined in this rule, to act in the best interest of the consumer when making a recommendation of an annuity and to require insurers to establish and maintain a system to supervise recommendations so that the insurance needs and financial objectives of consumers at the time of the transaction are effectively addressed.

(b) Nothing herein shall be construed to create or imply a private cause of action for a violation of this rule or to subject a producer to civil liability under the best interest standard of care outlined in Ins 305.05 of this rule or under standards governing the conduct of a fiduciary or a fiduciary relationship.

History

#9374, eff 1-30-09; ss by #10654, eff 1-1-15; ss by #13873, eff 2-16-24

N.H. Code Admin. R. Ann. Ins 305.02 Applicability and Scope {#sec-ins-305.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.02}

This rule shall apply to any sale or recommendation of an annuity.

History

#9374, eff 1-30-09; ss by #10654, eff 1-1-15; ss by #13873, eff 2-16-24

N.H. Code Admin. R. Ann. Ins 305.03 Exemptions {#sec-ins-305.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.03}

Unless otherwise specifically included, this rule shall not apply to transactions involving:

(a) Direct response solicitations where there is no recommendation based on information collected from the consumer pursuant to this rule;

(b) Contracts used to fund:

(1) An employee pension or welfare benefit plan that is covered by the Employee Retirement and Income Security Act (ERISA);

(2) A plan described by Sections 401(a), 401(k), 403(b), 408(k) or 408(p) of the Internal Revenue Code (IRC), as amended, if established or maintained by an employer;

(3) A government or church plan defined in Section 414 of the IRC, a government or church welfare benefit plan, or a deferred compensation plan of a state or local government or tax exempt organization under Section 457 of the IRC; or

(4) A nonqualified deferred compensation arrangement established or maintained by an employer or plan sponsor;

(c) Settlements of or assumptions of liabilities associated with personal injury litigation or any dispute or claim resolution process; or

(d) Formal prepaid funeral contracts.

History

#9374, eff 1-30-09; ss by #10654, eff 1-1-15; ss by #13873, eff 2-16-24

N.H. Code Admin. R. Ann. Ins 305.04 Definitions {#sec-ins-305.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.04}

(a) "Annuity" means an annuity that is an insurance product under state law that is individually solicited, whether the product is classified as an individual or group annuity.

(b) “Cash compensation” means any discount, concession, fee, service fee, commission, sales charge, loan, override, or cash benefit received by a producer in connection with the recommendation or sale of an annuity from an insurer, intermediary, or directly from the consumer.

(c) “Consumer profile information” means information that is reasonably appropriate to determine whether a recommendation addresses the consumer’s financial situation, insurance needs and financial objectives, including, at a minimum, the following:

(1) Age;

(2) Annual income;

(3) Financial situation and needs, including debts and other obligations;

(4) Financial experience;

(5) Insurance needs;

(6) Financial objectives;

(7) Intended use of the annuity;

(8) Financial time horizon;

(9) Existing assets or financial products, including investment, annuity and insurance holdings;

(10) Liquidity needs;

(11) Liquid net worth;

(12) Risk tolerance, including but not limited to, willingness to accept non-guaranteed elements in the annuity;

(13) Financial resources used to fund the annuity; and

(14) Tax status.

(d) “Continuing education credit” or “CE credit” means one continuing education credit as described in Ins 1300.

(e) “Continuing education provider” or “CE provider” means an individual or entity that is approved to offer continuing education courses pursuant to Ins 1303.

(f) “FINRA” means the Financial Industry Regulatory Authority or a succeeding agency.

(g) "Insurer" means a company required to be licensed under the laws of this state to provide insurance products, including annuities.

(h) “Intermediary” means an entity contracted directly with an insurer or with another entity contracted with an insurer to facilitate the sale of the insurer’s annuities by producers.

(i) “Material conflict of interest” means a financial interest of the producer in the sale of an annuity that a reasonable person would expect to influence the impartiality of a recommendation. “Material conflict of interest” does not include cash compensation or non-cash compensation.

(j) “Non-cash compensation” means any form of compensation that is not cash compensation, including, but not limited to, health insurance, office rent, office support and retirement benefits.

(k) “Non-guaranteed elements” means the premiums, credited interest rates (including any bonus), benefits, values, dividends, non-interest based credits, charges or elements of formulas used to determine any of these, that are subject to company discretion and are not guaranteed at issue. An element is considered nonguaranteed if any of the underlying non-guaranteed elements are used in its calculation.

(l) “Producer" means a person or entity required to be licensed under the laws of this state to sell, solicit or negotiate insurance, including annuities. For purposes of this rule, “producer” includes an insurer where no producer is involved.

(m) "Recommendation" means advice provided by a producer to an individual consumer that was intended to result or does result in a purchase, an exchange, or a replacement of an annuity in accordance with that advice. “Recommendation” does not include general communication to the public, generalized customer services assistance or administrative support, general educational information and tools, prospectuses, or other product and sales material.

(n) “Replacement” means a transaction in which a new annuity is to be purchased, and it is known or should be known to the proposing producer, or to the proposing insurer whether or not a producer is involved, that by reason of the transaction, an existing annuity or other insurance policy has been or is to be any of the following:

(1) Lapsed, forfeited, surrendered or partially surrendered, assigned to the replacing insurer or

otherwise terminated;

(2) Converted to reduced paid-up insurance, continued as extended term insurance, or otherwise

reduced in value by the use of nonforfeiture benefits or other policy values;

(3) Amended so as to effect either a reduction in benefits or in the term for which coverage would otherwise remain in force or for which benefits would be paid;

(4) Reissued with any reduction in cash value; or

(5) Used in a financed purchase.

(o) “SEC” means the United States Securities and Exchange Commission.

History

#9374, eff 1-30-09; ss by #10654, eff 1-1-15; ss by #13873, eff 2-16-24

N.H. Code Admin. R. Ann. Ins 305.05 Duties of Insurers and Producers {#sec-ins-305.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.05}

(a) Best Interest Obligations. A producer, when making a recommendation of an annuity, shall act in the best interest of the consumer under the circumstances known at the time the recommendation is made, without placing the producer’s or the insurer’s financial interest ahead of the consumer’s interest. The specific requirements of this subsection are established and described in their entirety in paragraphs (1)-(5), and a producer has acted in the best interest of the consumer if they are in compliance with this subsection. A producer has acted in the best interest of the consumer if they have satisfied the following obligations regarding care, disclosure, conflict of interest and documentation:

(1) a. Care Obligation. The producer, in making a recommendation shall exercise reasonable diligence, care and skill to:

Know the consumer’s financial situation, insurance needs and financial objectives;
Understand the available recommendation options after making a reasonable inquiry into options available to the producer;
Have a reasonable basis to believe the recommended option effectively addresses the consumer’s financial situation, insurance needs and financial objectives over the life of the product, as evaluated in light of the consumer profile information; and
Communicate the basis or bases of the recommendation.

b. The requirements under subparagraph a. of this paragraph include making reasonable efforts to obtain consumer profile information from the consumer prior to the recommendation of an annuity.

c. The requirements under subparagraph a. of this paragraph require a producer to consider the types of products the producer is authorized and licensed to recommend or sell that address the consumer’s financial situation, insurance needs and financial objectives. This does not require analysis or consideration of any products outside the authority and license of the producer or other possible alternative products or strategies available in the market at the time of the recommendation. Producers shall be held to standards applicable to producers with similar authority and licensure.

d. The requirements under this subsection do not create a fiduciary obligation or relationship and only create a regulatory obligation as established in this rule.

e. The consumer profile information, characteristics of the insurer, and product costs, rates, benefits and features are those factors generally relevant in making a determination whether an annuity effectively addresses the consumer’s financial situation, insurance needs and financial objectives, but the level of importance of each factor under the care obligation of this paragraph may vary depending on the facts and circumstances of a particular case. However, each factor may not be considered in isolation.

f. The requirements under subparagraph a. of this paragraph include having a reasonable basis to believe the consumer would benefit from certain features of the annuity, such as annuitization, death or living benefit or other insurance-related features.

g. The requirements under subparagraph a. of this paragraph apply to the particular annuity as a whole and the underlying subaccounts to which funds are allocated at the time of purchase or exchange of an annuity, and riders and similar product enhancements, if any.

h. The requirements under subparagraph a. of this paragraph do not mean the annuity with the lowest one-time or multiple occurrence compensation structure shall necessarily be recommended.

i. The requirements under subparagraph a. of this paragraph do not mean the producer has ongoing monitoring obligations under the care obligation under this paragraph, although such an obligation may be separately owed under the terms of a fiduciary, consulting, investment advising or financial planning agreement between the consumer and the producer.

j. In the case of an exchange or replacement of an annuity, the producer shall consider the whole transaction, which includes taking into consideration whether:

The consumer will incur a surrender charge, be subject to the commencement of a new surrender period, lose existing benefits, such as death, living or other contractual benefits, or be subject to increased fees, investment advisory fees or charges for riders and similar product enhancements;
The replacing product would substantially benefit the consumer in comparison to the replaced product over the life of the product; and
The consumer has had another annuity exchange or replacement and, in particular, an exchange or replacement within the preceding 60 months.

k. Nothing in this rule shall be construed to require a producer to obtain any license other than a producer license with the appropriate line of authority to sell, solicit or negotiate insurance in this state, including but not limited to any securities license, in order to fulfill the duties and obligations contained in this rule; provided the producer does not give advice or provide services that are otherwise subject to securities laws or engage in any other activity requiring other professional licenses.

(2) Disclosure obligation.

a. Prior to the recommendation or sale of an annuity, the producer shall prominently disclose to the consumer on a form substantially similar to Appendix A:

A description of the scope and terms of the relationship with the consumer and the role of the producer in the transaction;
An affirmative statement on whether the producer is licensed and authorized to sell the following products:

(i) Fixed annuities;

(ii) Fixed indexed annuities;

(iii) Variable annuities;

(iv) Life insurance;

(v) Mutual funds;

(vi) Stocks and bond; and

(vii) Certificates of deposit;

An affirmative statement describing the insurers the producer is authorized, contracted, or otherwise able to sell insurance products for, using the following descriptions:

(i) From one insurer;

(ii) From two or more insurers; or

(iii) From two or more insurers although primarily contracted with one insurer.

A description of the sources and types of cash compensation and non-cash compensation to be received by the producer, including whether the producer is to be compensated for the sale of a recommended annuity by commission as part of premium or other remuneration received from the insurer, intermediary or other producer or by fee as a result of a contract for advice or consulting services; and
A notice of the consumer’s right to request additional information regarding cash compensation described in subparagraph b. of this paragraph;

b. Upon request of the consumer or the consumer’s designated representative, the producer shall disclose:

A reasonable estimate of the amount of cash compensation to be received by the producer, which may be stated as a range of amounts or percentages; and
Whether the cash compensation is a one-time or multiple occurrence amount, and if a multiple occurrence amount, the frequency and amount of the occurrence, which may be stated as a range of amounts or percentages; and

c. Prior to or at the time of the recommendation or sale of an annuity, the producer shall have a reasonable basis to believe the consumer has been informed of various features of the annuity, such as the potential surrender period and surrender charge, potential tax penalty if the consumer sells, exchanges, surrenders or annuitizes the annuity, mortality and expense fees, investment advisory fees, any annual fees, potential charges for and features of riders or other options of the annuity, limitations on interest returns, potential changes in non-guaranteed elements of the annuity, insurance and investment components and market risk. The requirements of this section are intended to supplement and not replace the disclosure requirements of section Ins 306.

(3) Conflict of interest obligation. A producer shall identify and avoid or reasonably manage and disclose material conflicts of interest, including material conflicts of interest related to an ownership interest.

(4) Documentation obligation. A producer shall at the time of recommendation or sale:

a. Make a written record of any recommendation and the basis for the recommendation subject to this rule;

b. Obtain a consumer signed statement on a form substantially similar to Appendix B documenting:

A customer’s refusal to provide the consumer profile information, if any; and
A customer’s understanding of the ramifications of not providing his or her consumer profile information or providing insufficient consumer profile information; and

c. Obtain a consumer signed statement on a form substantially similar to Appendix C acknowledging the annuity transaction is not recommended if a customer decides to enter into an annuity transaction that is not based on the producer’s recommendation.

(5) Application of the best interest obligation. Any requirement applicable to a producer under this subsection shall apply to every producer who has exercised material control or influence in the making of a recommendation and has received direct compensation as a result of the recommendation or sale, regardless of whether the producer has had any direct contact with the consumer. Activities such as providing or delivering marketing or educational materials, product wholesaling or other back office product support, and general supervision of a producer do not, in and of themselves, constitute material control or influence.

(b) Transactions not based on a recommendation.

(1) Except as provided under paragraph (2), a producer shall have no obligation to a consumer under subsection (a)(1) related to any annuity transaction if;

a. No recommendation is made;

b. A recommendation was made and was later found to have been prepared based on materially inaccurate information provided by the consumer;

c. A consumer refuses to provide relevant consumer profile information and the annuity transaction is not recommended; or

d. A consumer decides to enter into an annuity transaction that is not based on a recommendation of the producer.

(2) An insurer’s issuance of an annuity subject to Paragraph (1) shall be reasonable under all the circumstances actually known to the insurer at the time the annuity is issued.

(1) Except as permitted under subsection (b), an insurer may not issue an annuity recommended to a consumer unless there is a reasonable basis to believe the annuity would effectively address the particular consumer’s financial situation, insurance needs and financial objectives based on the consumer’s consumer profile information;

(2) An insurer shall establish and maintain a supervision system that is reasonably designed to achieve the insurer’s and its producers’ compliance with this rule, including, but not limited to, the following:

a. The insurer shall establish and maintain reasonable procedures to inform its producers of the requirements of this rule and shall incorporate the requirements of this rule into relevant producer training manuals;

b. The insurer shall establish and maintain standards for producer product training and shall establish and maintain reasonable procedures to require its producers to comply with the requirements of Section 305.06 of this rule;

c. The insurer shall provide product-specific training and training materials which explain all material features of its annuity products to its producers;

d. The insurer shall establish and maintain procedures for the review of each recommendation prior to issuance of an annuity that are designed to ensure there is a reasonable basis to determine that the recommended annuity would effectively address the particular consumer’s financial situation, insurance needs and financial objectives. Such review procedures may apply a screening system for the purpose of identifying selected transactions for additional review and may be accomplished electronically or through other means including, but not limited to, physical review. Such an electronic or other system may be designed to require additional review only of those transactions identified for additional review by the selection criteria;

e. The insurer shall establish and maintain reasonable procedures to detect recommendations that are not in compliance with subsections (a), (b), (d), and (e). This may include, but is not limited to, confirmation of the consumer’s consumer profile information, systematic customer surveys, producer and consumer interviews, confirmation letters, producer statements or attestations and programs of internal monitoring. Nothing in this subparagraph prevents an insurer from complying with this subparagraph by applying sampling procedures, or by confirming the consumer profile information or other required information under this section after issuance or delivery of the annuity;

f. The insurer shall establish and maintain reasonable procedures to assess, prior to or upon issuance or delivery of an annuity, whether a producer has provided to the consumer the information required to be provided under this section;

g. The insurer shall establish and maintain reasonable procedures to identify and address suspicious consumer refusals to provide consumer profile information;

h. The insurer shall establish and maintain reasonable procedures to identify and eliminate any sales contests, sales quotas, bonuses, and non-cash compensation that are based on the sales of specific annuities within a limited period of time. The requirements of this subparagraph are not intended to prohibit the receipt of health insurance, office rent, office support, retirement benefits or other employee benefits by employees as long as those benefits are not based upon the volume of sales of a specific annuity within a limited period of time; and

i. The insurer shall annually provide a written report to senior management, including to the senior manager responsible for audit functions, which details a review, with appropriate testing, reasonably designed to determine the effectiveness of the supervision system, the exceptions found, and corrective action taken or recommended, if any.

(3) a. Nothing in this subsection restricts an insurer from contracting for performance of a function (including maintenance of procedures) required under this subsection. An insurer is responsible for taking appropriate corrective action and may be subject to sanctions and penalties in this rule regardless of whether the insurer contracts for performance of a function and regardless of the insurer’s compliance with subparagraph b. of this paragraph.

b. An insurer’s supervision system under this subsection shall include supervision of contractual performance under this subsection. This includes, but is not limited to, the following:

Monitoring and, as appropriate, conducting audits to assure that the contracted function is properly performed; and
Annually obtaining a certification from a senior manager who has responsibility for the contracted function that the manager has a reasonable basis to represent, and does represent, that the function is properly performed.

(4) An insurer is not required to include in its system of supervision:

a. A producer’s recommendations to consumers of products other than the annuities offered by the insurer; or

b. Consideration of or comparison to options available to the producer or compensation relating to those options other than annuities or other products offered by the insurer.

(d) Prohibited Practices. Neither a producer nor an insurer shall dissuade, or attempt to dissuade, a consumer from:

(1) Truthfully responding to an insurer’s request for confirmation of the consumer profile information;

(2) Filing a complaint; or

(3) Cooperating with the investigation of a complaint.

(e) Safe harbor.

(1) Recommendations and sales of annuities made in compliance with comparable standards shall satisfy the requirements under this rule. This subsection applies to all recommendations and sales of annuities made by financial professionals in compliance with business rules, controls and procedures that satisfy a comparable standard even if such standard would not otherwise apply to the product or recommendation at issue. However, nothing in this subsection shall limit the insurance commissioner’s ability to investigate and enforce the provisions of this rule.

(2) Nothing in paragraph (1) shall limit the insurer’s obligation to comply with Ins 305.05(c)(1) of this rule, although the insurer may base its analysis on information received from either the financial professional or the entity supervising the financial professional.

(3) For paragraph (1) to apply, an insurer shall:

a. Monitor the relevant conduct of the financial professional seeking to rely on paragraph (1) or the entity responsible for supervising the financial professional, such as the financial professional’s broker-dealer or an investment adviser registered under federal or New Hampshire securities laws using information collected in the normal course of an insurer’s business; and

b. Provide to the entity responsible for supervising the financial professional seeking to rely on paragraph (1), such as the financial professional’s broker-dealer or investment adviser registered under federal or New Hampshire securities laws, information and reports that are reasonably appropriate to assist such entity to maintain its supervision system.

(4) For purposes of this subsection, “financial professional” means a producer that is regulated and acting as:

a. A broker-dealer registered under federal or New Hampshire securities laws or a registered representative of a broker-dealer;

b. An investment adviser registered under federal or New Hampshire securities laws or an investment adviser representative associated with the federal or New Hampshire registered investment adviser; or

c. A plan fiduciary under Section 3(21) of the Employee Retirement Income Security Act of 1974 (ERISA) or fiduciary under Section 4975(e)(3) of the Internal Revenue Code (IRC) or any amendments or successor statutes thereto.

(5) For purposes of this subsection, “comparable standards” means:

a. With respect to broker-dealers and registered representatives of broker-dealers, applicable SEC and FINRA rules pertaining to best interest obligations and supervision of annuity recommendations and sales, including, but not limited to, Rule Best Interest and any amendments or successor rules thereto;

b. With respect to investment advisers registered under federal or state securities laws or investment adviser representatives, the fiduciary duties and all other requirements imposed on such investment advisers or investment adviser representatives by contract or under the Investment Advisers Act of 1940 or applicable state securities law, including but not limited to, the Form ADV and interpretations; and

c. With respect to plan fiduciaries or fiduciaries, the duties, obligations, prohibitions and all other requirements attendant to such status under ERISA or the IRC and any amendments or successor statutes thereto.

History

#9374, eff 1-30-09; ss by #10654, eff 1-1-15; ss by #13873, eff 2-16-24

N.H. Code Admin. R. Ann. Ins 305.06 Producer Training {#sec-ins-305.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.06}

(a) A producer shall not solicit the sale of an annuity product unless the producer has adequate knowledge of the product to recommend the annuity and the producer is in compliance with the insurer’s standards for product training. A producer may rely on insurer-provided product-specific training standards and materials to comply with this subsection.

(b) (1) a. A producer who engages in the sale of annuity products shall complete a one-time four (4) credit training course approved by the department of insurance and provided by a department of insurance-approved education provider.

b. Producers who hold a life insurance line of authority on the effective date of this rule and who desire to sell annuities shall complete the requirements of this subsection within six (6) months after the effective date of this rule. Individuals who obtain a life insurance line of authority on or after the effective date of this rule may not engage in the sale of annuities until the annuity training course required under this subsection has been completed.

(2) The minimum length of the training required under this subsection shall be sufficient to qualify for at least four (4) CE credits but may be longer.

(3) The training required under this subsection shall include information on the following topics:

a. The types of annuities and various classifications of annuities;

b. Identification of the parties to an annuity;

c. How product specific annuity contract features affect consumers;

d. The application of income taxation of qualified and non-qualified annuities;

e. The primary uses of annuities; and

f. Appropriate standard of conduct, sales practices, replacement and disclosure requirements.

(4) Providers of courses intended to comply with this subsection shall cover all topics listed in the prescribed outline and shall not present any marketing information or provide training on sales techniques or provide specific information about a particular insurer’s products. Additional topics may be offered in conjunction with and in addition to the required outline.

(5) A provider of an annuity training course intended to comply with this subsection shall register as a CE provider in this state and comply with the rules and guidelines applicable to producer continuing education courses as set forth in Ins 1303.

(6) A producer who has completed an annuity training course approved by the department of insurance prior to January 1, 2024 shall, within six (6) months after the effective date of this rule, complete either:

a. A new four (4) credit training course approved by the department of insurance after January 1, 2024; or

b. An additional one-time one (1) credit training course approved by the department of insurance and provided by a department of insurance-approved education provider on appropriate sales practices, replacement and disclosure requirements under this amended rule.

(7) Annuity training courses may be conducted and completed by classroom or self-study methods in accordance with Ins 1303.

(8) Providers of annuity training shall comply with the reporting requirements and shall issue certificates of completion in accordance with Ins 1303.

(9) The satisfaction of the training requirements of another state that are substantially similar to the provisions of this subsection shall be deemed to satisfy the training requirements of this subsection in this state.

(10) The satisfaction of the components of the training requirements of any course or courses with components substantially similar to the provisions of this subsection shall be deemed to satisfy the training requirements of this subsection in this state.

(11) An insurer shall verify that a producer has completed the annuity training course required under this subsection before allowing the producer to sell an annuity product for that insurer. An insurer may satisfy its responsibility under this subsection by obtaining certificates of completion of the training course or obtaining reports provided by commissioner-sponsored database systems or vendors or from a reasonably reliable commercial database vendor that has a reporting arrangement with approved insurance education providers.

History

#9374, eff 1-30-09; ss by #10654, eff 1-1-15; ss by #13873, eff 2-16-24

N.H. Code Admin. R. Ann. Ins 305.07 Compliance Mitigation; Penalties; Enforcement {#sec-ins-305.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.07}

(a) An insurer is responsible for compliance with this rule. If a violation occurs, either because of the action or inaction of the insurer or its producer, the commissioner may order:

(1) An insurer to take reasonably appropriate corrective action for any consumer harmed by a failure to comply with this rule by the insurer, an entity contracted to perform the insurer’s supervisory duties or by the producer;

(2) A general agency, independent agency or the producer to take reasonably appropriate corrective action for any consumer harmed by the producer's violation of this rule; and

(3) Appropriate penalties and sanctions.

(b) Any applicable penalty under RSA 400-A:15, III for a violation of this rule may be reduced or eliminated if corrective action for the consumer was taken promptly after a violation was discovered or the violation was not part of a pattern or practice.

History

#9374, eff 1-30-09; ss by #10654, eff 1-1-15; ss by #13873, eff 2-16-24

N.H. Code Admin. R. Ann. Ins 305.08 Recordkeeping {#sec-ins-305.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.08}

(a) Insurers, general agents, independent agencies and producers shall maintain or be able to make available to the commissioner records of the information collected from the consumer, disclosures made to the consumer, including summaries of oral disclosures, and other information used in making the recommendations that were the basis for insurance transactions for the same length of time as set forth in RSA 400-B:4, I.

(b) Records required to be maintained by this rule may be maintained in paper, photographic, microprocess, magnetic, mechanical or electronic media or by any process that accurately reproduces the actual document.

History

#10654, eff 1-1-15 (from Ins 305.07); ss by #13873, eff 2-16-24

N.H. Code Admin. R. Ann. Ins 305.09 Waiver or Suspension of Rules {#sec-ins-305.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 305.09}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) Waivers that are granted shall be in effect for the period of time requested and approved by the commissioner.

History

#13873, eff 2-16-24

Part Ins 306 Annuity Disclosure

N.H. Code Admin. R. Ann. Ins 306.01 Purpose {#sec-ins-306.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 306.01}

The purpose of this part is to provide standards for the disclosure of certain minimum information about annuity contracts to protect consumers and foster consumer education. The rule specifies the minimum information which must be disclosed, the method for disclosing it, and the use and content of illustrations, if used, in connection with the sale of annuity contracts. The goal of this rule is to ensure that purchasers of annuity contracts understand certain basic features of annuity contracts.

History

#2143, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12521, eff 4-28-18

N.H. Code Admin. R. Ann. Ins 306.02 Applicability and Scope {#sec-ins-306.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 306.02}

This part applies to all group and individual annuity contracts and certificates, including annuity riders to any life insurance policy, regardless of the issuer. This part does not apply to the following:

(a) Immediate and deferred annuities that do not contain any non-guaranteed elements.

(b) (1) Annuities used to fund:

a. An employee pension plan which is covered by the Employee Retirement Income Security Act (ERISA);

b. A plan described by Sections 401(a), 40l(k) or 403(b) of the Internal Revenue Code, where the plan, for purposes of ERISA, is established or maintained by an employer;

c. A governmental or church plan defined in Section 414 or a deferred compensation plan of a state or local government or a tax exempt organization under Section 457 of the Internal Revenue Code; or

d. A nonqualified deferred compensation arrangement established or maintained by an employer or plan sponsor; and

(2) Notwithstanding paragraph (b)(1), this part shall apply to annuities used to fund a plan or arrangement that is funded solely by contributions an employee elects to make, whether on a pre-tax or after-tax basis, and where the insurance company has been notified that plan participants may choose from among 2 or more fixed annuity providers, and there is a direct solicitation of an individual employee by a producer for the purchase of an annuity contract. As used in this section, direct solicitation shall not include any meeting held by a producer solely for the purpose of educating or enrolling employees in the plan or arrangement.

(c) Non-registered variable annuities issued exclusively to an accredited investor or qualified purchaser, as those terms are defined by the Securities Act of 1933 (15 U.S.C. Section 77a et seq.), the Investment Company Act of 1940 (15 U.S.C. Section 80a·l et seq.), or the rules promulgated under either of those acts, and offered for sale and sold in a transaction that is exempt from registration under the Securities Act of 1933 (15 U.S.C. Section 77a et seq.).

(d) (1) Transactions involving variable annuities and other registered products in compliance with Securities and Exchange Commission (SEC) rules and Financial Industry Regulatory Authority (FINRA) rules relating to disclosures and illustrations, provided that compliance with Ins 306.04 shall be required after the 2018 effective date of this part, unless or until such time as the SEC has adopted a summary prospectus rule or FINRA has approved for use a simplified disclosure form applicable to variable annuities or other registered products; and

(2) Notwithstanding paragraph (d)(1), the delivery of the Buyer’s Guide is required in sales of variable annuities and, when appropriate, in sales of other registered products.

(e) Structured settlement annuities.

(f) Charitable gift annuities.

(g) Funding agreements.

History

#2143, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12521, eff 4-28-18

N.H. Code Admin. R. Ann. Ins 306.03 Definitions {#sec-ins-306.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 306.03}

For the purposes of this part:

(a) "Buyer's Guide" means the National Association of Insurance Commissioner's approved Annuity Buyer's Guide, available as referenced in Appendix B.

(b) "Charitable gift annuity" means a transfer of cash or other property by a donor to a charitable organization in return for an annuity payable over one or 2 lives, under which the actuarial value of the annuity is less than the value of the cash or other property transferred and the difference in value constitutes a charitable deduction for federal tax purposes, as defined in RSA 403-E:1, but does not include a charitable remainder trust or a charitable lead trust or other similar arrangement where the charitable organization does not issue an annuity and incur a financial obligation to guarantee annuity payments.

(c) "Contract owner" means the owner named in the annuity contract or certificate holder in the case of a group annuity contract.

(d) "Determinable elements" means elements that are derived from processes or methods that are guaranteed at issue and not subject to company discretion, but where the values or amounts cannot be determined until some point after issue. These elements include the premiums, credited interest rates (including any bonus), benefits, values, non-interest based credits, charges, or elements of formulas used to determine any of these. These elements may be described as guaranteed but not determined at issue. An element is considered determinable if it was calculated from underlying determinable elements only or from both determinable and guaranteed elements.

(e) "Funding agreement" means “funding agreement” as defined in RSA 408-E:2.

(f) "Generic name" means a short title descriptive of the annuity contract being applied for or illustrated such as "single premium deferred annuity".

(g) "Guaranteed elements'' means the premiums, credited interest rates (including any bonus), benefits, values, non-interest based credits, charges, or elements of formulas used to determine any of these, that are guaranteed or have determinable elements at issue. An element is considered guaranteed if all of the underlying elements that go into its calculation are guaranteed.

(h) "Illustration" means a personalized presentation or depiction prepared for and provided to an individual consumer that includes non-guaranteed elements of an annuity contract over a period of years.

(i) "Market Value Adjustment" or "MVA" feature is a positive or negative adjustment that may be applied to the account value and/or cash value of the annuity upon withdrawal, surrender, contract annuitization, or death benefit payment based on either the movement of an external index or on the company's current guaranteed interest rate being offered on new premiums or new rates for renewal periods, if that withdrawal, surrender, contract annuitization, or death benefit payment occurs at a time other than on a specified guaranteed benefit date.

(j) "Non-guaranteed elements" means the premiums, credited interest rates (including any bonus), benefits, values, dividends, non-interest based credits, charges, or elements of formulas used to determine any of these, that are subject to company discretion and are not guaranteed at issue. An element is considered non-guaranteed if any of the underlying non-guaranteed elements are used in its calculation.

(k) "Registered product" means an annuity contract or life insurance policy subject to the prospectus delivery requirements of the Securities Act of 1933.

(l) ''Structured settlement annuity" means a "qualified funding asset" as defined in section 130(d) of the Internal Revenue Code or an annuity that would be a qualified funding asset under section 130(d) but for the fact that it is not owned by an assignee under a qualified assignment.

History

#2143, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12521, eff 4-28-18

N.H. Code Admin. R. Ann. Ins 306.04 Standards for the Disclosure Document and Buyer's Guide {#sec-ins-306.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 306.04}

(a) (1) Where the application for an annuity contract is taken in a face-to-face meeting, the applicant shall, at or before the time of application, be given both the disclosure document described in Ins 306.04(b) and the Buyer's Guide, if any; or

(2) Where the application for an annuity contract is taken by means other than in a face-to-face meeting, the applicant shall be sent both the disclosure document and the Buyer's Guide no later than 5 business days after the completed application is received by the insurer; and:

a. With respect to an application received as a result of a direct solicitation through the mail:

Providing a Buyer's Guide in a mailing, inviting prospective applicants to apply for an annuity contract, shall be deemed to satisfy the requirement that the Buyer's Guide be provided no later than 5 business days after receipt of the application; and
Providing a disclosure document in a mailing, inviting a prospective applicant to apply for an annuity contract, shall be deemed to satisfy the requirement that the disclosure document be provided no later than 5 business days after receipt of the application;

b. With respect to an application received via the Internet:

Taking reasonable steps to make the Buyer's Guide available for viewing and printing on the insurer's website shall be deemed to satisfy the requirement that the Buyer's Guide be provided no later than 5 business days after receipt of the application; and
Taking reasonable steps to make the disclosure document available for viewing and printing on the insurer's website shall be deemed to satisfy the requirement that the disclosure document be provided no later than 5 business days after receipt of the application;

c. A solicitation for an annuity contract provided in other than a face-to-face meeting shall include a statement that the proposed applicant may contact the New Hampshire insurance department for a free annuity Buyer's Guide, available at https://www.nh.gov/insurance/consumers/annuitieslife.htm. In lieu of the foregoing statement, an insurer may include a statement that the prospective applicant may contact the insurer for a free annuity Buyer's Guide; and

d. Where the Buyer's Guide and disclosure document are not provided at or before the time of application, a free look period of no less than 15 days shall be provided for the applicant to return the annuity contract without penalty. This free look shall run concurrently with any other free look as provided under state law or rule.

(b) Aside from the foregoing, an insurer, including direct response insurers, shall provide a disclosure document to any prospective purchaser upon request.

(c) At a minimum, the following information shall be included in the disclosure document required to be provided under this regulation:

(1) The generic name of the contract, the company product name, if different, and form number, and the fact that it is an annuity;

(2) The insurer's legal name, physical address, website address, and telephone number;

(3) A description of the contract and its benefits, emphasizing its long-term nature, including

examples where appropriate, for:

a. The guaranteed and non-guaranteed elements of the contract, and their limitations, if any, including for fixed indexed annuities, the elements used to determine the index-based interest, such as the participation rates, caps, or spread, and an explanation of how they operate;

b. An explanation of the initial crediting rate or, for fixed indexed annuities, an explanation of how the index-based interest is determined, specifying any bonus or introduction portion, the duration of the rate, and the fact that rates may change from time to time and are not guaranteed;

c. Periodic income options, both on a guaranteed and non-guaranteed basis;

d. Any value reductions caused by withdrawals from or surrender of the contract;

e. How values in the contract can be accessed;

f. The death benefit, if available, and how it will be calculated;

g. A summary of the federal tax status of the contract and any penalties applicable on

withdrawal of values from the contract; and

h. Impact of any rider, including, but not limited to, a guaranteed living benefit or long-

term care rider;

(4) Specific dollar amount or percentage charges and fees shall be listed with an explanation of how they apply; and

(5) Information about the current guaranteed rate or indexed crediting rate formula, if applicable, for new contracts that contains a clear notice that the rate is subject to change.

(d) Insurers shall define terms used in the disclosure statement in language that facilitates the understanding by a typical person within the segment of the public to which the disclosure statement is directed.

(e) The name, age, and sex of the proposed annuitant and the date on which the disclosure document was prepared.

History

#2143, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12521, eff 4-28-18

N.H. Code Admin. R. Ann. Ins 306.05 Standards for Annuity Illustrations {#sec-ins-306.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 306.05}

Please see Appendix I for an example.

(a) An insurer or producer may elect to provide a consumer an illustration at any time, provided that the illustration is in compliance with this section and:

(1) Clearly labeled as an illustration;

(2) Includes a statement referring consumers to the disclosure document and Buyer's Guide provided to them at time of purchase for additional information about their annuity; and

(3) Is prepared by the insurer or third party using software that is authorized by the insurer prior to its use, provided that the insurer maintains a system of control over the use of

illustrations.

(b) An illustration furnished to an applicant for a group annuity contract or contracts issued to a single applicant on multiple lives may be either an individual or composite illustration representative of the coverage on the lives of members of the group or the multiple lives covered.

(d) When using an illustration, the illustration shall not:

(1) Describe non-guaranteed elements in a manner that is misleading or has the capacity or tendency to mislead;

(2) State or imply that the payment or amount of non-guaranteed elements is guaranteed; or

(3) Be incomplete.

(e) Costs and fees of any type shall be individually noted and explained.

(f) An illustration shall conform to the following requirements:

(1) The illustration shall be labeled with the date on which it was prepared;

(2) Each page, including any explanatory notes or pages, shall be numbered and show its relationship to the total number of pages in the disclosure document (e.g., the fourth page of a seven-page disclosure document shall be labeled ''page 4 of 7 pages");

(3) The assumed dates of premium receipt and benefit payout within a contract year shall be clearly identified;

(4) If the age of the proposed insured is shown as a component of the tabular detail, it shall be issue age plus the numbers of years the contract is assumed to have been in force;

(5) The assumed premium on which the illustrated benefits and values are based shall be clearly identified, including rider premium for any benefits being illustrated;

(6) Any charges for riders or other contract features assessed against the account value or the crediting rate shall be recognized in the illustrated values and shall be accompanied by a statement indicating the nature of the rider benefits or the contract features, and whether or not they are included in the illustration;

(7) Guaranteed death benefits and values available upon surrender, if any, for the illustrated contract premium shall be shown and clearly labeled “guaranteed”;

(8) The non-guaranteed elements underlying the non-guaranteed illustrated values shall be no more favorable than current non-guaranteed elements and shall not include any assumed future improvement of such elements. Additionally, non-guaranteed elements used in calculating non-guaranteed illustrated values at any future duration shall reflect any planned changes, including any planned changes that may occur after expiration of an initial guaranteed or bonus period;

(9) In determining the non-guaranteed illustrated values for a fixed indexed annuity:

a. The index-based interest rate and account value shall be calculated for three different scenarios:

One to reflect historical performance of the index for the most recent 10 calendar years;
One to reflect the historical performance of the index for the continuous period of 10 calendar years out of the last 20 calendar years that would result in the least index value growth (the ''low scenario"); and
One to reflect the historical performance of the index for the continuous period of 10 calendar years out of the last 20 calendar years that would result in the most index value growth (the "high scenario"); and

b. The following requirements apply:

The most recent 10 calendar years and the last 20 calendar years are defined to end on the prior December 31, except for illustrations prepared during the first 3 months of the year, for which the end date of the calendar year period may be the December 31 prior to the last full calendar year;
If any index utilized in determination of an account value has not been in existence for at least 10 calendar years, indexed returns for that index shall not be illustrated. If the fixed indexed annuity provides an option to allocate account value to more than one indexed or fixed declared rate account, and one or more of those indexes has not been in existence for at least 10 calendar years, the allocation to such indexed account(s) shall be assumed to be zero;
If any index utilized in determination of an account value has been in existence for at least 10 calendar years but less than 20 calendar years, the 10 calendar year periods that define the low and high scenarios shall be chosen from the exact number of years the index has been in existence;
The non-guaranteed element(s), such as caps, spreads, participation rates or other interest crediting adjustments, used in calculating the non-guaranteed index-based interest rate shall be no more favorable than the corresponding current element(s);
If a fixed indexed annuity provides an option to allocate the account value to more than one indexed or fixed declared rate account:

(i) The allocation used in the illustration shall be the same for all three scenarios; and

(ii) The 10 calendar year periods resulting in the least and greatest index growth periods shall be determined independently for each indexed account option;

The geometric mean annual effective rate of the account value growth over the 10 calendar year period shall be shown for each scenario;
If the most recent 10 calendar year historical period experience of the index is shorter than the number of years needed to fulfill the requirement of Ins 306.05(h), the most recent 10 calendar year historical period experience of the index shall be used for each subsequent 10 calendar year period beyond the initial period for the purpose of calculating the account value for the remaining years of the illustration;
A graphical presentation shall also be included comparing the movement of the account value over the 10 calendar year period for the low scenario, the high scenario, and the most recent 10 calendar year scenario. The low and high scenarios:

(i) Need not show surrender values, if different than account values;

(ii) Shall not extend beyond 10 calendar years, and therefore are not subject to the requirements of Ins 306.05(h) beyond Ins 306.05(h)(1)a.; and

(iii) May be shown on a separate page; and

The low and high scenarios should reflect the irregular nature of the index performance and should trigger every type of adjustment to the index-based interest rate under the contract. The effect of the adjustments should be clear; for example, additional columns showing how the adjustment applied may be included. If an adjustment to the index-based interest rate is not triggered in the illustration, because no historical values of the index in the required illustration range would have triggered it, the illustration shall so state;

(10) The guaranteed elements, if any, shall be shown before corresponding nonguaranteed elements and shall be specifically referred to on any page of an illustration that shows or describes only the non-guaranteed elements, e.g., "see page 1 for guaranteed elements";

(11) The account or accumulation value of a contract, if shown, shall be identified by the name this value is given in the contract being illustrated and shown in close proximity to the corresponding value available upon surrender;

(12) The value available upon surrender shall be identified by the name this value is given in the contract being illustrated and shall be the amount available to the contract owner in a lump sum after deduction of surrender charges, bonus forfeitures, contract loans, contract loan interest, and application of any market value adjustment, as applicable;

(13) Illustrations may show contract benefits and values in graphic or chart form in addition to the tabular form;

(14) Any illustration of non-guaranteed elements shall be accompanied by a statement indicating that:

a. The benefits and values are not guaranteed;

b. The assumptions on which they are based are subject to change by the insurer; and

c. Actual results may be higher or lower;

(15) Illustrations based on non-guaranteed credited interest and non-guaranteed annuity income rates shall contain equally prominent comparisons to guaranteed credited interest and guaranteed annuity income rates, including any guaranteed and non-guaranteed participation rates, caps, or spreads for fixed indexed annuities;

(16) The annuity income rate illustrated shall not be greater than the current annuity income rate unless the contract guarantees are, in fact, more favorable;

(17) Illustrations shall be concise and easy to read;

(18) Key terms shall be defined and then used consistently throughout the illustration;

(19) Illustrations shall not depict values beyond the maximum annuitization age or date;

(20) Annuitization benefits shall be based on contract values that reflect surrender charges or any other adjustments, if applicable; and

(21) Illustrations shall show both annuity income rates per $1000.00 and the dollar amounts of the periodic income payable.

(g) An annuity illustration shall include a narrative summary that includes the following, unless provided at the same time in a disclosure document:

(1) A brief description of any contract features, riders, or options, guaranteed and/or non-guaranteed, shown in the basic illustration and the impact they may have on the benefits and values of the contract;

(2) A brief description of any other optional benefits or features that are selected, but not shown in the illustration, and the impact they have on the benefits and values of the contract;

(3) Identification and a brief definition of column headings and key terms used in the illustration;

(4) A statement containing, in substance, the following:

a. For other than fixed indexed annuities:

“This illustration assumes the annuity's current non-guaranteed elements will not change. It is likely that they will change and actual values will be higher or lower than those in this illustration but will not be less than the minimum guarantees.

“The values in this illustration are not guarantees or even estimates of the amounts you can expect from your annuity. Please review the entire Disclosure Document and Buyer's Guide provided with your Annuity Contract for more detailed information”; or

b. For fixed indexed annuities:

This illustration assumes the index will repeat historical performance and that the annuity's current non-guaranteed elements, such as caps, spreads, participation rates, or other interest crediting adjustments, will not change. It is likely that the index will not repeat historical performance, the non-guaranteed elements will change, and actual values will be higher or lower than those in this illustration but will not be less than the minimum guarantees.

(5) Additional explanations as follows:

a. Minimum guarantees shall be clearly explained;

b. The effect on contract values of contract surrender prior to maturity shall be explained;

c. Any conditions on the payment of bonuses shall be explained;

d. For annuities sold as an IRA, qualified plan, or in another arrangement subject to the required minimum distribution (RMD) requirements of the Internal Revenue Code, the effect of RMDs on the contract values shall be explained;

e. For annuities with recurring surrender charge schedules, a clear and concise

explanation of what circumstances will cause the surrender charge to recur; and

f. A brief description of the types of annuity income options available shall be explained,

including:

The earliest or only maturity date for annuitization, as the term is defined in the

contract;

For contracts with an optional maturity date, the periodic income amount for at least one of the annuity income options available, based on the guaranteed rates in the contract, at the later of age 70 or 10 years after issue, but in no case later than the maximum annuitization age or date in the contract;
For contracts with a fixed maturity date, the periodic income amount for at least one of the annuity income options available, based on the guaranteed rates in the contract at the fixed maturity date; and
The periodic income amount based on the currently available periodic income rates for the annuity income option in item 2. or item 3., above, if desired.

(h) Following the narrative summary, an illustration shall include a numeric summary which shall include at minimum, numeric values at the following durations:

(1) First 10 contract years or surrender charge period, if longer than 10 years, including any renewal surrender charge period(s);

(2) Every tenth contract year, up to the later of 30 years or age 70;

(3) Required annuitization age or required annuitization date.

(i) If the annuity contains a market value adjustment, hereafter referred to as MVA, the following provisions apply to the illustration:

(1) The MVA shall be referred to as such throughout the illustration;

(2) The narrative shall include an explanation, in simple terms, of the potential effect of the

MVA on the value available upon surrender;

(3) The narrative shall include an explanation, in simple terms, of the potential effect of the

MVA on the death benefit;

(4) A statement shall be included, containing, in substance, the following:

“When you make a withdrawal, the amount you receive may be increased or decreased by a Market Value Adjustment (MVA). If interest rates on which the MVA is based go up after you buy your annuity, the MVA likely will decrease the amount you receive. If interest rates go down, the MVA will likely increase the amount you receive”;

(5) Illustrations shall describe both the upside and the downside aspects of the contract features relating to the market value adjustment;

(6) The illustrative effect of the MVA shall be shown under at least one positive and one negative scenario. This demonstration shall appear on a separate page and be clearly labeled that it is information demonstrating the potential impact of a MVA, as the example in Appendix II shows;

(7) Actual MVA floors and ceilings as listed in the contract shall be illustrated; and

(8) If the MVA has significant characteristics not addressed by subparagraphs (1) – (6) above, the effect of such characteristics shall be shown in the illustration.

(j) Unless provided at the same time in a disclosure document, a narrative summary for a fixed indexed annuity illustration shall also include the following:

(1) An explanation, in simple terms, of the elements used to determine the index-based interest, including but not limited to the following elements:

a. The Index(es) which will be used to determine the index-based interest;

b. The Indexing Method, such as point-to-point, daily averaging, or monthly averaging;

c. The Index Term, which is the period over which indexed-based interest is calculated;

d. The Participation Rate, if applicable;

e. The Cap, if applicable; and

f. The Spread, if applicable;

(2) The narrative shall include an explanation, in simple terms, of how index-based interest is

credited in the indexed annuity;

(3) The narrative shall include a brief description of the frequency with which the company can re-set the elements used to determine the index-based credits, including the participation rate, the cap, and the spread, if applicable; and

(4) If the product allows the contract holder to make allocations to declared-rate segment, then the narrative shall include a brief description of:

a. Any options to make allocations to a declared-rate segment, both for new premiums and for transfers from the indexed-based segments; and

b. Differences in guarantees applicable to the declared-rate segment and the indexed-based segments.

(k) A numeric summary for a fixed indexed annuity illustration shall include, at a minimum, the following elements:

(1) The assumed growth rate of the index in accordance with Ins 306.05(f)(9);

(2) The assumed values for the participation rate, cap and spread, if applicable; and

(3) The assumed allocation between indexed-based segments and declared-rate segments, if applicable, in accordance with Ins 306.05(f)(9).

(l) If the contract is issued other than as applied for, a revised illustration conforming to the contract as issued shall be sent with the contract, except that non-substantive changes, including but not limited to changes in the amount of expected initial or additional premiums, any changes in amounts of exchanges pursuant to Section 1035 of the Internal Revenue Code, and rollovers or transfers which do not alter the key benefits and features of the annuity as applied for, will not require a revised illustration unless requested by the applicant.

History

#2143, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12521, eff 4-28-18

N.H. Code Admin. R. Ann. Ins 306.06 Report to Contract Owners {#sec-ins-306.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 306.06}

For annuities in the payout period that include non-guaranteed elements, and for deferred annuities in the accumulation period, the insurer shall provide each contract owner with a report on the status of the contract, at least annually, that contains at least the following information:

(a) The beginning and the end date of the current report period;

(b) The accumulation and cash surrender value;

(c) The total amounts, if any, that have been credited, charged to the contract value, or paid during the current report period; and

(d) The amount of outstanding loans, if any, as of the end of the current report period.

History

#2143, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12521, eff 4-28-18

N.H. Code Admin. R. Ann. Ins 306.07 Penalties {#sec-ins-306.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 306.07}

In addition to any other penalties provided by RSA 400-A15, III, an insurer or producer that violates a requirement of Ins 306 shall also be subject to the provisions of RSA 417:3

and 4.

History

#2143, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12521, eff 4-28-18

N.H. Code Admin. R. Ann. Ins 306.08 Waiver or Suspension of Rules {#sec-ins-306.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 306.08}

(a) The commissioner, upon the commissioner’s own initiative or upon request by an insurer, shall waive any requirement of Ins 306 if such waiver does not contradict the objective or intent of the rule and:

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any

History

#2143, eff 1-1-83; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01, EXPIRED: 2-16-09
#12521, eff 4-28-18

Part Ins 307 Mortality Tables for Use in Determining Reserve Liabilities for Annuities

N.H. Code Admin. R. Ann. Ins 307.01 Purpose {#sec-ins-307.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 307.01}

The purpose of this part is to recognize the following mortality tables, which are available as referenced in Appendix B, for use in determining the minimum standard of valuation for annuity and pure endowment contracts:

(a) The 1983 Table "a";

(b) The 1983 Group Annuity Mortality (1983 GAM) Table;

(d) The 2012 Individual Annuity Reserving (2012 IAR) Mortality Table; and

(e) The 1994 Group Annuity Reserving (1994 GAR) Table.

History

#3163, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01; ss by #9494, eff 6-29-09; ss by #12034, eff 12-31-16

N.H. Code Admin. R. Ann. Ins 307.02 Scope {#sec-ins-307.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 307.02}

The provisions of this part shall be used by insurers to determine minimum standards of valuation for annuity and pure endowment contracts, subject to RSA 410:3.

History

#3163, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01; ss by #9494, eff 6-29-09; ss by #12034, eff 12-31-16

N.H. Code Admin. R. Ann. Ins 307.03 Definitions {#sec-ins-307.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 307.03}

(a) “Annuity 2000 Mortality Table” means that mortality table developed by the Society of Actuaries Committee on Life Insurance Research.

(b) “Annuity 2012 IAR Mortality Table” means that Generational mortality table developed by the Society of Actuaries Committee on Life Insurance Research and containing rates, qx2012+n, derived from a combination of the 2012 IAM Period Table and Projection Scale G2, using the methodology stated in Ins 307.07.

(c) “Generational Mortality Table” means a mortality table containing a set of mortality rates that decrease for a given age from one year to the next, based on a combination of a Period table and a projection scale containing rates of mortality improvement.

(d) "1983 Table 'a'" means that mortality table developed by the Society of Actuaries Committee to Recommend a New Mortality Basis for Individual Annuity Valuation and adopted as a recognized mortality table for annuities in June 1982 by the National Association of Insurance Commissioners.

(e) "1983 GAM Table" means that mortality table developed by the Society of Actuaries Committee on Annuities and adopted as recognized mortality tables for annuities in December 1983 by the National Association of Insurance Commissioners.

(f) “1994 GAR Table” means that mortality table developed by the Society of Actuaries Group Annuity Valuation Table Task Force.

(g) “Period table” means a table of mortality rates applicable to a given calendar year known as the Period.

(h) “Projection Scale G2 (Scale G2)” is a table of annual rates, G2x, of mortality improvement by age for projecting future mortality rates beyond calendar year 2012. This table was developed by the Society of Actuaries Committee on Life Insurance Research and is available as referenced in Appendix B.

(i) “2012 Individual Annuity Mortality Period Life (2012 IAM Period) Table” means the Period table containing loaded mortality rates for calendar year 2012. This table contains rates, qx2012, developed by the Society of Actuaries Committee on Life Insurance Research and is available as referenced in Appendix B.

History

#3163, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01; ss by #9494, eff 6-29-09; ss by #12034, eff 12-31-16

N.H. Code Admin. R. Ann. Ins 307.04 Individual Annuity or Pure Endowment Contracts {#sec-ins-307.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 307.04}

(a) Expect as provided in (b) and (c) below, the 1983 Table “a” is recognized and approved as an individual annuity mortality table for valuation and, at the option of the company, may be used for purposes of determining the minimum standard of valuation for any individual annuity or pure endowment contract issued on or after August 1, 1979, but before December 31, 1985.

(b) Except as provided in (c) below, either the 1983 Table “a” or the Annuity 2000 Mortality Table shall be used for determining the minimum standard of valuation for any individual annuity or pure endowment contract issued on or after December 31, 1985 and before July 1, 2000.

(c) Except as provided in (d) below, the Annuity 2000 Mortality Table shall be used for determining the minimum standard of valuation for any individual annuity or pure endowment contract issued on or after July 1, 2000.

(d) Except as provided in (e) below, the 2012 IAR Mortality Table shall be used for determining the minimum standard of valuation for any individual annuity or pure endowment contract issued on or after January 1, 2017.

(e) The 1983 Table "a" without projection is to be used for determining the minimum standards of valuation for any individual annuity or pure endowment contract issued on or after July 1, 2000, solely when the contract is based on life contingencies and is issued to fund periodic benefits arising from:

(1) Settlements of various forms of claims pertaining to court settlements or out of court settlements from tort actions;

(2) Settlements involving similar actions such as workers' compensation claims; or

(3) Settlements of long-term disability claims where a temporary or life annuity has been used in lieu of continuing disability payments.

History

#3163, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01; amd by #7614, eff 12-24-01; ss by #9494, eff 6-29-09; ss by #12034, eff 12-31-16

N.H. Code Admin. R. Ann. Ins 307.05 Group Annuity or Pure Endowment Contracts {#sec-ins-307.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 307.05}

(a) Except as provided in (b) and (c) below, the 1983 GAM Table, the 1983 Table “a” and the 1994 GAR Table are recognized and approved as group annuity mortality tables for valuation and, at the option of the company, any one of these tables may be used for purposes of valuation for any annuity or pure endowment purchased on or after August 1, 1979, but before December 31, 1985, under a group annuity or pure endowment contract.

(b) Except as provided in (c) below, either the 1983 GAM Table or the 1994 GAR Table shall be used for determining the minimum standard of valuation for any annuity or pure endowment purchased on or after December 31, 1985 and before July 1, 2000, under a group annuity or pure endowment contract.

(c) The 1994 GAR Table shall be used for determining the minimum standard of valuation for any annuity or pure endowment purchased on or after July 1, 2000 under a group annuity or pure endowment contract.

History

#3163, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5657, eff 7-1-93; ss by #7015, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7450, eff 2-16-01; ss by #9494, eff 6-29-09; ss by #12034, eff 12-31-16

N.H. Code Admin. R. Ann. Ins 307.06 Application of the 1994 GAR Table {#sec-ins-307.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 307.06}

In using the 1994 GAR Table, the mortality rate for a person age x in years (1994 + n) is calculated as follows:

qx 1994+n = qx1994 (1 - AAx) n

where the qx1994 and AAxs are as specified in the 1994 GAR Table.

History

#9494, eff 6-29-09; ss by #12034, eff 12-31-16

N.H. Code Admin. R. Ann. Ins 307.07 Application of the 2012 IAR Mortality Table {#sec-ins-307.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 307.07}

In using the 2012 IAR Mortality Table, the mortality rate for a person age x in years (2012+n) is calculated as follows:

qx2012+n = qx2012(1 - G2x)n

The resulting qx2012+n shall be rounded to three decimal places per 1,000, e.g., 0.741 deaths per 1,000. Also, the rounding shall occur according to the formula above, starting at the 2012 period table rate.

For example, for a male age 30, qx2012 = 0.741:

(a) qx2013 = 0.741 * (1 - 0.010) ^ 1 = 0.73359, which is rounded to 0.734; and

(b) qx2014 = 0741 * (1 - 0.010) ^ 2 = 0.7262541, which is rounded to 0.726.

A method leading to incorrect rounding would be to calculate qx2014 as qx2013 * (1 - 0.010), or

0.734 * 0.99 = 0.727. It is incorrect to use the already rounded qx2013 to calculate qx2014.

History

#12034, eff 12-31-16

Part Ins 308 Life and Health Reinsurance Agreements

N.H. Code Admin. R. Ann. Ins 308.01 Preamble {#sec-ins-308.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 308.01}

(a) The New Hampshire insurance department recognizes that licensed insurers routinely enter into reinsurance agreements. These agreements can yield legitimate relief to the ceding insurer. A “ceding insurer” is an insurance company that passes a part or all of its risks from its insurance policy portfolio to another insurer (reinsurer).

(b) However, it is improper for a licensed insurer, in the capacity of a ceding insurer, to enter into reinsurance agreements for the principal purpose of producing significant surplus for the ceding insurer, typically on a temporary basis, while not transferring all of the significant risks inherent in the business being reinsured. In substance or effect, the expected potential liability to the ceding insurer remains basically unchanged by the reinsurance transaction, notwithstanding certain risk elements contained in the reinsurance agreement, such as catastrophic mortality or extraordinary survival. The terms of such agreements referred to herein and described in Ins 308.05 violate:

(1) RSA 400-A:36 and RSA 405:47 relating to financial statements which do not properly reflect the financial condition of the ceding insurer;

(2) RSA 405:47 relating to reinsurance reserve credits, thus resulting in a ceding insurer improperly reducing liabilities or establishing assets for reinsurance ceded; and

(3) RSA 400-A:36, RSA 405:45, RSA 405:47 and Ins 1500 relating to creating a situation that may be hazardous to policyholders and the people of this state.

History

#5480, eff 10-1-92; ss by #6522, eff 6-6-97; ss by #8239, eff 1-3-05; ss by #10196, eff 1-3-13; ss by #13494, eff 11-22-22

N.H. Code Admin. R. Ann. Ins 308.02 Purpose {#sec-ins-308.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 308.02}

The purpose of this rule is to establish requirements for life, accident and health insurers that cede insurance to reinsurers to assure that their financial statements properly reflect their financial condition thereby protecting policyholders and the public from possible future hazardous financial conditions.

History

#5480, eff 10-1-92; ss by #6522, eff 6-6-97; ss by #8239, eff 1-3-05; ss by #10196, eff 1-3-13 (from Ins 308.01); ss by #13494, eff 11-22-22

N.H. Code Admin. R. Ann. Ins 308.03 Scope {#sec-ins-308.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 308.03}

This rule shall apply to all domestic life and accident and health insurers and to all other licensed life and accident and health insurers that are not subject to a substantially similar regulation in their domiciliary state. This rule shall also similarly apply to licensed property and casualty insurers with respect to their accident and health business. This rule shall not apply to assumption reinsurance, yearly renewable term reinsurance or certain nonproportional reinsurance such as stop loss or catastrophe reinsurance.

History

#5480, eff 10-1-92; ss by #6522, eff 6-6-97; ss by #8239, eff 1-3-05; ss by #10196, eff 1-3-13 (from Ins 308.02); ss by #13494, eff 11-22-22

N.H. Code Admin. R. Ann. Ins 308.04 Accounting Requirements {#sec-ins-308.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 308.04}

(a) No ceding insurer subject to this rule shall reduce any liability or establish any asset in any financial statement whether or not filed with the insurance department if, by the terms of the reinsurance agreement, in substance or effect, any of the following conditions exist:

(1) Renewal expense allowances provided or to be provided to the ceding insurer by the reinsurer in any accounting period, are not sufficient to cover anticipated allocable renewal expenses of the ceding insurer on the portion of the business reinsured, unless a liability is established for the present value of the shortfall (using assumptions equal to the applicable statutory reserve basis on the business reinsured). Those expenses include commissions, premium taxes and direct expenses including, but not limited to, billing, valuation, claims and maintenance expected by the ceding insurer at the time the business is reinsured;

(2) The ceding insurer can be deprived of surplus or assets at the reinsurer's option or automatically upon the occurrence of some event, such as the insolvency of the ceding insurer, except that termination of the reinsurance agreement by the reinsurer for nonpayment of reinsurance premiums or other amounts due, such as modified coinsurance reserve adjustments, interest and adjustments on funds withheld, and tax reimbursements, shall not be considered to be such a deprivation of surplus or assets;

(3) The ceding insurer is required to reimburse the reinsurer for negative experience under the reinsurance agreement. Negative experience shall not include (1) offsetting experience refunds against current and prior years' losses under the agreement or (2) payment by the ceding insurer of an amount equal to the current and prior years' losses under the agreement upon voluntary termination of in force reinsurance by the ceding insurer. Voluntary termination does not include situations where termination occurs because of unreasonable provisions that allow the reinsurer to reduce its risk under the agreement. An example of such a provision is the right of the reinsurer to increase reinsurance premiums or risk and expense charges to excessive levels forcing the ceding insurer to prematurely terminate the reinsurance treaty;

(4) The ceding insurer shall, at specific points in time scheduled in the agreement or otherwise, terminate or automatically recapture all or part of the reinsurance ceded;

(5) The reinsurance agreement involves the possible payment by the ceding insurer to the reinsurer of amounts realized from the reinsured policies other than from income. For example, it is improper for a ceding insurer to pay reinsurance premiums, or other fees or charges to a reinsurer that are greater than the direct premiums collected by the ceding insurer;

(6) The treaty does not transfer all of the significant risk inherent in the business being reinsured. The following table identifies a representative sampling of products or type of business, the risks that are considered to be significant. For products not specifically included, the risks determined to be significant shall be consistent with this table:

Table 308.1 Risk Categories

Risk categories:

a. Morbidity;

b. Mortality;

c. Lapse

This is the risk that a policy will voluntarily terminate prior to the recoupment of a statutory surplus strain experienced at issue of the policy;

d. Credit Quality (C1)

This is the risk that invested assets supporting the reinsured business will decrease in value. The main hazards are that assets will default or that there will be a decrease in earning power. It excludes market value declines due to changes in interest rate;

e. Reinvestment (C3)

This is the risk that interest rates will fall and funds reinvested (coupon payments or monies received upon asset maturity or call) will therefore earn less than expected. If asset durations are less than liability durations, the mismatch will increase;

f. Disintermediation (C3)

This is the risk that interest rates rise and policy loans and surrenders increase or maturing contracts do not renew at anticipated rates of renewal. If asset durations are greater than the liability durations, the mismatch will increase. Policyholders will move their funds into new products offering higher rates. The company may have to sell assets at a loss to provide for these withdrawals;

- Significant 0 – Insignificant

Health Insurance – other than LTC/LTD*

Health Insurance – LTC/LTD*

Immediate Annuities

Single Premium Deferred Annuities

Flexible Premium Deferred Annuities

Guaranteed Interest Contracts

Other Annuity Deposit Business

Single Premium Whole Life

Traditional Non-Par Permanent

Traditional Non-Par Term

Traditional Par Permanent

Traditional Par Term

Adjustable Premium Permanent

Indeterminate Premium Permanent

Universal Life Flexible Premium

Universal Life Fixed Premium

dump-in premiums allowed

*LTC = Long Term Care Insurance

LTD = Long Term Disability Insurance

(7) Assets:

a. The credit quality, reinvestment, or disintermediation risk is significant for the business reinsured and the ceding insurer does not (other than for the classes of business excepted in b. below) either transfer the underlying assets to the reinsurer or legally segregate such assets in a trust or escrow account or otherwise establish a mechanism satisfactory to the commissioner that legally segregates, by contract or contract provision, the underlying assets;

b. Notwithstanding the requirements of paragraph a. above, the assets supporting the reserves for the following classes of business and any classes of business that do not have a significant credit quality, reinvestment or disintermediation risk may be held by the ceding insurer without segregation of such assets:

Health Insurance – LTC/LTD
Traditional Non-Par Permanent
Traditional Par Permanent
Adjustable Premium Permanent
Indeterminate Premium Permanent
Universal Life Fixed Premium (no dump-in premiums allowed)

c. The associated formula for determining the reserve interest rate adjustment shall use a formula that reflects the ceding insurer’s investment earnings and incorporates all realized and unrealized gains and losses reflected in the statutory statement. The following is an acceptable formula:

Rate = 2 (I + CG)

X + Y – I – CG

Where:

I is the net investment income (Exhibit 2, Line 16, Column 7)

CG is the capital gains less capital losses (Exhibit 4, Line 10, Column 6)

X is the current year cash and invested assets (Page 2, Line 10A, Column 1) plus investment income due and accrued (Page 2, Line 16, Column 1) less borrowed money (Page 3, Line 22, Column 1)

Y is the same as X but for the prior year

(8) Settlements are made less frequently than quarterly or payments due from the reinsurer are not made in cash within 90 days of the settlement date;

(9) The ceding insurer is required to make representations or warranties not reasonably related to the business being reinsured;

(10) The ceding insurer is required to make representations or warranties about future performance of the business being reinsured; and

(11) The reinsurance agreement is entered into for the principal purpose of producing significant surplus aid for the ceding insurer, typically on a temporary basis, while not transferring all of the significant risks inherent in the business required and, in substance or effect, the expected potential liability to the ceding insurer remains basically unchanged.

(b) Notwithstanding (a) above, a ceding insurer subject to this rule may, with the prior approval of the commissioner, take such reserve credit or establish such asset as the commissioner may deem consistent with RSA 405:47, including actuarial interpretations or standards adopted by the department.

(1) Agreements entered into after the effective date of this rule that involve the reinsurance of business along with any subsequent amendments thereto, shall be filed by the ceding insurer with the commissioner within 30 days from its date of execution. Each filing shall include data detailing the financial impact of the transaction. The ceding insurer's actuary who signs the financial statement actuarial opinion with respect to valuation of reserves shall consider this rule and any applicable actuarial standards of practice when determining the proper credit in financial statements filed with this department. The actuary should maintain adequate documentation and be prepared upon request to describe the actuarial work performed for inclusion in the financial statements and to demonstrate that such work conforms to this rule; and

(2) Any increase in surplus net of federal income tax resulting from arrangements described in (c)(1) shall be identified separately on the insurer's statutory financial statement as a surplus item (aggregate write-ins for gains and losses in surplus in the Capital and Surplus Account, page 4 of the Annual Statement) and recognition of the surplus increase as income shall be reflected on a net of tax basis in the "Reinsurance ceded" line, page 4 of the Annual Statement as earnings emerge from the business reinsured.

For example, on the last day of calendar year N, company XYZ pays a $20 million initial commission and expense allowance to company ABC for reinsuring an existing block of business. Assuming a 34% tax rate, the net increase in surplus at inception is $13.2 million ($20 million - $6.8 million) that is reported on the "Aggregate write-ins for gains and losses in surplus" line in the Capital and Surplus account. $6.8 million (34% of $20 million) is reported as income on the "Commissions and expense allowances on reinsurance ceded" line of the Summary of Operations.

At the end of year N+1 the business has earned $4 million. ABC has paid $.5 million in profit and risk charges in arrears for the year and has received a $1 million experience refund. Company ABC's annual statement would report $1.65 million (66% of ($4 million - $1 million - $.5 million) up to a maximum of $13.2 million) on the "Commissions and expense allowance on reinsurance ceded" line of the Summary of Operations, and -$1.65 million on the "Aggregate write-ins for gains and losses in surplus" line of the Capital and Surplus account. The experience refund would be reported separately as a miscellaneous income item in the Summary of Operations.

History

#5480, eff 10-1-92; ss by #6522, eff 6-6-97; ss by #8239, eff 1-3-05; ss by #10196, eff 1-3-13 (from Ins 308.03); ss by #13494, eff 11-22-22

N.H. Code Admin. R. Ann. Ins 308.05 Written Agreements {#sec-ins-308.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 308.05}

(a) No reinsurance agreement or amendment to any agreement may be used to reduce any liability or to establish any asset in any financial statement filed with the department, unless the agreement, amendment or a binding letter of intent has been duly executed by both parties no later than the "as of date" of the financial statement.

(b) In the case of a letter of intent, a reinsurance agreement or an amendment to a reinsurance agreement shall be executed within a reasonable period of time, not exceeding 90 days from the execution date of the letter of intent, in order for credit to be granted for the reinsurance ceded.

(1) The agreement shall constitute the entire agreement between the parties with respect to the business being reinsured thereunder and that there are no understandings between the parties other than as expressed in the agreement; and

(2) Any change or modification to the agreement shall be null and void unless made by amendment to the agreement and signed by both parties.

History

#5480, eff 10-1-92; ss by #6522, eff 6-6-97; ss by #8239, eff 1-3-05; ss by #10196, eff 1-3-13 (from Ins 308.04); ss by #13494, eff 11-22-22

N.H. Code Admin. R. Ann. Ins 308.06 Existing Agreements {#sec-ins-308.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 308.06}

Insurers subject to this rule shall reduce to zero by December 31, 1998 any reserve credits or assets established with respect to reinsurance agreements entered into prior to the effective date of this rule that, under the provisions of this rule would not be entitled to recognition of the reserve credits or assets; provided, however, that the reinsurance agreements shall have been in compliance with laws or rules in existence immediately preceding the effective date of this rule.

History

#10196, eff 1-3-13 (from Ins 308.05); ss by #13494, eff 11-22-22

N.H. Code Admin. R. Ann. Ins 308.07 Waiver or Suspension of Rules {#sec-ins-308.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 308.07}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) Waivers that are granted shall be in effect for the period of time requested and approved by the commissioner.

History

#13494, eff 11-22-22

Part Ins 309 Life Insurance Illustrations

N.H. Code Admin. R. Ann. Ins 309.01 Purpose {#sec-ins-309.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.01}

The purpose of this part is to provide rules for life insurance policy illustrations that will protect consumers and foster consumer education. The part provides illustration formats, prescribes standards to be followed when illustrations are used, and specifies the disclosures that are required in connection with illustrations. The goals of this part are to ensure that illustrations do not mislead purchasers

of life insurance and to make illustrations more understandable. Insurers will, as far as possible, eliminate the use of footnotes and caveats and define terms used in the illustration in language that would be understood by a typical person within the segment of the public to which the illustration is directed.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.02 Applicability and Scope {#sec-ins-309.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.02}

(a) This part applies to all group and individual life insurance policies and certificates except:

(1) Variable life insurance;

(2) Individual and group annuity contracts;

(3) Credit life insurance; or

(4) Life insurance policies with no illustrated death benefits on any individual exceeding $10,000.

(b) If an illustration is required to be used in the sale of a policy under this part, the insurer shall not be required to also provide a policy summary under Ins 301.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.03 Definitions {#sec-ins-309.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.03}

For the purposes of this part:

(a) “Actuarial Standards Board” means the board established by the American Academy of Actuaries to develop and promulgate standards of actuarial practice.

(b) "Contract premium" means the gross premium that is required to be paid under a fixed premium policy, including the premium for a rider for which benefits are shown in the illustration.

(c) “Currently payable scale” means a scale of non-guaranteed elements in effect for a policy form as of the preparation date of the illustration or declared to become effective within 95 days.

(d) “Disciplined current scale” means a scale of non-guaranteed elements constituting a limit on illustrations currently being illustrated by an insurer that is reasonably based on actuarial recent historical experience, as certified annually by an illustration actuary designated by the insurer. Further guidance in determining the disciplined current scale as contained in the standards established by the Actuarial Standards Board may be relied upon if the standards:

(1) Are consistent with all provisions of this part;

(2) Limit a disciplined current scale to reflect only actions that have already been taken or events that have already occurred;

(3) Do not permit a disciplined current scale to include any projected trends of improvements in experience or any assumed improvements in experience beyond the illustration date; and

(4) Do not permit assumed expenses to be less than minimum assumed expenses.

(e) “Generic name” means a short title descriptive of the policy being illustrated such as “whole life”, “term life” or “flexible premium adjustable life”.

(f) “Guaranteed elements” and "non-guaranteed elements":

(1) "Guaranteed elements" means the premiums, benefits, values, credits, or charges under a policy of life insurance that are guaranteed and determined at issue; and

(2) "Non-guaranteed elements" means the premiums, benefits, values, credits, or charges under a policy of life insurance that are not guaranteed or not determined at issue.

(g) “Illustrated scale” means a scale of non-guaranteed elements currently being illustrated that is not more favorable to the policy owner than the lesser of:

(1) The disciplined current scale; or

(2) The currently payable scale.

(h) “Illustration” means a presentation or depiction that includes non-guaranteed elements of a policy of life insurance over a period of years and that is one of the 3 types defined below:

(1) "Basic illustration" means a ledger or proposal used in the sale of a life insurance policy that shows both guaranteed and non-guaranteed elements;

(2) "Supplemental illustration" means an illustration furnished in addition to a basic illustration that meets the applicable requirements of this part, and that may be presented in a format differing from the basic illustration, but may only depict a scale of non-guaranteed elements that is permitted in a basic illustration; or

(3) "In force illustration" means an illustration furnished at any time after the policy that it depicts has been in force for one year or more.

(i) “Illustration actuary” means an actuary meeting the requirements of Ins 309.10, who certifies to illustrations based on the standards of practice promulgated by the Actuarial Standards Board.

(j) "Lapse-supported illustration" means an illustration of a policy form failing the test of self-supporting as defined in this part, under a modified persistency rate assumption using persistency rates underlying the disciplined current scale for the first 5 years and 100 percent policy persistency thereafter.

(k) “Minimum assumed expenses” means the minimum expenses that may be used in the calculation of the disciplined current scale for a policy form. The insurer may choose to designate each year the method of determining assumed expenses for all policy forms from the following:

(1) Fully allocated expenses;

(2) Marginal expenses; or

(3) A generally recognized expense table based on fully allocated expenses representing a significant portion of insurance companies and published by the National Association of Insurance Commissioners and approved by the commissioner.

(l) Marginal expenses may be used only if greater than a generally recognized expense table. If no generally recognized expense table is approved, fully allocated expenses shall be used.

(m) “Non-term group life” means a group policy or individual policies of life insurance issued to members of an employer group or other permitted group where:

(1) Every plan of coverage was selected by the employer or other group representative;

(2) Some portion of the premium is paid by the group or through payroll deduction; and

(3) Group underwriting or simplified underwriting is used.

(n) “Policy owner” means the owner named in the policy or the certificate holder in the case of a group policy.

(o) “Premium outlay” means the amount of premium assumed to be paid by the policy owner or other premium payer out-of-pocket.

(p) "Self-supporting illustration" means an illustration of a policy form for which it can be demonstrated that, when using experience assumptions underlying the disciplined current scale, for all illustrated points in time on or after the 15th policy anniversary or the 20th policy anniversary for second-or-later-to-die policies, or upon policy expiration if sooner, the accumulated value of all policy cash flows equals or exceeds the total policy owner value available. For this purpose, policy owner value will include cash surrender values and any other illustrated benefit amounts available at the policy owner's election.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.04 Policies to be Illustrated {#sec-ins-309.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.04}

(a) Each insurer marketing policies to which this part is applicable shall notify the commissioner whether a policy form is to be marketed with or without an illustration. For all policy forms being actively marketed on the effective date of this part, the insurer shall identify in writing those forms and whether or not an illustration will be used with them. For policy forms filed after the effective date of this part, the identification shall be made at the time of filing. Any previous identification may be changed by notice to the commissioner.

(b) If the insurer identifies a policy form as one to be marketed without an illustration, any use of an illustration for any policy using that form prior to the first policy anniversary is prohibited.

(c) If a policy form is identified by the insurer as one to be marketed with an illustration, a basic illustration prepared and delivered in accordance with this part is required, except that a basic illustration need not be provided to individual members of a group or to individuals insured under multiple lives coverage issued to a single applicant, unless the coverage is marketed to these individuals. The illustration furnished to an applicant for a group life insurance policy or policies issued to a single applicant on multiple lives shall be either an individual or composite illustration, representative of the coverage on the lives of members of the group or the multiple lives covered.

(d) Potential enrollees of non-term group life subject to this part shall be furnished a quotation with the enrollment materials. The quotation shall show potential policy values for sample ages and policy years on a guaranteed and non-guaranteed basis appropriate to the group and the coverage. This quotation shall not be considered an illustration for purposes of this part, but all information provided shall be consistent with the illustrated scale. A basic illustration shall be provided at delivery of the certificate to enrollees for non-term group life who enroll for more than the minimum premium necessary to provide pure death benefit protection. In addition, the insurer shall make a basic illustration available to any non-term group life enrollee who requests it.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.05 General Rules and Prohibitions {#sec-ins-309.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.05}

(a) An illustration used in the sale of a life insurance policy shall satisfy the applicable requirements of this part, be clearly labeled "life insurance illustration", and contain the following basic information:

(1) Name of insurer;

(2) Name and business address of producer or insurer’s authorized representative, if any;

(3) Name, age, and sex of proposed insured, except where a composite illustration is permitted under this part;

(4) Underwriting or rating classification upon which the illustration is based;

(5) Generic name of policy, the company product name, if different, and form number;

(6) Initial death benefit; and

(7) Dividend option election or application of non-guaranteed elements, if applicable.

(b) When using an illustration in the sale of a life insurance policy, an insurer or its producers or other authorized representatives shall not:

(1) Represent the policy as anything other than a life insurance policy;

(2) Use or describe non-guaranteed elements in a manner that is misleading or has the capacity or tendency to mislead;

(3) State or imply that the payment or amount of non-guaranteed elements is guaranteed;

(4) Use an illustration that does not comply with the requirements of this part;

(5) Use an illustration that at any policy duration depicts policy performance more favorable to the policy owner than that produced by the illustrated scale of the insurer whose policy is being illustrated;

(6) Provide an applicant with an incomplete illustration;

(7) Represent in any way that premium payments will not be required for each year of the policy in order to maintain the illustrated death benefits, unless that is the fact;

(8) Use the term “vanish” or “vanishing premium” or a similar term that implies the policy becomes paid up to describe a plan for using non-guaranteed elements to pay a portion of future premiums;

(9) Except for policies that can never develop non-forfeiture values, use an illustration that is "lapse-supported"; or

(10) Use an illustration that is not "self-supporting".

(c) If an interest rate used to determine the illustrated non-guaranteed elements is shown, it shall not be greater than the earned interest rate underlying the disciplined current scale.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.06 Standards for Basic Illustrations {#sec-ins-309.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.06}

(a) Format. A basic illustration shall conform to the following requirements:

(1) The illustration shall be labeled with the date on which it was prepared;

(2) Each page, including any explanatory notes or pages, shall be numbered and show its relationship to the total number of pages in the illustration (e.g., the 4th page of a 7-page illustration shall be labeled "page 4 of 7 pages");

(3) The assumed dates of payment receipt and benefit pay-out within a policy year shall be clearly identified;

(4) If the age of the proposed insured is shown as a component of the tabular detail, it shall be issue age plus the number of years the policy is assumed to have been in force;

(5) The assumed payments on which the illustrated benefits and values are based shall be identified as premium outlay or contract premium, as applicable. For policies that do not require a specific contract premium, the illustrated payments shall be identified as premium outlay;

(6) Guaranteed death benefits and values available upon surrender, if any, for the illustrated premium outlay or contract premium shall be shown and clearly labeled guaranteed;

(7) If the illustration shows any non-guaranteed elements, they cannot be based on a scale more favorable to the policy owner than the insurer's illustrated scale at any duration. These elements shall be clearly labeled non-guaranteed;

(8) The guaranteed elements, if any, shall be shown before corresponding non-guaranteed elements and shall be specifically referred to on any page of an illustration that shows or describes only the non-guaranteed elements (e.g., "see page one for guaranteed elements");

(9) The account or accumulation value of a policy, if shown, shall be identified by the name this value is given in the policy being illustrated and shown in close proximity to the corresponding value available upon surrender;

(10) The value available upon surrender shall be identified by the name this value is given in the policy being illustrated and shall be the amount available to the policy owner in a lump sum after deduction of surrender charges, policy loans, and policy loan interest, as applicable;

(11) Illustrations may show policy benefits and values in graphic or chart form in addition to the tabular form;

(12) Any illustration of non-guaranteed elements shall be accompanied by a statement indicating that:

a. The benefits and values are not guaranteed;

b. The assumptions on which they are based are subject to change by the insurer; and

c. Actual results may be more or less favorable;

(13) If the illustration shows that the premium payer may have the option to allow policy charges to be paid using non-guaranteed values, the illustration must clearly disclose that a charge continues to be required and that, depending on actual results, the premium payer may need to continue or resume premium outlays. Similar disclosure shall be made for premium outlay of lesser amounts or shorter durations than the contract premium. If a contract premium is due, the premium outlay display shall not be left blank or show zero unless accompanied by an asterisk or similar mark to draw attention to the fact that the policy is not paid up; and

(14) If the applicant plans to use dividends or policy values, guaranteed or non-guaranteed, to pay all or a portion of the contract premium or policy charges, or for any other purpose, the illustration may reflect those plans and the impact on future policy benefits and values.

(b) Narrative Summary. A basic illustration shall include the following:

(1) A brief description of the policy being illustrated, including a statement that it is a life insurance policy;

(2) A brief description of the premium outlay or contract premium, as applicable for the policy. For a policy that does not require payment of a specific contract premium, the illustration shall show the premium outlay that must be paid to guarantee coverage for the term of the contract, subject to maximum premiums allowable to qualify as a life insurance policy under the applicable provisions of the internal revenue code;

(3) A brief description of any policy features, riders or options, guaranteed or non-guaranteed, shown in the basic illustration and the impact they may have on the benefits and values of the policy;

(4) Identification and a brief definition of column headings and key terms used in the illustration; and

(5) A statement containing in substance the following: "This illustration assumes that the currently illustrated non-guaranteed elements will continue unchanged for all years shown. This is not likely to occur, and actual results may be more or less favorable than those shown."

(1) Following the narrative summary, a basic illustration shall include a numeric summary of the death benefits and values and the premium outlay and contract premium, as applicable. For a policy that provides for a contract premium, the guaranteed death benefits and values shall be based on the contract premium. This summary shall be shown for at least policy years 5, 10, and 20, and at age 70, if applicable, on the 3 bases shown below. For multiple life policies, the summary shall show policy years 5, 10, 20, and 30:

a. Policy guarantees;

b. Insurer’s illustrated scale;

c. Insurer's illustrated scale used but with the non-guaranteed elements reduced as follows:

Dividends at 50% of the dividends contained in the illustrated scale used;
Non-guaranteed credited interest at rates that are the average of the guaranteed rates and the rates contained in the illustrated scale used; and
All non-guaranteed charges, including but not limited to term insurance charges, mortality and expense charges, at rates that are the average of the guaranteed rates and the rates contained in the illustrated scale used; and

(2) In addition, if coverage would cease prior to policy maturity or age 100, the year in which coverage ceases shall be identified for each of the 3 bases.

(d) Statements. Statements substantially similar to the following shall be included on the same page as the numeric summary and signed by the applicant, or the policy owner in the case of an illustration provided at time of delivery, as required in this part:

(1) A statement to be signed and dated by the applicant or policy owner reading as follows: “I have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be either higher or lower. The agent has told me they are not guaranteed.”; or

(2) A statement to be signed and dated by the insurance producer or other authorized representative of the insurer reading as follows: "I certify that this illustration has been presented to the applicant and that I have explained that any non-guaranteed elements illustrated are subject to change. I have made no statements that are inconsistent with the illustration”.

(e) Tabular Detail.

(1) A basic illustration shall include the following for at least each policy year from one to 10 and for every 5th policy year thereafter ending at age 100, policy maturity, or final expiration and, except for term insurance beyond the 20th year, for any year in which the premium outlay and contract premium, if applicable, is to change:

a. The premium outlay and mode the applicant plans to pay and the contact premium, as applicable;

b. The corresponding guaranteed death benefit, as provided in the policy; and

c. The corresponding guaranteed value available upon surrender, as provided in the policy;

(2) For a policy that provides for a contract premium, the guaranteed death benefit and value available upon surrender shall correspond to the contract premium; and

(3) Non-guaranteed elements may be shown if described in the contract. In the case of an illustration for a policy on which the insurer intends to credit terminal dividends, they may be shown if the insurer's current practice is to pay terminal dividends. If any non-guaranteed elements are shown they must be shown at the same durations as the corresponding guaranteed elements, if any. If no guaranteed benefit or value is available at any duration for which a non-guaranteed benefit or value is shown, a zero shall be displayed in the guaranteed column.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.07 Standards for Supplemental Illustrations {#sec-ins-309.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.07}

(a) A supplemental illustration may be provided so long as:

(1) It is appended to, accompanied by, or preceded by a basic illustration that complies with this part;

(2) The non-guaranteed elements shown are not more favorable to the policy owner than the corresponding elements based on the scale used in the basic illustration;

(3) It contains the same statement required of a basic illustration that non-guaranteed elements are not guaranteed; and

(4) For a policy that has a contract premium, the contract premium underlying the supplemental illustration is equal to the contract premium shown in the basic illustration. For policies that do not require a contract premium, the premium outlay underlying the supplemental illustration shall be equal to the premium outlay shown in the basic illustration.

(b) The supplemental illustration shall include a notice referring to the basic illustration for guaranteed elements and other important information.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.08 Delivery of Illustration and Record Retention {#sec-ins-309.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.08}

(a) (1) If a basic illustration is used by an insurance producer or other authorized representative of the insurer in the sale of a life insurance policy and the policy is applied for as illustrated, a copy of that illustration, signed in accordance with this part, shall be submitted to the insurer at the time of policy application. A copy also shall be provided to the applicant; and

(2) If the policy is issued other than as applied for, a revised basic illustration conforming to the policy as issued shall be sent with the policy. The revised illustration shall conform to the requirements of this part, shall be labeled "Revised Illustration" and shall be signed and dated by the applicant or policy owner and producer or other authorized representative of the insurer no later than the time the policy is delivered. A copy shall be provided to the insurer and the policy owner.

(b) (1) If no illustration is used by an insurance producer or other authorized representative in the sale of a life insurance policy or if the policy is applied for other than as illustrated, the producer or representative shall certify to that effect in writing on a form provided by the insurer. On the same form the applicant shall acknowledge that no illustration conforming to the policy applied for was provided and shall further acknowledge an understanding that an illustration conforming to the policy as issued will be provided no later than at the time of policy delivery. This form shall be submitted to the insurer at the time of policy application; and

(2) If the policy is issued, a basic illustration conforming to the policy as issued shall be sent with the policy and signed no later than the time the policy is delivered. A copy shall be provided to the insurer and the policy owner.

(c) If the basic illustration or revised illustration is sent to the applicant or policy owner by mail from the insurer, it shall include instructions for the applicant or policy owner to sign the duplicate copy of the numeric summary page of the illustration for the policy issued and return the signed copy to the insurer. The insurer's obligation under this subsection shall be satisfied if it can demonstrate that it has made a diligent effort to secure a signed copy of the numeric summary page. The requirement to make a diligent effort shall be deemed satisfied if the insurer includes in the mailing a self-addressed postage paid envelope with instructions for the return of the signed numeric summary page.

(d) A copy of the basic illustration and a revised basic illustration, if any, signed as applicable, along with any certification that either no illustration was used or that the policy was applied for other than as illustrated, shall be retained by the insurer until 3 years after the policy is no longer in force. A copy need not be retained if no policy is issued.

History

#7195, eff 4-1-00; amd by #7565, eff 1-1-02; EXPIRED: 4-1-08 except for paras. (a) intro, and paragraphs (a)(1)-(5); ss by #9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.09 Annual Report; Notice to Policy Owners {#sec-ins-309.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.09}

(a) In the case of a policy designated as one for which illustrations will be used, the insurer shall provide each policy owner with an annual report on the status of the policy that shall contain at least the following information:

(1) For universal life policies, the report shall include the following:

a. The beginning and end date of the current report period;

b. The policy value at the end of the previous report period and at the end of the current report period;

c. The total amounts that have been credited or debited to the policy value during the current report period, identifying each by type (e.g., interest, mortality, expense and rider);

d. The current death benefit at the end of the current report period on each life covered by the policy;

e. The net cash surrender value of the policy as of the end of the current report period;

f. The amount of outstanding loans, if any, as of the end of the current report period;

g. For fixed premium policies, if, assuming guaranteed interest, mortality and expense loads, and continued scheduled premium payments, the policy’s net cash surrender value is such that it would not maintain insurance in force until the end of the next reporting period, a notice to this effect shall be included in the report; and

h. For flexible premium policies, if, assuming guaranteed interest, mortality and expense loads, the policy’s net cash surrender value will not maintain insurance in force until the end of the next reporting period unless further premium payments are made, a notice to this effect shall be included in the report;

(2) For all other policies, where applicable:

a. Current death benefit;

b. Annual contract premium;

c. Current cash surrender value;

d. Current dividend;

e. Application of current dividend; and

f. Amount of outstanding loan.

(b) Insurers writing life insurance policies that do not build non-forfeiture values shall only be required to provide an annual report with respect to these policies for those years when a change has been made to non-guaranteed policy elements by the insurer.

(c) If the annual report does not include an in force illustration, it shall contain the following notice displayed prominently: “IMPORTANT POLICY OWNER NOTICE: You should consider requesting more detailed information about your policy to understand how it may perform in the future. You should not consider replacement of your policy or make changes in your coverage without requesting a current illustration. You may annually request, without charge, such an illustration by calling (insurer's phone number), writing to (insurer's name) at (insurer's address) or contacting your agent. If you do not receive a current illustration of your policy within 30 days from your request, you should contact your state insurance department." The insurer may vary the sequential order of the methods for obtaining an in force illustration.

(d) Upon request of the policy owner the insurer shall furnish an in force illustration of current and future benefits and values based on the insurer's present illustrated scale. This illustration shall comply with the requirements of Ins 309.05(a), Ins 309.05(b), Ins 309.05(c), Ins 309.06(a), and Ins 309.06(d). No signature or other acknowledgment of receipt of this illustration shall be required.

(e) If an adverse change in non-guaranteed elements that could affect the policy has been made by the insurer since the last annual report, the annual report shall contain a notice of that fact and the nature of the change prominently displayed.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.10 Annual Certifications {#sec-ins-309.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.10}

(a) The board of directors of each insurer shall appoint one or more illustration actuaries.

(b) The illustration actuary shall certify that the disciplined current scale used in illustrations is in conformity with the Actuarial Standards of Practice for Compliance with the NAIC Model Regulation on Life Insurance Illustrations promulgated by the Actuarial Standards Board, No. 24, available as indicated in Appendix B, and that the illustrated scales used in insurer-authorized illustrations meet the requirements of this part.

(1) Be a member in good standing of the American Academy of Actuaries;

(2) Be familiar with the standards of practice regarding life insurance policy illustrations;

(3) Not have been found by the commissioner, following appropriate notice and hearing, to have:

a. Violated any provision of, or any obligation imposed by, the insurance laws or other laws in the course of his or her dealings as an illustration actuary;

b. Been found guilty of fraudulent or dishonest practices;

c. Demonstrated his or her incompetence, lack of cooperation, or untrustworthiness to act as an illustration actuary; or

d. Resigned or been removed as an illustration actuary within the past 5 years as a result of acts or omissions indicated in any adverse report or examination or as a result of a failure to adhere to generally acceptable actuarial standards;

(4) Not fail to notify the commissioner of any action taken by a commissioner of another state similar to that under paragraph (3) above;

(5) Disclose in the annual certification whether, since the last certification, a currently payable scale applicable for business issued within the previous five years and within the scope of the certification has been reduced for reasons other than changes in the experience factors underlying the disciplined current scale. If non-guaranteed elements illustrated for new policies are not consistent with those illustrated for similar in force policies, this must be disclosed in the annual certification. If non-guaranteed elements illustrated for both new and in force policies are not consistent with the non-guaranteed elements actually being paid, charged, or credited to the same or similar forms, this must be disclosed in the annual certification; and

(6) Disclose in the annual certification the method used to allocate overhead expenses for all illustrations:

a. Fully allocated expenses;

b. Marginal expenses; or

c. A generally recognized expense table based on fully allocated expenses representing a significant portion of insurance companies and published by the NAIC and approved by the commissioner.

(d) The illustration actuary shall file a certification with the board and with the commissioner:

(1) Annually for all policy forms for which illustrations are used; and

(2) Before a new policy form is illustrated.

(e) If an error in a previous certification is discovered, the illustration actuary shall notify the board of directors of the insurer and the commissioner promptly.

(f) If an illustration actuary is unable to certify the scale for any policy form illustration the insurer intends to use, the actuary shall notify the board of directors of the insurer and the commissioner promptly of his or her inability to certify.

(g) A responsible officer of the insurer, other than the illustration actuary, shall certify annually:

(1) That the illustration formats meet the requirements of this part and that the scales used in insurer authorized illustrations are those scales certified by the illustration actuary; and

(2) That the company has provided its agents with information about the expense allocation method used by the company in its illustrations and disclosed as required in Ins 309.10(c)(6).

(h) The annual certifications shall be provided to the commissioner each year by a date determined by the insurer.

(i) If the insurer changes the illustration actuary responsible for all or a portion of the company's policy forms, the insurer shall notify the commissioner of that fact promptly and disclose the reason for the change.

History

#7195, eff 4-1-00; amd by #7565, eff 1-1-02; EXPIRED: 4-1-08, except for para. (d); ss by #9401, eff 3-9-09; ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.11 Penalties {#sec-ins-309.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.11}

In addition to any other penalties provided by the laws of this state, an insurer or producer that violates a requirement of this rule shall be guilty of a violation of RSA 417.

History

#7195, eff 4-1-00, EXPIRED: 4-1-08
#9401, eff 3-9-09 (formerly Ins 309.12); ss by #12097, eff 3-9-17

N.H. Code Admin. R. Ann. Ins 309.12 Effective Date and Policy Sales {#sec-ins-309.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 309.12}

All policies sold on or after the effective date of this part shall be subject to the provisions herein.

History

#7195, eff 4-1-00; amd by #7565, eff 1-1-02; EXPIRED: 4-1-08 except for paras. (a), (b), (d), (g), & (i); ss by #9401, eff 3-9-09 (formerly Ins 309.11); ss by #12097, eff 3-9-17

Part Ins 310 Military Sales Practices

N.H. Code Admin. R. Ann. Ins 310.01 Purpose {#sec-ins-310.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 310.01}

(a) The purpose of this part is to set forth standards to protect active duty service members of the United States armed forces from dishonest and predatory insurance sales practices by declaring certain identified practices to be false, misleading, deceptive or unfair.

(b) Nothing herein shall be construed to create or imply a private cause of action for a violation of this part.

History

#9042, eff 12-1-07, EXPIRED: 12-1-15
#11078, eff 4-22-16; ss by #14639, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 310.02 Scope {#sec-ins-310.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 310.02}

This part shall apply only to the solicitation or sale of any life insurance or annuity product by an insurer or insurance producer to an active duty service member of the United States armed forces.

History

#9042, eff 12-1-07, EXPIRED: 12-1-15
#11078, eff 4-22-16; ss by #14639, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 310.03 Exemptions {#sec-ins-310.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 310.03}

(a) This part shall not apply to solicitations or sales involving:

(1) Credit insurance;

(2) Group life insurance or group annuities where there is no in-person, face-to-face solicitation of individuals by an insurance producer or where the contract or certificate does not include a side fund;

(3) An application to the existing insurer that issued the existing policy or contract when a contractual change or a conversion privilege is being exercised; or, when the existing policy or contract is being replaced by the same insurer pursuant to a program filed and approved by the commissioner; or, when a term conversion privilege is exercised among corporate affiliates;

(4) Individual stand-alone health policies, including disability income policies;

(5) Contracts offered by Servicemembers' Group Life Insurance (SGLI) or Veterans' Group Life Insurance (VGLI), as authorized by 38 U.S.C. section 1965 et seq.;

(6) Life insurance contracts offered through or by a non-profit military association, qualifying under section 501 (c)(23) of the Internal Revenue Code (IRC), and which are not underwritten by an insurer; or

(7) Contracts used to fund:

a. An employee pension or welfare benefit plan that is covered by the Employee Retirement and Income Security Act (ERISA);

b. A plan described by sections 401(a), 401(k), 403(b), 408(k) or 408(p) of the IRC, as amended, if established or maintained by an employer;

c. A government or church plan defined by section 414 of the IRC, a government or church welfare benefit plan, or a deferred compensation plan of a state or local government or tax exempt organization under section 457 of the IRC;

d. A nonqualified deferred compensation arrangement established or maintained by an employer or plan sponsor;

e. Settlements of or assumptions of liabilities associated with personal injury litigation or any dispute or claim resolution process; or

f. Prearranged funeral contracts.

(b) Nothing herein shall be construed to abrogate the ability of nonprofit organizations, and/or other organizations, to educate members of the United States Armed Forces in accordance with Department of Defense DoD Instruction 1344.07 - PERSONAL COMMERCIAL SOLICITATION ON DoD INSTALLATIONS or successor directive.

(c) For purposes of this part, general advertisements, direct mail and internet marketing shall not constitute "solicitation." Telephone marketing shall not constitute "solicitation" provided the caller explicitly and conspicuously discloses that the product concerned is life insurance and makes no statements that avoid a clear and unequivocal statement that life insurance is the subject matter of the solicitation. Provided however, nothing in this subsection shall be construed to exempt an insurer or insurance producer from this part in any in-person, face-to-face meeting established as a result of the "solicitation" exemptions identified in this subsection.

History

#9042, eff 12-1-07, EXPIRED: 12-1-15
#11078, eff 4-22-16; ss by #14639, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 310.04 Definitions {#sec-ins-310.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 310.04}

(a) "Active Duty" means full-time duty in the active military service of the United States and includes members of the reserve component, National Guard and Reserve, while serving under published orders for active duty or full-time training. The term does not include members of the reserve component who are performing active duty or active duty for training under military calls or orders specifying periods of less than 31 calendar days.

(b) "Department of Defense (DoD) Personnel" means all active duty service members and all civilian employees, including non-appropriated fund employees and special government employees, of the Department of Defense.

(c) "Door to Door" means a solicitation or sales method whereby an insurance producer proceeds randomly or selectively from household to household without prior specific appointment.

(d) "General Advertisement" means an advertisement having as its sole purpose the promotion of the reader's or viewer's interest in the concept of insurance, or the promotion of the insurer or the insurance producer.

(e) "Insurer" means an insurance company required to be licensed under the laws of this state to provide life insurance products, including annuities.

(f) "Insurance producer" means a person required to be licensed under the laws of this state to sell, solicit or negotiate life insurance, including annuities.

(g) "Known" or "Knowingly" means, depending on its use herein, the insurance producer or insurer had actual awareness, or in the exercise of ordinary care should have known, at the time of the act or practice complained of, that the person solicited is a service member.

(h) "Life insurance" means insurance coverage on human lives including benefits of endowment and annuities, and may include benefits in the event of death or dismemberment by accident and benefits for disability income and unless otherwise specifically excluded, includes individually issued annuities.

(i) "Military Installation" means any federally owned, leased, or operated base, reservation, post, camp, building, or other facility to which service members are assigned for duty, including barracks, transient housing, and family quarters.

(j) "MyPay" is a Defense Finance and Accounting Service (DFAS) web-based system that enables service members to process certain discretionary pay transactions or provide updates to personal information data elements without using paper forms.

(k) "Service Member" means any active duty officer, commissioned and warrant, or enlisted member of the United States Armed Forces.

(l) "Side Fund" means a fund or reserve that is part of or otherwise attached to a life insurance policy, excluding individually issued annuities, by rider, endorsement or other mechanism which accumulates premium or deposits at interest or by other means. The term does not include:

(1) Accumulated value or cash value or secondary guarantees provided by a universal life policy;

(2) Cash values provided by a whole life policy which are subject to standard nonforfeiture laws for life insurance; or

(3) A premium deposit fund which:

a. Contains only premiums paid in advance which accumulate at interest;

b. Imposes no penalty for withdrawal;

c. Does not permit funding beyond future required premiums;

d. Is not marketed or intended as an investment; and

e. Does not carry a commission, either paid or calculated.

(m) "Specific Appointment" means a prearranged appointment agreed upon by both parties and definite as to place and time.

(n) "United States Armed Forces" means all components of the Army, Navy, Air Force, Marine Corps, and Coast Guard.

History

#9042, eff 12-1-07, EXPIRED: 12-1-15
#11078, eff 4-22-16; ss by #14639, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 310.05 Practices Declared False, Misleading, Deceptive or Unfair on a Military Installation {#sec-ins-310.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 310.05}

(a) The following acts or practices when committed on a military installation by an insurer or insurance producer with respect to the in-person, face-to-face solicitation of life insurance are declared to be false, misleading, deceptive or unfair:

(1) Knowingly soliciting the purchase of any life insurance product "door to door" or without first establishing a specific appointment for each meeting with the prospective purchaser;

(2) Soliciting service members in a group or "mass" audience or in a "captive" audience where attendance is not voluntary;

(3) Knowingly making appointments with or soliciting service members during their normally scheduled duty hours;

(4) Making appointments with or soliciting service members in barracks, day rooms, unit areas, or transient personnel housing or other areas where the installation commander has prohibited solicitation;

(5) Soliciting the sale of life insurance without first obtaining permission from the installation commander or the commander's designee;

(6) Posting unauthorized bulletins, notices or advertisements;

(7) Failing to present DD Form 2885, Personal Commercial Solicitation Evaluation, to service members solicited or encouraging service members solicited not to complete or submit a DD Form 2885; or

(8) Knowingly accepting an application for life insurance or issuing a policy of life insurance on the life of an enlisted member of the United States Armed Forces without first obtaining for the insurer's files a completed copy of any required form which confirms that the applicant has received counseling or fulfilled any other similar requirement for the sale of life insurance established by regulations, directives or rules of the DoD or any branch of the Armed Forces.

(b) The following acts or practices when committed on a military installation by an insurer or insurance producer constitute corrupt practices, improper influences or inducements and are declared to be false, misleading, deceptive or unfair:

(1) Using DoD personnel, directly or indirectly, as a representative or agent in any official or business capacity with or without compensation with respect to the solicitation or sale of life insurance to service members; or

(2) Using an insurance producer to participate in any United States Armed Forces sponsored education or orientation program.

History

#9042, eff 12-1-07, EXPIRED: 12-1-15
#11078, eff 4-22-16; ss by #14639, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 310.06 Practices Declared False, Misleading, Deceptive or Unfair Regardless of Location {#sec-ins-310.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 310.06}

(a) The following acts or practices by an insurer or insurance producer constitute corrupt practices, improper influences or inducements and are declared to be false, misleading, deceptive or unfair:

(1) Submitting, processing or assisting in the submission or processing of any allotment form or similar device used by the United States Armed Forces to direct a service member's pay to a third party for the purchase of life insurance. The foregoing includes, but is not limited to, using or assisting in using a service member's "MyPay" account or other similar internet or electronic medium for such purposes. This subsection does not prohibit assisting a service member by providing insurer or premium information necessary to complete any allotment form;

(2) Knowingly receiving funds from a service member for the payment of premium from a depository institution with which the service member has no formal banking relationship. For purposes of this section, a formal banking relationship is established when the depository institution:

a. Provides the service member a deposit agreement and periodic statements and makes the disclosures required by the Truth in Savings Act, 12 U.S.C. § 4301 et seq. and the regulations promulgated thereunder; and

b. Permits the service member to make deposits and withdrawals unrelated to the payment or processing of insurance premiums.

(3) Employing any device or method or entering into any agreement whereby funds received from a service member by allotment for the payment of insurance premiums are identified on the service member's Leave and Earnings Statement or equivalent or successor form as "savings" or "checking" and where the service member has no formal banking relationship as defined in (a)(2) above;

(4) Entering into any agreement with a depository institution for the purpose of receiving funds from a service member whereby the depository institution, with or without compensation, agrees to accept direct deposits from a service member with whom it has no formal banking relationship;

(5) Using DoD personnel, directly or indirectly, as a representative or agent in any official or unofficial capacity with or without compensation with respect to the solicitation or sale of life insurance to service members who are junior in rank or grade, or to the family members of such personnel;

(6) Offering or giving anything of value, directly or indirectly, to DoD personnel to procure their assistance in encouraging, assisting or facilitating the solicitation or sale of life insurance to another service member.

(7) Knowingly offering or giving anything of value to a service member for his or her attendance to any event where an application for life insurance is solicited; or

(8) Advising a service member to change their income tax withholding or state of legal residence for the sole purpose of increasing disposable income to purchase life insurance.

(b) The following acts or practices by an insurer or insurance producer lead to confusion regarding source, sponsorship, approval or affiliation and are declared to be false, misleading, deceptive or unfair:

(1) Making any representation, or using any device, title, descriptive name or identifier that has the tendency or capacity to confuse or mislead a service member into believing that the insurer, insurance producer or product offered is affiliated, connected or associated with, endorsed, sponsored, sanctioned or recommended by the U.S. Government, the United States Armed Forces, or any state or federal agency or government entity. Examples of prohibited insurance producer titles include, but are not limited to, "Battalion Insurance Counselor," "Unit Insurance Advisor," "Servicemen's Group Life Insurance Conversion Consultant" or "Veteran's Benefits Counselor." Nothing herein shall be construed to prohibit a person from using a professional designation awarded after the successful completion of a course of instruction in the business of insurance by an accredited institution of higher learning. Such designations include, but are not limited to, Chartered Life Underwriter (CLU), Chartered Financial Consultant (ChFC), Certified Financial Planner (CFP), Master of Science in Financial Services (MSFS), or Masters of Science Financial Planning (MS);

(2) Soliciting the purchase of any life insurance product through the use of or in conjunction with any third party organization that promotes the welfare of or assists members of the United States Armed Forces in a manner that has the tendency or capacity to confuse or mislead a service member into believing that either the insurer, insurance producer or insurance product is affiliated, connected or associated with, endorsed, sponsored, sanctioned or recommended by the U.S. Government, or the United States Armed Forces.

(c) The following acts or practices by an insurer or insurance producer lead to confusion regarding premiums, costs or investment returns and are declared to be false, misleading, deceptive or unfair:

(1) Using or describing the credited interest rate on a life insurance policy in a manner that implies that the credited interest rate is a net return on premium paid; or

(2) Excluding individually issued annuities, misrepresenting the mortality costs of a life insurance product, including or implying that the product "costs nothing" or is "free”.

(d) The following acts or practices by an insurer or insurance producer regarding SGLI or VGLI are declared to be false, misleading, deceptive or unfair:

(1) Making any representation regarding the availability, suitability, amount, cost, exclusions or limitations to coverage provided to a service member or dependents by SGLI or VGLI, which is false, misleading or deceptive;

(2) Making any representation regarding conversion requirements, including the costs of coverage, or exclusions or limitations to coverage of SGLI or VGLI to private insurers which is false, misleading or deceptive; or

(3) Suggesting, recommending or encouraging a service member to cancel or terminate their SGLI policy or issuing a life insurance policy which replaces an existing SGLI policy unless the replacement shall take effect upon or after the service member's separation from the United States Armed Forces.

(e) The following acts or practices by an insurer and or insurance producer regarding disclosure are declared to be false, misleading, deceptive or unfair:

(1) Deploying, using or contracting for any lead generating materials designed exclusively for use with service members that do not clearly and conspicuously disclose that the recipient will be contacted by an insurance producer, if that is the case, for the purpose of soliciting the purchase of life insurance;

(2) Failing to disclose that a solicitation for the sale of life insurance will be made when establishing a specific appointment for an in-person, face-to-face meeting with a prospective purchaser;

(3) Excluding individually issued annuities, failing to clearly and conspicuously disclose the fact that the product being sold is life insurance;

(4) Failing to make, at the time of sale or offer to an individual known to be a service member, the written disclosures required by Section 10 of the "Military Personnel Financial Services Protection Act," Pub. L. No. 109-290, p. 16; or

(5) Excluding individually issued annuities, when the sale is conducted in-person face-to-face with an individual known to be a service member, failing to provide the applicant at the time the application is taken:

a. An explanation of any free look period with instructions on how to cancel if a policy is issued; and

b. Either a copy of the application or a written disclosure. The copy of the application or the written disclosure shall clearly and concisely set out the type of life insurance, the death benefit applied for and its expected first year cost. A basic illustration that meets the requirement of Ins 309 shall be deemed sufficient to meet this requirement for a written disclosure.

(f) The following acts or practices by an insurer or insurance producer with respect to the sale of certain life insurance products are declared to be false, misleading, deceptive or unfair:

(1) Excluding individually issued annuities, recommending the purchase of any life insurance product which includes a side fund to a service member in pay grades E-4 and below unless the insurer has reasonable grounds for believing that the life insurance death benefit, standing alone, is suitable; or

(2) Offering for sale or selling a life insurance product which includes a side fund to a service member in pay grades E-4 and below who is currently enrolled in SGLI, is presumed unsuitable unless, after the completion of a needs assessment, the insurer demonstrates that the applicant's SGLI death benefit, together with any other military survivor benefits, savings and investments, survivor income, and other life insurance are insufficient to meet the applicant's insurable needs for life insurance:

a. "Insurable needs" are the risks associated with premature death taking into consideration the financial obligations and immediate and future cash needs of the applicant's estate and/or survivors or dependents.

b. "Other military survivor benefits" include, but are not limited to: the Death Gratuity, Funeral Reimbursement, Transition Assistance, Survivor and Dependent's Educational Assistance, Dependency and Indemnity Compensation, TRICARE Healthcare benefits, Survivor Housing Benefits and Allowances, Federal Income Tax Forgiveness, and Social Security Survivor Benefits.

(g) Excluding individually issued annuities, offering for sale or selling any life insurance contract which includes a side fund:

(1) Unless interest credited accrues from the date of deposit to the date of withdrawal and permits withdrawals without limit or penalty;

(2) Unless the applicant has been provided with a schedule of effective rates of return based upon cash flows of the combined product. For this disclosure, the effective rate of return will consider all premiums and cash contributions made by the policyholder and all cash accumulations and cash surrender values available to the policyholder in addition to life insurance coverage. This schedule will be provided for at least each policy year from one to 10 and for every fifth policy year thereafter ending at age 100, policy maturity or final expiration; and

(3) Which by default diverts or transfers funds accumulated in the side fund to pay, reduce or offset any premiums due.

(h) Excluding individually issued annuities, offering for sale or selling any life insurance contract which after considering all policy benefits, including but not limited to endowment, return of premium or persistency, does not comply with standard nonforfeiture law for life insurance.

(i) Selling any life insurance product to an individual known to be a service member that excludes coverage if the insured's death is related to war, declared or undeclared, or any act related to military service except for an accidental death coverage, e.g., double indemnity, which may be excluded.

History

#9042, eff 12-1-07, EXPIRED: 12-1-15
#11078, eff 4-22-16; ss by #14639, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 311 Use of Senior-Specific Certifications and Professional Designations in the Sale of Life Insurance and Annuities

N.H. Code Admin. R. Ann. Ins 311.01 Purpose {#sec-ins-311.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 311.01}

The purpose of this part is to set forth standards to protect customers from misleading and fraudulent marketing practices with respect to the use of senior-specific certifications and professional designations in the solicitation, sale or purchase of, or advice made in connection with, a life insurance or annuity product.

History

#9397, eff 3-1-09; ss by #12098, eff 3-1-17

N.H. Code Admin. R. Ann. Ins 311.02 Scope {#sec-ins-311.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 311.02}

This part shall apply to any solicitation, sale or purchase of, or advice made in connection with, a life insurance or annuity product by an insurance producer.

History

#9397, eff 3-1-09; ss by #12098, eff 3-1-17

N.H. Code Admin. R. Ann. Ins 311.03 Definitions {#sec-ins-311.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 311.03}

For the purposes of this part:

(a) "Insurance producer" means a person required to be licensed under RSA 402-J to sell, solicit, advise or negotiate insurance, including annuities.

History

#9397, eff 3-1-09; ss by #12098, eff 3-1-17

N.H. Code Admin. R. Ann. Ins 311.04 Prohibited Uses of Senior-Specific Certifications and Professional Designations {#sec-ins-311.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 311.04}

(a) (1) It is an unfair and deceptive act or practice in the business of insurance within the meaning of RSA 417 for an insurance producer to use a senior-specific certification or professional designation that indicates or implies in such a way as to mislead a purchaser or prospective purchaser that the insurance producer has special certification or training in advising or servicing seniors in connection with the solicitation, sale, or purchase of a life insurance or annuity product or in the provision of advice as to the value of or the advisability of purchasing or selling a life insurance or annuity product, either directly or indirectly through publications or writings, or by issuing or promulgating analyses or reports related to a life insurance or annuity product.

(2) The prohibited use of senior-specific certifications or professional designations includes, but is not limited to, the following:

a. Use of a certification or professional designation by an insurance producer who has not actually earned or is otherwise ineligible to use such certification or designation;

b. Use of a nonexistent or self-conferred certification or professional designation;

c. Use of a certification or professional designation that indicates or implies a level of occupational qualifications obtained through education, training, or experience that the insurance producer using the certification or designation does not have; and

d. Use of a certification or professional designation that was obtained from a certifying or designating organization that:

Is primarily engaged in the business of instruction in sales or marketing;
Does not have reasonable standards or procedures for assuring the competency of its certificants or designees;
Does not have reasonable standards or procedures for monitoring and disciplining its certificants or designees for proper or unethical conduct; or
Does not have reasonable continuing education requirements for its certificants or designees in order to maintain the certificate or designation.

(b) There is a rebuttable presumption that a certifying or designating organization is not disqualified solely for purposes of (a)(1)d. above when the certification or designation issued from the organization does not primarily apply to sales or marketing and when the organization or the certification or designation in question has been accredited by:

(1) The American National Standards Institute (ANSI);

(2) The National Commission for Certifying Agencies; or

(3) Any organization that is on the U.S. Department of Education's list entitled "Accrediting Agencies Recognized for Title IV Purposes", publication date 9/1/98, available as referenced in Appendix B.

(c) In determining whether a combination of words or an acronym standing for a combination of words constitutes a certification or professional designation indicating or implying that a person has special certification or training in advising or servicing seniors, factors to be considered shall include:

(1) Use of one or more words such as "senior," "retirement," "elder," or like words combined with one or more words such as "certified," "registered," "chartered," "advisor," "specialist," "consultant," "planner," or like words, in the name of the certification or professional designation; and

(2) The manner in which those words are combined.

(d) (1) For purposes of this part, a job title within an organization that is licensed or registered by a state or federal financial services regulatory agency is not a certification or professional designation, unless it is used in a manner that would confuse or mislead a reasonable consumer, when the job title:

a. Indicates seniority or standing within the organization; or

b. Specifies an individual's area of specialization within the organization.

(2) For purposes of this part, financial services regulatory agency includes, but is not limited to, an agency that regulates insurers, insurance producers, broker-dealers, investment advisers, or investment companies as defined under the Investment Company Act of 1940, available as referenced in Appendix B.

History

#9397, eff 3-1-09; ss by #12098, eff 3-1-17

Part Ins 312 Standards for Preparing Annual Life Insurance Disclosures

N.H. Code Admin. R. Ann. Ins 312.01 Purpose {#sec-ins-312.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 312.01}

The purpose of this part is to establish standards for the disclosures required to be issued by life insurers pursuant to RSA 408-D:8.

History

#9937, eff 6-6-11; ss by #12772, eff 6-6-19

N.H. Code Admin. R. Ann. Ins 312.02 Applicability & Scope {#sec-ins-312.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 312.02}

This part shall apply to all licensed writers of life insurance in this state.

History

#9937, eff 6-6-11; ss by #12772, eff 6-6-19

N.H. Code Admin. R. Ann. Ins 312.03 Definitions {#sec-ins-312.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 312.03}

The definitions in RSA 408-D:2 shall apply to this part.

History

#9937, eff 6-6-11; ss by #12772, eff 6-6-19

N.H. Code Admin. R. Ann. Ins 312.04 Life Insurer Disclosures to Policyholders {#sec-ins-312.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 312.04}

(a) A life insurer disclosure to policyholders shall be issued and delivered to every policyholder of individual life insurance residing in New Hampshire regardless of whether the life insurance policy was delivered or issued for delivery in this state.

(b) The life insurer disclosure to policyholders shall be provided upon the issuance of a new policy of life insurance and no less than annually thereafter for each year the policy is renewed.

(1) Any of the following actions related to the policyholder’s life insurance policy may have significant future financial, tax, or other implications:

a. Surrender of the policy;

b. Lapse of the policy;

c. Failure to pay premium;

d. Application of the equity of the policy toward payment of premium;

e. Application of accumulated dividends toward payment of premium;

f. Financing premium payments;

g. Sale of the policy; and

h. Assignment of the policy or any right under the policy; and

(2) A notice to the policyholder advising:

"Before you act, you need to consider all options carefully and seek advice from a licensed financial advisor, attorney, or other professional who can explain all available options and consequences. If you have questions about this notice or your policy, please contact customer service at [insert 1-800-xxx-xxxx]."

(d) The life insurer disclosure to policyholders shall be conspicuous and printed with a minimum font size of 12-point type on company letterhead.

(e) The life insurer disclosure to policyholders may be provided together with the annual report required by Ins 309.09, provided it otherwise meets the requirements of this part.

History

#9937, eff 6-6-11; ss by #12772, eff 6-6-19

N.H. Code Admin. R. Ann. Ins 312.05 Waiver of Rules {#sec-ins-312.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 312.05}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, it any.

APPENDIX I

Sample illustration of flexible premium fixed deferred annuity with a market value adjustment

For column descriptions, see next page

APPENDIX II

Sample illustrations of cash surrender values of market value adjusted annuities

MVA-adjusted Cash Surrender Values (CSVs) Under Sample Scenarios

The graphs below show MVA-adjusted Cash Surrender Values (CSVs) during the first five years of the contract, as illustrated on page 2 of the Annuity Illustration example ($100,000 single premium, a 5-year MVA Period) under two sample scenarios, as described below.

Graph #1 shows if the interest rate on new contracts is 3% LOWER than you Initial Guaranteed Interest Rate, the MVA will increase the amount you receive (upper line). The lower line shows the Cash Surrender Values if the Initial Guaranteed Interest Rates continue (From Column 9 on Page 2 of the Annuity Illustration example).

Graph #2 shows if the interest rate on new contracts is 3% HIGHER than your Initial Guaranteed Interest Rate, the MVA will decrease the amount you receive, but not below the minimum set by law (Column 6 on Page 2 of the Annuity Illustration example), which, in this scenario, limits the decrease for the first 2 years (lower line). The upper line shows the Cash Surrender Values if the Initial Guaranteed Interest Rates continue (from column 9 on Page 2 of the Annuity Illustration example).

These graphs and the sample guaranteed interest rates on new contracts used are for demonstration purposes only and are not intended to be a projection of how guaranteed interest rates on new contracts are likely to behave.

APPENDIX A

Rule

Specific State Statute the Rule Implements

Ins 301.01

RSA 400-A:15, I; RSA 417:1; RSA 417:3; RSA 417:4, I and III

Ins 301.02

RSA 400-A:15, I; RSA 417:1, RSA 417:2; RSA 417:3; RSA 417:4, I and III;

RSA 418:18, VI; RSA 418:21, III; 29 U.S.C. Section 101 et seq

Ins 301.03

RSA 400-A:15, I

Ins 301.04

RSA 400-A:15, I; RSA 417:4, I and III

Ins 301.05

RSA 400-A:15, I; RSA 417:4, I and III

Ins 301.06

RSA 400-A:15, I; RSA 400-B:4; RSA 402-J:3; RSA 405:17-b; RSA 405:44-a;

RSA 417:4, I

Ins 301.07

RSA 400-A:15, I; RSA 417:4, I

Ins 301.08

RSA 400-A:15, I; RSA 417:4, I; RSA 417:10

Ins 301.09

RSA 408:1; RSA 408:12; RSA 294-E; RSA 420-Q:2

Ins 301.10

RSA 400-A:15, I

Ins 302.01

RSA 400-A:15, I; RSA 408:51; RSA 408:53; RSA 408:55; RSA 417:4

Ins 302.02

RSA 400-A:15, I; RSA 408:51; RSA 408:53; RSA 408:55; RSA 417:4

Ins 302.03

RSA 400-A:15, I; RSA 408:51; RSA 408:53; RSA 408:55; RSA 417:4

Ins 302.04

RSA 400-A:15, I; RSA 408:51; RSA 408:53; RSA 408:55; RSA 417:4

Ins 302.05

RSA 400-A:15, I; RSA 408:51; RSA 408:53; RSA 408:55; RSA 417:4

Ins 302.06

RSA 400-A:15, I; RSA 408:51; RSA 408:53; RSA 408:55; RSA 417:4

Ins 302.07

RSA 400-A:15, I; RSA 408:51; RSA 408:53; RSA 408:55; RSA 417:4

Ins 302.08

RSA 400-A:15, I; RSA 408:15; RSA 408:16; RSA 408:29; RSA 408:51;

RSA 408:53; RSA 408:55; RSA 417:4

Ins 302.09

RSA 400-A:15, I and III.; RSA 402-J:12; RSA 408:62; RSA 417:10

Ins 302.10

RSA 400-A:15, I

Appendix A

RSA 400-A:15, I

Appendix B

RSA 400-A:15, I

Appendix C

RSA 400-A:15, I

Ins 303.01

RSA 417:1, RSA 417:2, RSA 417:3 and RSA 409-A:2

Ins 303.03

RSA 409-A:2, RSA 417:3, RSA 417:4

Ins 303.04

RSA 417:4

Ins 303.05

RSA 409-A:3 and RSA 417:4

Ins 303.06

RSA 400-A:15, RSA 417:10 and RSA 541-A:16

Ins 304.01

RSA 400-A:15, I; 415-B

Ins 304.02

RSA 400-A:15, I; 15 U.S.C. 77 et seq. (Securities Act of 1933)

Ins 304.03

RSA 400-A:15, I

Ins 305.01

RSA 402:47; 408:27-29; 408:35; 408:51; 417:4, I., II.

Ins 305.02

RSA 402:47; 408:19; 408:38; 408:40

Ins 305.03

RSA 401:1, III.; 405:1; 405:12

Ins 305.04

RSA 401:1, III.; 402-J:3; 408:27

Ins 305.05

RSA 402:12; 402-J:14, I., IV.; 405:17-b; 408:7; 408:38; 408:40; 408:42-43

Ins 305.06

RSA 401:12; 402-J:14, I., IV.; 405:17-b; 408:38; 408:40; 408:42-43

Ins 305.07

RSA 402-J:14, IV.; 417:10, II.

Ins 305.08

RSA 400-B:1, 3-4

Ins 305.09

RSA 400-A:15, I; RSA 408:1

Ins 306.01

RSA 400-A:15, I; RSA 408:52, II; RSA 417:3 & 4;

Ins 306.02

RSA 400-A:15, I; Securities Act of 1933 (15 U.S.C. Section 77a et seq.); Investment Company Act of 1940 (15 U.S.C. Section 80a·l et seq.)

Ins 306.03

RSA 400-A:15, I; RSA 403-E; RSA 408-E

Ins 306.04

RSA 400-A:15, I; RSA 408:29; RSA 417:3 & 4

Ins 306.05

RSA 400-A:15, I; RSA 417:3 & 4

Ins 306.06

RSA 400-A:15, I; RSA 417:3 & 4

Ins 306.07

RSA 400-A:15, I & III; RSA 417:3 & 4

Ins 306.08

RSA 400-A:15, I

Appendix I

RSA 400-A:15, I

Appendix II

RSA 400-A:15, I

Ins 307.01

RSA 400-A:15, I; 410:2; 410:3; 410:4

Ins 307.02

RSA 400-A:15, I; 410:2; 410:3; 410:4

Ins 307.03

RSA 400-A:15, I; 410:2; 410:3; 410:4

Ins 307.04

RSA 400-A:15, I; 410:2; 410:3; 410:4

Ins 307.05

RSA 400-A:15, I; 410:2; 410:3

Ins 307.06

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 410:8; 410:9; 410:12; 410:13

Ins 307.07

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 410:8; 410:9; 410:12; 410:13

Ins 308.01

RSA 400-A:15, I; RSA 400-A:36; RSA 405:45; RSA 405:46; RSA 405:47;

RSA 405:48; RSA 405:49; RSA 405:50; RSA 405:51; RSA 405:52

Ins 308.02

RSA 400-A:15, I; RSA 400-A:36; RSA 405:45; RSA 405:46; RSA 405:47;

RSA 405:48; RSA 405:49; RSA 405:50; RSA 405:51; RSA 405:52

Ins 308.03

RSA 400-A:15, I; RSA 400-A:36; RSA 405:45; RSA 405:46; RSA 405:47;

RSA 405:48; RSA 405:49; RSA 405:50; RSA 405:51; RSA 405:52

Ins 308.04

RSA 400-A:15, I; RSA 400-A:36; RSA 405:45; RSA 405:46; RSA 405:47;

RSA 405:48; RSA 405:49; RSA 405:50; RSA 405:51; RSA 405:52

Ins 308.05

RSA 400-A:15, I; RSA 400-A:36; RSA 405:45; RSA 405:46; RSA 405:47;

RSA 405:48; RSA 405:49; RSA 405:50; RSA 405:51; RSA 405:52

Ins 308.06

RSA 400-A:15, I; RSA 400-A:36; RSA 405:45; RSA 405:46; RSA 405:47;

RSA 405:48; RSA 405:49; RSA 405:50; RSA 405:51; RSA 405:52

Ins 308.07

RSA 400-A:15, I

Ins 309.01

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.02

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.03

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.04

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.05

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.06

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.07

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.08

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.09

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.10

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 309.11

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII; 417:10

Ins 309.12

RSA 400-A:15, I; 417:3; 417:4, I, II, VIII, IX, XII

Ins 310

10 U.S.C. 992 note; 15 U.S.C. 78o, 78o-3, 80a-27, 80b-10, 80b-3a and 80b-4;

38 U.S.C. Chapter 19

Ins 310.01

RSA 408:1; RSA 417:4; RSA 417:5; RSA 417:5-a

Ins 310.02

RSA 408:1; RSA 417:4; RSA 417:5; RSA 417:5-a

Ins 310.03

RSA 408:1; RSA 417:4; RSA 417:5; RSA 417:5-a

Ins 310.04

RSA 408:1; RSA 417:4; RSA 417:5; RSA 417:5-a

Ins 310.05

RSA 408:1; RSA 417:4; RSA 417:5; RSA 417:5-a

Ins 310.06

RSA 408:1; RSA 417:4; RSA 417:5; RSA 417:5-a

Also: Military Personnel Financial Services Act of 2006, Pub. L. No. 109-290, 120 Stat. 1317

Ins 311.01

RSA 400-A:15, I; 408:5; 408:13; 408:42; 408:51; 408:52, II; 408:55; 408:60; 408:62; 417:4, I, II, III, IV; 417:5-a

Ins 311.02

RSA 400-A:15, I; 408:5; 408:13; 408:42; 408:51; 408:52, II; 408:55; 408:60; 408:62; 417:4, I, II, III, IV; 417:5-a

Ins 311.03

RSA 400-A:15, I; 408:5; 408:13; 408:42; 408:51; 408:52, II; 408:55; 408:60; 408:62; 417:4, I, II, III, IV; 417:5-a

Ins 311.04

RSA 400-A:15, I; 408:5; 408:13; 408:42; 408:51; 408:52, II; 408:55; 408:60; 408:62; 417:4, I, II, III, IV; 417:5-a

Ins 312.01

RSA 400-A:15, I; RSA 408-D:8; RSA 408-D:17

Ins 312.02

RSA 400-A:15, I; RSA 408-D:17

Ins 312.03

RSA 400-A:15, I; RSA 408-D:2

Ins 312.04

RSA 400-A:15, I; RSA 408-D:8; RSA 408-D:17

Ins 312.05

RSA 400-A:15, I; RSA 408-D:17; RSA 541-A:22, IV

Appendix B Incorporation by Reference Information

Rule

Title of Material

Publisher; How to Obtain; and Cost

Ins 301.03

Life Insurance Buyer’s Guide

Association of Insurance Commissioners

Published by the NAIC. Available at no cost at:

https://content.naic.org/sites/default/files/publication

-lig-lp-consumer-life.pdf

Ins 306.03(a)

Annuity Buyer’s Guide

Published by the NAIC

Available for no cost at:

http://www.naic.org/documents/prod_serv_consumer_anb_la.pdf

Ins 307.01 (a);

Ins 307.03 (b);

Ins 307.04 (a), (b), (d);

Ins 307.05 (a)

The 1983 Table “a” developed by the Society of Actuaries Committee to Recommend a New Mortality Basis for Individual Annuity Valuation.

Published by Society of Actuaries

Available for no cost at:

http://mort.soa.org/

Ins 307.01 (b);

Ins 307.03 (e);

Ins 307.05 (a), (b)

The 1983 Group Annuity Mortality (1983 GAM) Table developed by the Society of Actuaries Committee on Annuities.

Published by Society of Actuaries

Available for no cost at:

http://mort.soa.org/

Ins 307.01 (c);

Ins 307.04 (b), (c)

Annuity 2000 Mortality Table developed by Society of Actuaries Committee on Life Insurance Research

Published by Society of Actuaries

Available for no cost at:

http://mort.soa.org/

Ins 307.01 (d);

Ins 307.03 (b);

Ins 307.04 (d)

The 2012 Individual Annuity Reserving (2012 IAR) Mortality Table developed by the Society of Actuaries Committee on Life Insurance Research

Published by Society of Actuaries

Available for no cost at:

http://mort.soa.org/

Ins 307.01 (e);

Ins 307.03 (f);

Ins 307.05 (a), (b), (c);

Ins 307.06

The 1994 Group Annuity Reserving (1994 GAR) Table developed by the Society of Actuaries Group Annuity Valuation Table Task Force

Published by Society of Actuaries

Available for no cost at:

http://mort.soa.org/

Ins 307.03 (b), (h)

Projection Scale G2 (Scale G2) developed by the Society of Actuaries Committee on Life Insurance Research

Published by Society of Actuaries

Available for no cost at:

http://mort.soa.org/

Ins 307.03 (b), (i)

2012 Individual Annuity Mortality Period Life (2012 IAM Period) Table developed by the Society of Actuaries Committee on Life Insurance Research

Published by Society of Actuaries

Available for no cost at:

http://mort.soa.org/

Ins 309.10 (b)

Actuarial Standards of Practice for Compliance with the NAIC Model Regulation on Life Insurance Illustrations, No. 24

Online for no cost: www.actuarialstandardsboard.org

Ins 311.04(b)(3)

Accrediting Agencies Recognized for Title IV Purposes, prepared by the U.S. Department of Education; Publication date 9/1/98

Online for no cost at:

https://ifap.ed.gov/aagencies/doc0023_bodyoftext.htm

Ins 311.04(d)(2)

Investment Company Act of 1940, an act of Congress in 1940

Online for no cost at:

https://www.sec.gov/about/laws/ica40.pdf

History

#12772, eff 6-6-19

Chapter Ins 400 Filings for Life, Accident, and Health Insurance

Part Ins 401 Form and Rate Filings

N.H. Code Admin. R. Ann. Ins 401.01 Purpose and Scope {#sec-ins-401.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.01}

(a) The purpose of this chapter is to establish standards and procedures for the filing of life, accident, and health insurance forms to be used within the state to facilitate consumer understanding in the purchase of life, accident, and health insurance and the coverages provided.

(b) This chapter shall apply to all licensed writers of life, accident and health insurance in this state, including health service organizations and health maintenance organizations, and shall also apply to life settlement providers.

History

#1900, eff 1-1-82; amd by #2372, eff 5-31-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8726, eff 9-18-06, EXPIRED: 9-18-14
#12126, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 401.02 Definitions {#sec-ins-401.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.02}

(a) "Commissioner" means the insurance commissioner.

(b) "Department" means the New Hampshire insurance department.

(d) "System for Electronic Rate and Form Filing" (SERFF) means the system for electronic rate and form filing supported by the NAIC.

History

#1900, eff 1-1-82; amd by #2049, eff 7-l-82; amd by #2226, eff 1-1-83; amd by #2372, eff 6-1-83; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8726, eff 9-18-06; amd by #9334, eff 12-5-08; paras. (a)-(d) EXPIRED: 9-18-14; ss by #12126, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 401.03 Policy Definition Requirements {#sec-ins-401.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.03}

(a) Except as provided in this part, an individual insurance policy or group insurance policy or certificate delivered or issued for delivery to any person in this state and to which this part applies shall contain definitions respecting matters set forth below that comply with the requirements of this section.

(b) “Accident,” “accidental injury,” and “accidental means” shall be defined to employ “result” language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization;

(1) The definition shall not be more restrictive than the following: “injury” or injuries” means accidental bodily injury sustained by the insured person that is the direct cause of the condition for which benefits are provided, independent of disease or bodily infirmity or any other cause and that occurs while the insurance is in force; and

(2) The definition may provide that injuries shall not include injuries for which benefits are provided under workers’ compensation, employers’ liability or similar law or injuries occurring while the insured person is engaged in any activity pertaining to a trade, business, employment or occupation for wage or profit.

(c) “Convalescent nursing home,” “extended care facility,” or “skilled nursing facility” shall be defined in relation to its status, facility, and available services, and:

(1) A definition of the home or facility shall not be more restrictive than one requiring that it:

a. Be operated pursuant to law;

b. Be approved for payment of Medicare benefits or be qualified to receive approval

for payment of Medicare benefits, if so requested;

c. Be primarily engaged in providing, in addition to room and board accommodations,

skilled nursing care under the supervision of a duly licensed physician;

d. Provide continuous 24 hour-a-day nursing service by or under the supervision of a

registered nurse; and

e. Maintain a daily medical record of each patient; and

(2) The definition of the home or facility may provide that the term shall not be inclusive of:

a. A home, facility, or part of a home or facility used primarily for rest;

b. A home or facility for the aged or for the care of drug addicts or alcoholics; or

c. A home or facility primarily used for the care and treatment of mental diseases or disorders, or for custodial or educational care.

(d) “Hospital” may be defined in relation to its status, facilities, and available services or to reflect its accreditation by The Joint Commission on Accreditation of Healthcare Organizations.

(1) The definition of the term “hospital” shall not be more restrictive than one requiring that the hospital:

a. Be an institution licensed to operate as a hospital pursuant to law;

b. Be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of licensed physicians, medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an in-patient basis for which a charge is made; and

c. Provide 24-hour nursing service by or under the supervision of registered nurses; and

(2) The definition of the term “hospital” may state that the term shall not be inclusive of:

a. Convalescent homes or convalescent, rest, or nursing facilities;

b. Facilities affording primarily custodial, educational, or rehabilitory care;

c. Facilities for the aged, drug addicts, or alcoholics; or

d. A military or veterans’ hospital, a soldiers’ home, or a hospital contracted for or operated by any national government or governmental agency for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis where a legal liability for the patient exists for charges made to the individual for the services.

(e) “Medicare” means The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended.

(f) “Mental or nervous disorder” shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychosis, or mental or emotional disease or disorder of any kind.

(g) “Nurse” may be defined so that the description of nurse is restricted to a type of nurse, such as a registered nurse, a licensed practical nurse, or a licensed vocational nurse. If the words “nurse,” “trained nurse” or “registered nurse” are used without specific instruction, then the use of these terms requires the insurer to recognize the services of any individual who qualifies under the terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.

(h) “One period of confinement” shall not be defined more restrictively than consecutive days of in-hospital services received as an in-patient, or successive confinements when discharge from and readmission to the hospital occurs within a period of time not more than 90 days or 3 times the maximum number of days of in-hospital coverage provided by the policy to a maximum of 180 days.

(i) “Partial disability” shall be defined in relation to the individual’s inability to perform one or more but not all of the “major,” “important,” or “essential” duties of employment or occupation, or may be related to a percentage of time worked or to a specified number of hours or to compensation.

(j) “Physician” may be defined by including words such as “qualified physician” or “licensed physician.” The use of these terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when the services are within the scope of the provider’s licensed authority and are provided pursuant to applicable laws.

(k) “Preexisting condition”:

(1) With respect to disability insurance, preexisting condition shall not be defined more restrictively than the following: “Preexisting condition means the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis, care, or treatment within a 24-month period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician within a 24-month period preceding the effective date of the coverage of the insured person”; and

(2) With respect to other insurance, preexisting condition shall not be defined more restrictively than the following: “Preexisting condition means the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis, care, or treatment within a 6-month period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician within a 6-month period preceding the effective date of the coverage of the insured person.”

(l) “Sickness” shall not be defined to be more restrictive than the following: “Sickness means sickness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force.” The definition may be further modified to exclude sickness or disease for which benefits are provided under the workers’ compensation, occupational disease, employer’s liability or similar law. Probationary periods shall not apply to policies or certificates issued pursuant to RSA 420-G.

(m) “Total disability”:

(1) A general definition of total disability shall not be more restrictive than one requiring that

the individual who is totally disabled not be engaged in any employment or occupation for which he or she is or becomes qualified by reason of education, training, or experience, and is not in fact engaged in any employment or occupation for wage or profit;

(2) Total disability may be defined in relation to the inability of the person to perform duties but shall not be based solely upon an individual’s inability to:

a. Perform “any occupation whatsoever,” “any occupational duty,” or “any and every duty of his occupation;” or

b. Engage in a training or rehabilitation program;

(3) An insurer may require the complete inability of the person to perform all of the substantial and material duties of his or her regular occupation or words of similar import; and

(4) An insurer may require care by a physician other than the insured or a member of the insured’s immediate family.

History

#12126, eff 3-8-17; amd by #12882, eff 9-30-19

N.H. Code Admin. R. Ann. Ins 401.04 Rules Applicable to All Forms {#sec-ins-401.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.04}

(a) Each form shall be designated by a form number composed of either figures or letters or both.

(1) The form number shall be:

a. Sufficient to distinguish the form from all other forms used by the company; and

b. Placed in the lower left-hand corner on the front of each form;

(2) The form number for a policy form may contain the prefix "Form No.";

(3) Policy forms utilizing less than a full sheet as the face page or cover page shall place the form number in the lower left-hand corner of the specifications page; and

(4) Any time any change is made, the form shall be resubmitted as a new form with a new form number.

(b) Each policy and certificate shall recite on the back page or specifications page the:

(1) Full corporate or legal title of the company, association, exchange, or society;

(2) Official home address, including city and state or province;

(3) Administrative office address, if different from address in (2) above; and

(4) Toll-free telephone number of the company and, if available, a facsimile number and website address.

(1) The brief description shall be printed on:

a. The face page, specifications page, or the back page, if the policy form has a full size cover page; or

b. On the specifications page so that the description is visible, if the policy form has less than a full size cover page; and

(2) In the instance of individual life or individual annuity contracts, the brief description shall contain a statement indicating whether the policy is "participating" or "nonparticipating".

(d) The words, "preferred," "special," "unlimited," "union," "labor," "New Hampshire," or any other words or combination of words shall not be used in any way that might reasonably cause anyone to believe that they are receiving or shall receive preferential treatment unless that person is, in fact, receiving preferential treatment or will receive preferential treatment.

(e) No policy or group certificate providing accident and health insurance benefits shall use the terms "major," "comprehensive," "catastrophic" or words of similar import in its title or brief description unless such policy or certificate satisfies the minimum benefit standards for major medical expense coverage.

(f) The word "compensation" shall not be used in any way that might reasonably cause the policyholder to be confused with workers' compensation coverage.

(g) The word "medicare" shall not be used in any way that might reasonably cause anyone to believe that the policyholder is participating in a government program.

(h) If the policy contains an exception for injury arising out of riots, the exception shall be confined to those instances in which the insured is injured while participating in such riot.

(i) Any policy or certificate that contains exclusions, limitations, reductions, or conditions of such a restrictive nature that the payment of benefits under such policies is limited in frequency or in amounts shall carry the legend "This is a Limited Policy - Read it Carefully" imprinted across the face and filing back, if any, of the policy in not less than 18-point outline type of contrasting color, not less than 24-point outline type of non-contrasting color diagonally, or not less than 24-point bold within a black border.

(j) Any provision, requirement, or other document standard contained in this part shall not act to prevent the use of any other language that is at least as favorable to any insured or group policyholder.

(k) Except as otherwise specifically provided by New Hampshire statutes or this part, any contract or policy of insurance or annuity contract issued, delivered, used, or sold in this state that violates any of the provisions of New Hampshire statutes or this part shall be:

(1) Valid and binding upon the insurer making or issuing the policy; and

(2) Enforceable as if it conformed to such requirements or prohibitions.

(l) Discretionary clauses relating to life, accident, or health policies shall be approved by the department only when such clauses:

(1) Are contained in a separate endorsement containing no other language, terms or provisions;

(2) Are offered on an optional basis to the plan sponsor;

(3) Implement a policy governed by the Employment Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. and those policies contain the following language:

"The following applies only when the administration of the policy is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq.:

Under ERISA, [the Company] is hereby designated by the plan sponsor as a claim fiduciary with discretionary authority to determine eligibility for benefits and to interpret and construe the terms and provisions of the policy. As claim fiduciary, [the Company] has a duty to administer claims solely in the interest of the [participants and beneficiaries] of the employee benefit plan and in accordance with the documents and instruments governing the plan. This assignment of discretionary authority does not prohibit a participant or beneficiary from seeking judicial review of [the Company's] benefit eligibility determination after exhausting administrative remedies. The assignment of discretionary authority made under this provision may affect the standard of review that a court will use in reviewing the appropriateness of [the Company's] determination. In order to prevail, a plan participant or beneficiary may be required to prove that [the Company's] determination was arbitrary and capricious or an abuse of discretion"; and

(4) Pursuant to (l)(3) above, if a health carrier, as this term is defined in RSA 420-J:3, is a claim fiduciary, the following sentence shall be included at the end of the second paragraph in (l)(3) above,:

"This designation as a claim fiduciary under ERISA does not apply to determinations that health carriers make as to whether a health care service, supply, or drug meets requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness."

(m) Policies providing disability income protection shall not in any way condition benefit payments for "total disability" on "continuous confinement within doors" or language of similar import.

(n) Short term major medical shall comply with RSA 415:5, III.

(o) All policy forms and certificates issued on or after January 1, 2010, that provide coverage as defined in RSA 420-G:2, IX or prescription drug and dental benefits offered separately as described in RSA 420-G:2, IX(j), issued on or after January 1, 2010, shall clearly state that the benefit plan or coverage represented by the policy is under the jurisdiction of the New Hampshire insurance commissioner pursuant to RSA 400-A:15-c.

(p) All policy forms filed with the commissioner shall be written in the English language.

(q) An insurer may also provide applicants and insureds with a policy, application, or other forms in a language other than English if the non-English version of the policy, application, or other form, that has not been reviewed by the commissioner:

(1) Is a certified translation of a policy, application, or other form that has been filed with and approved by the commissioner;

(2) Is accompanied by a certification written in English that the non-English version is a complete and accurate translation of the English form filed;

(3) Is in the same format as the English version;

(4) Contains a disclosure, both in the non-English language and in English, that is attached to the front of the policy, application, or other forms, including a statement that:

a. The policy, application, or other form is a translation that has not been approved by the commissioner; and

b. The English version of the policy, application, or other forms shall control in any disputes, complaints, or litigation; and

(5) Identifies the English form number that corresponds to the non-English version.

(r) If an insurer offers a non-English policy, application, or other form in accordance with (q), the insurer shall file the translator certification and disclosure required by (q)(2) and (q)(4) with the commissioner as an information filing.

(s) This paragraph shall not prohibit an insurer from advertising or providing information related to the policy or claims with translations to consumers in a language other than English.

(t) If there is a dispute between the English version and the non-English version, the English version shall control and the non-English version shall carry a disclaimer in the non-English language to this effect. The insurance policy is controlling and any advertisements or informational materials used by an insurer shall not be construed to modify or change the insurance policy.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; amd by #5117, eff 5-1-91; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8726, eff 9-18-06; amd by #9602, eff 12-1-09; amd by #10195, eff 10-1-12; paras. (a)-(n) EXPIRED: 9-18-14; ss by #12126, eff 3-8-17 (from Ins 401.03)

N.H. Code Admin. R. Ann. Ins 401.05 Individual Life and Annuity Contracts {#sec-ins-401.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.05}

(a) All individual life policies and individual annuity contracts shall contain the following provisions:

(1) All premiums shall be payable in advance either at the home office of the company or to the company's appointed producer upon delivery of the policy or contract, and:

a. If requested, the policy or contract shall be signed by one or more of the officers of the company who shall be designated by title in the policy, and countersigned by the appointed producer; and

b. The policy itself shall be a receipt for the first premium payment;

(2) There shall be a grace period of 31 days within which the payment of any premium after the first payment may be made, during which period of grace:

a. The policy shall continue in force;

b. The amount of such premiums in arrears plus accrued interest, at a rate not exceeding the policy loan rate, shall be deducted from any claim arising in such period; and

c. This premium provision shall not be applicable to single premium contracts, or to flexible payment annuity contracts that do not default upon nonpayment of premium;

(3) For flexible premium life policies, there shall be a provision for a grace period beginning on the policy processing day when the total charges authorized by the policy that are necessary to keep the policy in force until the next policy processing day exceed the amounts available under the policy to pay such charges in accordance with the terms of the policy. The grace period shall end on a date not less than 61 days after the mailing of the notice to the policyholder pursuant to Ins 401.10(f), below;

(4) There shall be provisions addressing cancellation of the policy and refund of unearned premium, provided however, if the policy provides for no refund of paid premium, the cancellation date shall be set, at earliest, on the first day the next premium payment would otherwise be due and owing;

(5) The entire contract between the parties shall consist of the policy together with a copy of the signed and completed application;

(6) No statement made by the insured or on his behalf shall be used in defense of a claim under the policy unless it is contained in a written application and a copy endorsed upon or attached to the policy when issued;

(7) All statements made by, or by the authority of, the applicant for the issuance, reinstatement, or renewal of the contract shall, in the absence of fraud, be deemed representations and not warranties;

(8) Pursuant to the provisions of RSA 408:10, the policy shall be incontestable after it has been in force during the lifetime of the insured for 2 years from its date, except for:

a. The nonpayment of premiums;

b. Violations of the policy relating to naval or military service in time of war; or

c. At the option of the company:

Provisions granting or increasing benefits in the event of total and permanent disability; and
Provisions that grant additional insurance specifically against death by accident;

(9) An incontestable provision shall not be required in any policy or contract where the only statements required as a condition of issuing the contract are those pertaining to age, gender, and personal identity;

(10) If the insured's age or gender has been misstated, any benefit under the policy shall be such as the premiums would have purchased for the correct age or gender; and

(11) The policy or contract shall participate in its share of the divisible surplus of the company at annual intervals that begin no later than the fifth policy year, unless such policies or contracts are nonparticipating, issued as sub-standard, or provide nonforfeiture benefits in exchange for lapsed or surrendered policies or contracts.

(b) Policy loan values and policy loan provisions for individual life insurance and annuities shall provide that:

(1) After the policy has been in force for 3 full years with all premiums due having been paid, the insurer shall advance an amount up to but not exceeding the loan value of the policy upon proper assignment or pledge of the policy and on the sole security thereof;

(2) The loan value shall be at least equal to the cash surrender value available at the end of the policy year, less the sum of premiums falling due from the date of the loan to the end of the policy year, less any existing indebtedness, less the interest on any existing indebtedness to the end of the policy year;

(3) Interest due at the end of the policy year, if not paid when due, shall be added to the existing loan payable at the same interest rate as the existing loan or in advance at the equivalent effective rate;

(4) Policy provisions reserve to the insurer the right to defer loan grants for up to 6 months after the application is filed, other than for the payment of premiums;

(5) The provisions of Ins 401.05 (b)(1) and (2) shall not be applicable to term insurance or to any policy or contract of pure endowment, variable annuity, annuity, or reversionary annuity; and

(6) The provisions of Ins 401.05 (b)(1) and (2) shall not be construed as prohibiting policy loan provisions in any annuity contract.

(1) A provision permitting a maximum interest rate of not more than 8 percent per annum;

(2) A provision permitting an adjustable maximum interest rate established from time to time by the life insurer, which interest rate shall not exceed the higher of a. or b. below:

a. The published monthly average for the calendar month ending 2 months before the date on which the rate is determined. For purposes of this rule, "published monthly average" means the Moody's Corporate Bond Yield Average - Monthly Averages Corporates as published by Moody's Investors Service, Inc. and available as referenced in Appendix B; or

b. The rate used to compute the cash surrender values under the policy during the applicable period plus one percent per annum;

(3) If the maximum rate of interest to be charged on a policy loan is subject to (2) above, the policy shall contain a provision setting forth the frequency at which the rate is to be determined for that policy;

(4) If the maximum rate of interest to be charged on a policy loan is subject to (2) above, the maximum rate for each policy shall be determined:

a. At regular intervals at least once every 12 months, but not more frequently than once in any 3-month period;

b. At the intervals specified in the policy, wherein the rate being charged may be increased whenever such increase as determined pursuant to (2) above would increase that rate by 1/2 percent or more per annum; and

c. At the same intervals, wherein there is a reduction in the rate being charged whenever such reduction as determined pursuant to (2) above would decrease the rate being charged by 1/2 percent or more per annum;

(5) The insurer shall:

a. Notify the policyholder at the time a cash loan is made of the initial rate of interest on the loan;

b. Notify the policyholder with respect to premium loans of the initial rate of interest on the loan as soon as it is practical to do so after making the initial loan. Notice to the policyholder shall not be required when a further premium loan is added, except as provided in c. below;

c. Send advance notice of any increase in the rate to policyholders with outstanding loans; and

d. Include in the notices required in c. above the policy loan interest rates and, if an adjustable interest rate, the frequency at which the rate will change;

(6) No policy shall terminate nor shall the insurer deny or fail to provide coverage during the policy term solely as a result of a change in the policy loan interest rate, and the life insurer shall maintain coverage during that policy year until the time at which the policy would otherwise have terminated if there had been no change during that policy year; and

(7) For purposes of this paragraph:

a. The rate of interest on policy loans permitted by the rules stated above includes the interest rate charged on reinstatement of policy loans for the period during and after any lapse of a policy;

b. The term "policy loan" shall include any premium loan made under a policy to pay one or more premiums that were not paid to the life insurer as they fell due;

c. The term "policyholder" shall include the owner of the policy or the person designated to pay premiums as shown on the records of the life insurer; and

d. The term "policy" shall include certificates issued by a fraternal benefit society and annuity contracts that provide for policy loans.

(d) Upon the request of the policyholder, unless the cash surrender value of a permanent life insurance policy has been paid out in full or the period of extended insurance has expired, any life insurance policy shall be reinstated during the life of the insured anytime within 3 years of the date of default if:

(1) Evidence of insurability satisfactory to the insurer is provided to the insurer;

(2) Payment is tendered to the insurer in an amount not to exceed the larger of:

a. The sum of:

Overdue premiums, including interest at a rate not to exceed 8 percent per annum, compounded annually; and
Any outstanding policy loans, including interest at a rate that would be permitted under this rule if the policy had not lapsed; or

b. One hundred ten percent of the increase in cash surrender value resulting from reinstatement.

(e) Term life insurance policies shall provide for reinstatement subject to the same requirements set forth in (d)(1) and (2)a.1. and b. above, any time during the life of the insured and prior to the policy expiration date.

(f) Except for funding agreements, the following provision or its equivalent shall appear in a conspicuous place on the face page of the policy:

"This policy may, at any time within 10 days after its receipt by the policyholder, be returned by delivering it or mailing it to the company or to the agent through whom it was purchased. Immediately upon delivery or mailing, the policy will be deemed void from the beginning, and any premium paid on it will be refunded."

(g) For purposes of (f) above, a "funding agreement" means an agreement issued by a life insurance company, not based on mortality or morbidity, providing for the accumulation of funds by the insurer for the purpose of making one or more payments to a designated individual or entity, where the initial premium paid is $1,000,000 or more.

(h) Unless the insurer has adopted a procedure to obtain a policyholder's dated and signed receipt for the delivery of the policy pursuant to (f) above, it shall be presumed that the date of delivery is the date shown in the policyholder's records or by his memory unless there is evidence sufficient to void this presumption.

(i) Life insurance policies designed to permit increases or decreases in the premiums payable shall state in the policy the maximum premium or the schedule of maximum premiums applicable for the entire duration of the policy.

(j) Supplemental contracts shall be subject to all insurance laws and parts that would be applicable to accident and health insurance forms containing similar provisions or benefits.

(k) Arbitration provisions shall be prohibited.

(l) Graded death benefits life insurance policies shall pay the policy face value after 2 years of premium payments.

(m) The following exclusions shall be the only exclusions permitted in an individual life policy or individual annuity contract:

(1) Except for those exclusions that relate to accidental death benefits, any policies that contain any exclusions violating this part shall be operative as if such prohibited exclusions were not included;

(2) Policy exclusion provisions shall:

a. Contain language substantially similar to the language of the following subclauses;

b. Be set out in a separately titled policy section; and

c. Prominently display reference to exclusion (3)c. below in the letter of transmittal and on the policy face in type at least as large as 12-point boldface type;

(3) If a policy includes an exclusion, it shall contain only those exclusions listed below:

a. Death resulting from suicide within 2 years of the issue date of the policy, or, if later, the last date on which reinstatement was applied for in writing and accepted by the insurer;

b. Death resulting from a declared or undeclared war, if death occurs:

While the insured is outside the 50 states of the United States, D.C., and Canada and is in military service or a civilian unit required to serve with a military force;
Within 6 months after the insured returns to the United States, D.C., or Canada from military service or from service in a civilian unit required to serve with a military force, provided the insured is still in military service at the time of death; or
Within 6 months after the insured returns from service in a civilian unit required to serve with a military force outside the 50 states of the United States, D.C., or Canada, provided the insured is still in such service at the time of death; and

c. Death as a result of aviation, other than as a fare-paying passenger, or other than military personnel, except the crew, aboard military multi-engine fixed wing air transports within the United States; and

(4) In the event of death occurring from one of the causes delineated in (3) above, the premium shall be returned in at least the following manner:

a. The amount of the gross premiums paid, less dividends applicable, and less any indebtedness for policies up to and including 2 years from the date of issue; and

b. After 2 years from date of issue, the greater of:

The reserve on the face amount of the policy together with the reserve for any dividend additions, less indebtedness and including interest; or
Due and accrued of gross premiums paid, less dividends applicable, and less any indebtedness.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8726, eff 9-18-06; amd by #10195, eff 10-1-12; paras. (a) intro., (a)(1), (a)(2), (a)(4)-(10), (b) intro., (b)(1)-(4), (c)-(e), and (h)-(m) EXPIRED: 9-18-14; ss by #12126, eff 3-18-17 (from Ins 401.04)

N.H. Code Admin. R. Ann. Ins 401.06 Individual Accident and Health {#sec-ins-401.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.06}

(a) Travel insurance policies shall comply with RSA 415:18, I-a(e) and Ins 4700. Long-term care policies shall comply with RSA 415-D and Ins 3600. Medicare supplemental insurance policies shall comply with RSA 415-F and Ins 1902 or Ins 1905. All other individual accident and health policy forms submitted shall comply with the provisions of RSA 415 and RSA 415-A.

(b) Additional policy form filing standards, with the exception of policies regulated by Ins 3600, Ins 4700, Ins 1902, or Ins 1905, shall be as follows:

(1) If the policy provides for any reduction in benefits or benefit period because of the attainment of a specified age limit, reference thereto shall be set forth on the first or specifications page;

(2) Loss of time policies shall not require that the loss from accidental injury commence within less than 30 days after the date of an accident;

(3) No policy of health and accident insurance shall be approved that contains a provision that the disability period shall be considered to commence with the date on which written notice is actually received by the company;

(4) Noncancellable policies with premium rates that are not presumed level but are expected to change periodically with the insured's attained age shall include the entire premium scale applicable to the insured;

(5) All other policies with premium rates that are not presumed level but are expected to change periodically with the insured's attained age shall not be required to include the entire premium scale applicable to the insured but shall disclose on the face page or the specifications page that the premium rates are subject to change based on the attained age of the insured and also identify the attained ages at which such changes will occur;

(6) With respect to policies where there exists an option for continuation of coverage at a specified time after attainment of age 65 or commencement of Medicare coverage, whichever is earlier, and where the insurer reserves the right to change the coverages and/or the premium scale for such continuation, such premium scale may be omitted from the policy;

(7) For the purposes of subparagraphs (5) and (6) above, all conditions pertaining to the option of continuation of coverage and any changes in coverage shall be contained in the policy;

(8) Except in those instances where riders are prohibited by RSA 420-G:5 IV, any rider or endorsement that reduces or eliminates coverage under the policy shall provide for signed acceptance by the policyholder except in the case of a rider or endorsement that is used only at the time of policy issue;

(9) Any individual accident and health policy insuring against loss resulting from accidental bodily injuries only shall specify on the face of the policy in no less than 14 point, bold face type, "This policy does not insure against loss resulting from sickness";

(10) The following provision shall appear in a conspicuous place on the face page of all accident and health policies:

"This policy may, at any time within 30 days after its receipt by the policyholder, be returned by delivering it or mailing it to the company or the agent through whom it was purchased. Immediately upon such delivery or mailing, the policy will be deemed void from the beginning, and any premium paid on it will be refunded."

(11) Unless the insurer has adopted a procedure to obtain a policyholder's dated and signed receipt for the delivery of the policy, it shall be presumed that the date of delivery is the date shown by the policyholder's records or by his or her memory;

(12) Any provision that excludes coverage by use of the terms "chronic disease" or "organic disease" shall not be permitted;

(13) Diseases sought to be excluded from coverage shall be stated with sufficient clarity to be readily identifiable;

(14) Common terms such as "heart disease," "pulmonary disease" or "disease of the generative organs" shall be acceptable;

(15) 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;

(16) Where the insurer reserves the right to cancel, the provisions of RSA 415:6, II (8) or RSA 420-G:6, VI or VII shall be delineated in the policy;

(17) In order to close a block of business, the insurer shall make such request in writing and include in such request:

a. The number of New Hampshire policies currently in force;

b. An explanation of the classification of risk involved therein to indicate that such classification is reasonable and nondiscriminatory; and

c. Statistical data sufficient to indicate that the cancellation or nonrenewal requested is reasonable and nondiscriminatory;

(18) With respect to all individual accident and health policies, including those sold on a franchise basis, 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;

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

d. That no refund need be made if premiums are payable monthly;

(19) In the event of any renewal rate increase, insurers shall provide policyholders with prior notice of any such increase such that:

a. A 30 days’ notice is provided for policies subject to RSA 415, which are not subject to RSA 420-G provisions; and

b. A 60 days’ notice is provided for policies subject to RSA 420-G; and

(20) All policies of accident and health insurance shall define terms in the policy in a manner at least as favorable as the policy definition requirements contained in Ins 401.03.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8726, eff 9-18-06; amd by #9334, eff 12-5-08; paras. (a),(b), intro., (b)(1)-(10) and (b)(12)-(13) EXPIRED: 9-18-14; ss by #12126, eff 3-18-17

N.H. Code Admin. R. Ann. Ins 401.07 Group Life Policies {#sec-ins-401.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.07}

(a) The required provisions for group life policies shall be established in RSA 408:16;

(b) Other required policy standards shall be as follows:

(1) The policy shall apply to a group qualified for such insurance as provided by RSA 408:15;

(2) All group life certificates filed with this department shall provide for the identification of the individual(s) insured by having the name(s) of the insured(s) stated on the certificate or any code in the certificate sufficient to identify the insured(s);

(3) As an alternative to (2) above, any group life certificate shall define eligibility and benefit amounts;

(4) Each employee insured under a form of group life insurance shall be given evidence of his beneficiary in the certificate;

(5) In the case of a group life insurance plan that contains a disability benefit extension of any type including, but not limited to, premium waiver extension, extended death benefit in event of total disability, or payment of income for a specified period during total disability, the discontinuance of the group policy shall not operate to terminate such extension;

(6) Coverage may be provided to dependents in a contract of group life insurance pursuant to RSA 408:15, VIII and IX; and

(7) Arbitration provisions shall be prohibited.

History

#8726, eff 9-18-06; EXPIRED: 9-18-14
#12126, eff 3-18-17 (from Ins 401.06)

N.H. Code Admin. R. Ann. Ins 401.08 Group and Blanket Accident and Health {#sec-ins-401.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.08}

(a) Travel insurance policies shall comply with RSA 415:18, I-a(e) and Ins 4700. Long-term care insurance policies shall comply with RSA 415-D and Ins 3600. Medicare Supplemental insurance policies shall comply with RSA 415-F and Ins 1902 or Ins 1905. Required provisions for all other group accident and health insurance policies shall be those established in RSA 415:18.

(b) Other group accident and health policy standards, with the exception of policies regulated by Ins 3600, Ins 4700, Ins 1902, or Ins 1905, shall be as follows:

(1) Exclusions that are ambiguous or unfairly discriminatory shall be prohibited;

(2) All master policies and certificates shall contain a clear explanation as to continuance of coverage after termination of the policy;

(3) No group accident and health policy shall contain a provision for automatic termination of an individual's coverage upon the happening of a loss, except a loss that has exhausted all possible benefits under the policy;

(4) A certificate shall:

a. State the benefits applicable to the person insured or state the schedule of benefits applicable to the class to which he or she belongs; or

b. Define eligibility and benefit amounts clearly enough for a person to determine whether he or she is an insured and the amount of any benefits to which he or she is entitled;

(5) A policy may require that the insured:

a. Incur expenses that the insured is legally responsible to pay for;

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

c. Be responsible for non-covered services;

(6) All group certificates shall include a complete statement of the policy provisions regarding coordination or nonduplication of benefits in the event of other coverage;

(7) In the event of any renewal rate increase, insurers shall provide policyholders with prior notice of any such increase such that:

a. A 30 days’ notice is provided for policies subject to RSA 415, which are not subject to RSA 420-G provisions; and

b. A 60 days’ notice is provided for policies subject to RSA 420-G;

(8) Declination of renewal or termination of insurance provisions shall be as follows:

a. No insurer shall decline to renew a group policy unless the cause of its action is based on one or more of the reasons for declination of renewal stated in the policy;

b. Any such reason shall be stated in a group policy and shall be objective in nature;

c. Declination of renewal shall be defined so as to include any termination of a group policy by the insurer for any reason except for nonpayment of premiums; and

d. Notice of nonrenewal or termination of a group policy by the insurer shall provide for at least 45 days prior notice, except policies subject to RSA 420-G:6 VI. and VII;

(9) Non-duplication of coverage and subrogation provisions shall be as follows:

a. Benefit provisions for group medical expense insurance coverages may provide for non-duplication or coordination with any plan or government program providing benefits or services for medical or dental care and treatment;

b. All policies with non-duplication or coordination of benefit provisions shall:

Clearly stipulate how these provisions will be administered; and
Be at least as favorable to the insured as the provisions of Ins 1904; and

c. Group policies providing medical expense insurance coverages may include subrogation provisions or provisions that are similar in their intent and purpose; and

(10) In no case shall the benefits provided under the policy or the definitions contained in the policy be less favorable to the insured than the minimum standards for individual accident and health benefits set forth in RSA 415.

(d) Group excess policies shall be prohibited.

(e) The required provisions for blanket accident and health insurance policies shall be those established in RSA 415:18.

(f) Other blanket policy requirements shall be as follows:

(1) Except as provided in (2) below:

a. An individual certificate shall not be issued to the person or persons who may receive

benefits under group blanket accident and health coverage; and

b. A person or persons who receive benefits under blanket policy shall not contribute directly to the premium payment for the policy; and

(2) Blanket accident and health insurance shall meet all requirements of individual limited benefit health insurance if coverage:

a. Is issued to identified members or subscribers;

b. Is based on individual enrollment; and

c. Provides that a certificate of coverage to enrolled members shall be issued on an individual basis.

(g) File and use provisions for complete filings shall be as follows:

(1) A form shall be deemed approved for use after the form has:

a. Been received by the commissioner as complete;

b. Been under review by the commissioner for at least 30 days from the date of filing; and

c. Not been objected to or rejected by the commissioner within 30 days from the date of filing;

(2) In order for a form to be deemed approved pursuant to subparagraph (1) above, the company shall notify the commissioner in writing of the date such form was deemed; and

(3) When a company withdraws from use any form that it has used in this state, written notice of such withdrawal shall be provided to the commissioner advising the commissioner of the date of such withdrawal.

History

#8726, eff 9-18-06, EXPIRED: 9-18-14
#12126, eff 3-18-17 (from Ins 401.07)

N.H. Code Admin. R. Ann. Ins 401.09 Group Annuity Contracts {#sec-ins-401.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.09}

(a) The following provisions shall be required in group annuity contracts:

(1) A provision that there shall be a grace period of 31 days within which any stipulated payment to be remitted by the policyholder to the insurer, falling due after one year from date of issue, may be made, subject to the option of the insurer, to an interest charge thereon, at a rate to be specified in the contract, for the number of days elapsing before such payment is received by the insurer;

(2) A provision specifying the document or documents constituting the entire contract between the parties that shall include the policy, the application, and any individual enrollment forms, if any; and

(3) A provision for the equitable adjustment of benefits payable under the policy if gender, age, service, salary or any other factor determining the amount of any stipulated payment or the amount or dates of payment of any benefit with respect to any annuitant covered thereby, has been misstated.

(b) A group shall be qualified for such annuity if it meets one of the following requirements:

(1) Under a contract issued to an employer if:

a. The stipulated payments are to be remitted by the employer; and

b. The contract permits all of the employees of such employer, or any specified class or classes thereof, to become annuitants; and

c. Any group of employees, under b. above, may include:

Retired employees;
Officers and managers as employees;
The employees of subsidiary or affiliated corporations of a corporation employer; and
The individual proprietors, partners and employees of affiliated individuals and firms controlled by the holder through stock ownership, contract,

or otherwise;

(2) Under a contract issued to an employers' association that:

a. May, but shall not be required to, provide for the representation of annuitants on its board of directors;

b. Permits all of the employees of such employers, or of any specified class or classes thereof, to become annuitants; and

c. Requires that the stipulated payments under such contract shall be remitted by such employers' association;

(3) Under a contract issued to a labor union that:

a. Permits all of the members of such union, or of any specified class or classes thereof, to become annuitants; and

b. Requires that the stipulated payments under such contract shall be remitted by such union;

(4) Under a contract issued to an association or to trustees of a fund established by such an association, if the persons in the association have a common interest, calling, or profession and constitute a homogeneous group and the association:

a. Has a constitution and bylaws;

b. Is organized and maintained in good faith for purposes other than obtaining annuities; and

c. Permits all members of the association and their employees, or any specified class or

classes thereof, to become annuitants; or

(5) Under a contract issued to the trustees of a fund established by an employer, or by an employers' association, or by one or more labor unions or by one or more employers and one or more labor unions if:

a. The trustees are deemed the contract holders;

b. The contract permits all of the employees of the employers or all of the members of the unions, or all of any class or classes thereof, to become annuitants;

c. The stipulated payments under such contract remitted by the trustees are not derived

wholly from funds contributed by the person covered thereunder; and

d. The term “employees” may include retired employees, officers, and managers of an employer.

History

#8726, eff 9-18-06, EXPIRED: 9-18-14
#12126, eff 3-18-17 (from Ins 401.08)

N.H. Code Admin. R. Ann. Ins 401.10 Variable Contracts {#sec-ins-401.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.10}

(a) Variable contracts shall include all contracts that do either or both of the following:

(1) Place funds in any separate account or accounts maintained by the insurance company for accumulation purposes and where the value of the funds being accumulated may vary according to the investment experience of the separate account or accounts; and

(2) Provide annuity benefit payments to annuitants from any separate account or accounts maintained by the insurance company and where the value of the annuity benefit payments can vary according to the investment experience of the separate account or accounts;

(b) Individual variable annuity contracts shall be subject to the applicable provisions of RSA 408 and all of the applicable provisions of Ins 401.05 except for Ins 401.05(f) and (g).

(c) Group variable annuity contracts shall be subject to the applicable provisions of RSA 408 and all of the provisions of Ins 401.09.

(d) Additional provisions required for variable annuity contracts shall include that:

(1) Any variable contract providing benefits payable in variable amounts delivered or issued for delivery in this state shall contain a statement of the essential features of the procedures to be followed by the insurance company in determining the dollar amount of such variable benefits;

(2) Any such contract, including a group contract and any certificate in evidence of variable benefits issued thereunder, shall state that such dollar amount may vary to reflect investment experience;

(3) Any such contract shall contain on its first page a clear statement to the effect that the benefits thereunder are on a variable basis;

(4) No individual variable annuity contract calling for the payment of periodic stipulated payments shall be delivered or issued for delivery in this state unless it contains in substance the following provision or provisions:

a. A provision that there shall be a grace period of 31 days within which any stipulated payment to the insurer falling due after the first may be made, and during which period of grace the contract shall continue in force;

b. For the purposes of a. above, the contract may include a statement of the basis for determining the date as of which any such payment received during the grace period shall be applied to produce the values under the contract arising therefrom;

c. A provision that, at any time within 3 years from the date of default, in making periodic stipulated payments to the insurer during the life of the annuitant and unless the cash surrender value has been paid, the contract may be reinstated upon payment to the insurer of such overdue payments as required by the contract and of all indebtedness to the insurer on the contract, including interest;

d. For the purposes of c. above, the contract may include a statement of the basis for determining the date as of which the amount to cover such overdue payments and indebtedness shall be applied to produce the values under the contract arising therefrom; and

e. A provision specifying the options available in the event of default in a periodic stipulated payment, such as an option to surrender the contract for a cash value as determined by the contract including an option to receive a paid-up annuity if the contract is not surrendered for cash, the amount of which is determined under the terms of the contract by applying the value of the contract at the annuity commencement date;

(5) Any variable annuity contract delivered or issued for delivery in this state shall stipulate the investment in increment factors to be used in computing the dollar amount of variable benefits or other variable contractual payments or values thereunder, and may guarantee that expense and/or mortality results shall not adversely affect such dollar amounts; and

(6) In the case of an individual variable annuity contract under which the expense and mortality results could adversely affect the dollar amount of benefits, the expense and mortality factors shall be stipulated in the contract as follows:

a. In computing the dollar amount of variable benefits or other contractual payments or values under an individual variable annuity contract;

The annual net investment increment assumption shall not exceed 5 percent;
To the extent that the level of benefits may be affected by future mortality results, the mortality factor shall be determined from the Annuity 2000 Mortality Table, available as referenced in Appendix B, or any modification of that table not having a lower life expectancy at any age, or any annuity mortality table adopted after 1996 by the National Association of Insurance Commissioners; and
"Expense," as used in this paragraph may exclude some or all taxes, as stipulated in the contract.

(e) No individual variable life insurance policy shall be delivered or issued for delivery in this state unless it contains in substance the following:

(1) A provision that there shall be a grace period of 31 days, within which payment of any premium after the first may be made, and during which grace period the policy shall continue in force;

(2) For flexible premium policies, a provision for a grace period beginning on the policy processing day when the total charges authorized by the policy that are necessary to keep the policy in force until the next policy processing day exceed the amounts available under the policy to pay such charges in accordance with the terms of the policy. The grace period shall end on a date not less than 61 days after the mailing of the notice to the policyholder pursuant to Ins 401.10(f), below;

(3) A provision that if a claim arises under the policy during the grace period and before the overdue premiums or the deferred premiums of the current policy year, if any, are paid, the amount of such premiums, together with interest not to exceed 6 percent per annum compounded annually, may be deducted from any amount payable under the policy in settlement;

(4) A statement of the basis for determining any variation in benefits that may occur as a result of the payment of premium during the grace period;

(5) Upon the request of the policyholder, unless the cash surrender value of a variable life insurance policy has been paid out in full or the period of extended insurance has expired, any variable life insurance policy shall be reinstated during the life of the insured anytime within 3 years of the date of default if:

a. Evidence of insurability satisfactory to the insurer is provided to the insurer;

b. Payment is tendered to the insurer in an amount not to exceed the larger of:

The sum of:

(i) Overdue premiums, including interest at a rate not to exceed 8 percent per annum, compounded annually; and

(ii) Any outstanding policy loans, including interest at a rate that would be permitted under this rule if the policy had not lapsed; or

One hundred ten percent of the increase in cash surrender value resulting from reinstatement; and

c. Premium payments prior to default have been paid for at least 3 years;

(6) Any variable annuity contract delivered or issued for delivery in this state shall stipulate the investment in increment factors to be used in computing the dollar amount of variable benefits or other variable contractual payments or values thereunder and may guarantee that expense and/or mortality results shall not adversely affect such dollar amounts; and

(7) In the case of an individual variable annuity contract under which the expense and mortality results could adversely affect the dollar amount of benefits, the expense and mortality factors shall be stipulated in the contract as follows:

a. In computing the dollar amount of variable benefits or other contractual payments or values under an individual variable annuity contract;

The annual net investment increment assumption shall not exceed 5 percent, except;
To the extent that the level of benefits may be affected by future mortality results, the mortality factor shall be determined from the Annuity 2000 Mortality Table, available as referenced in Appendix B, or any modification of that table not having a lower life expectancy at any age, or any annuity mortality table adopted after 1996 by the National Association of Insurance Commissioners; and
"Expense," as used in this paragraph may exclude some or all taxes, as stipulated in the contract; and

b. Any individual variable life insurance policy delivered or issued for delivery in this state shall stipulate the investment increment factor to be used in computing the dollar amount of variable benefits or other variable contractual payments or values thereunder and shall guarantee that expense and mortality results shall not adversely affect such dollar amounts.

(f) For flexible premium policies, a notice shall be sent to the policyholder if the amounts available under the policy on any policy processing day to pay the charges authorized by the policy are less than the amount necessary to keep the policy in force until the next following policy processing day. The notice shall indicate the minimum payment required under the terms of the policy to keep it in force and the length of the grace period for payment of the amount.

History

#8726, eff 9-18-06; amd by #10195, eff 10-1-12; paras. (a), (c), and (d) EXPIRED: 9-18-14; ss by #12126, eff 3-18-17 (from Ins 401.10)

N.H. Code Admin. R. Ann. Ins 401.11 Computation of Cash Values for Variable Annuities {#sec-ins-401.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.11}

(a) If the variable annuity policy does not include a table of figures for the options available, the policy shall provide that the company will furnish at least once in each policy year a statement showing the cash value as of a date no earlier than the prior policy anniversary.

(b) The method of computation of cash values and other nonforfeiture benefits, as described either in the policy or in a statement filed with the commissioner of the jurisdiction in which the policy is delivered, shall be in accordance with actuarial procedures that recognize the variable nature of the policy.

(c) The method of computation shall be such that, if the net investment return credited to the contract at all times from the date of issue should be equal to the assumed investment increment factor if the contract provides for such a factor or 3-1/2 percent if not, with premiums and benefits determined accordingly under the terms of the policy, the resulting cash values and other nonforfeiture benefits would be at least equal to the minimum values required by RSA 409 Standard Nonforfeiture Law for a fixed dollar policy with such premiums and benefits.

(d) The method of computation may disregard incidental minimum guarantees as to the dollar amounts payable. Incidental minimum guarantees shall include, for example, but shall not be limited to, a guarantee under a policy that provides for an assumed investment increment factor that the amount payable at death or maturity shall be at least equal to the amount that otherwise would have been payable if the net investment return credited to the contract at all times from the date of issue had been equal to such factor.

History

#8726, eff 9-18-06, EXPIRED: 9-18-14
#12126, eff 3-18-17 (from Ins 401.10)

N.H. Code Admin. R. Ann. Ins 401.12 Applications {#sec-ins-401.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.12}

The following standards shall apply to all application forms used in connection with the offer and acceptance of insurance, whether or not attached to the contract:

(a) The declarative portion of the application, if any, shall imply a representation of facts to the best of the applicant's knowledge. "I represent," or "To the best of my knowledge and belief," shall be examples of such wording. Wording implying a warranty shall be prohibited. "I Certify" shall be such an example;

(b) There shall be no provisions for automatic rejection;

(c) Medical questions of a technical nature beyond the capability of the average applicant, such as a detailed gastrointestinal questionnaire, shall be prohibited;

(d) No provision shall be permitted in an application that changes the terms of the policy to which it is attached;

(e) Questions as to race or ethnicity shall be prohibited;

(f) All applications shall contain a question inquiring whether the policy sought is intended to replace an existing policy;

(g) The requirement in (f) above shall not apply to applications for:

(1) Group insurance;

(2) Group annuity policies;

(3) Individual accident only policies; or

(4) Policies solicited by direct-response means.

(h) No application or any detachable part thereof that contains an advertisement that is directed toward effecting a policy sale without opportunity for additional explanation of the coverage advertised shall:

(1) Offer any reduced initial premium without stating all subsequent premium changes applicable to the insured;

(2) State or imply falsely that prospective policyholders become group or quasi-group members and as such enjoy special rates or underwriting privileges; or

(3) State or imply falsely that a particular policy or combination of policies is an:

a. Introductory;

b. Initial;

c. Special; or

d. Limited enrollment offer and that the applicant will receive advantages by accepting the offer; and

(i) To the extent that any provision within (h) above conflicts with Ins 2600, Ins 2600 shall apply.

History

#8726, eff 9-18-06, EXPIRED: 9-18-14
#12126, eff 3-18-17 (from Ins 401.11)

N.H. Code Admin. R. Ann. Ins 401.13 Life Settlement Filings {#sec-ins-401.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.13}

(a) The commissioner shall, for the purpose of examining and analyzing life settlement filings, contract with an attorney or law firm. The examination and analysis of any life settlement filing shall be undertaken by a contracting attorney or law firm only when the insurance department is unable to provide the resources necessary to review such filings. The contracting attorney or law firm shall provide advice to the commissioner on the life settlement filing and perform other legal services related to the life settlement filing as required.

(b) The expense of the life settlement review required by this part, and all other expenses associated with any legal services performed related to a life settlement filing, shall be borne by the insurer or life settlement provider submitting the life settlement filing, in accordance with RSA 400-A:37, III(d).

History

#12882, eff 9-30-19

N.H. Code Admin. R. Ann. Ins 401.14 Forms Filing, Review, and Inventory Procedures {#sec-ins-401.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.14}

(a) All policies, contracts, certificates, endorsements, riders, applications, and other forms used in connection therewith shall be submitted to the insurance department for approval prior to their use.

(b) All submissions shall be made by the home office of the company.

(c) In instances where a filing is being made on behalf of a company, a letter or other documentation authorizing the firm to file on behalf of the company shall be attached to the supporting documentation tab in SERFF.

(d) All submissions and associated fees shall be submitted electronically through SERFF and electronic funds transfer (EFT), pursuant to Ins 3101.

(e) A certification of compliance statement shall be signed by a representative of the company authorized to certify compliance and attached to the supporting document tab in SERFF.

(f) All filings shall include the following:

(1) A brief description of each form, including any new or unusual features, and a listing of forms to which it will be attached;

(2) A statement indicating the current submission's filing status in the state of domicile, the date approved by the state of domicile, and state of domicile status comments shall be completed on the general information tab in SERFF;

(3) If this form is replacing another form, said other form shall be identified. If this form is not replacing another form, it shall be so stated; and

(4) Where a form is replacing another form, a letter shall itemize each of the differences between the new form and the form being replaced which shall be attached to the supporting documentation tab in SERFF. A copy of the new form showing each change highlighted or otherwise indicated shall also be attached to the supporting documentation tab in SERFF.

(g) All forms shall be submitted for review in the same layout as sold to consumers in New Hampshire. Except as expressly provided by statute or rule, multiple product line filings shall not be submitted as a single policy if any product line in the filing may be marketed or issued as a separate policy.

(h) All policy forms containing 3,000 or more words or printed on 3 or more pages shall contain a table of contents or an index of the principal sections of the policy and shall be electronically bookmarked.

(i) The specifications page of a policy or contract shall be completed with hypothetical data that is realistic and consistent with the other contents of the policy or contract.

(j) With respect to any submission of a company domiciled in a state or country where the state insurance department or comparable agency requires foreign or alien insurers to pay any fees for the filing or examination of policy forms, the submission shall include an EFT payment of the retaliatory fee due to the state of New Hampshire pursuant to RSA 400-A:35.

(k) All forms shall be filed as intended for use, with all necessary related forms.

(l) Certificates shall include enrollment forms.

(m) Policies, certificates, and rates shall be submitted together to the department.

(n) Where amendatory pages are submitted, those pages shall be properly executed as such.

(o) A rider, amendment, or endorsement that changes or adds language to another form shall be filed together with the complete form it is replacing or amending, including the underlying policy form, showing all changes highlighted or otherwise indicated on the supporting document tab in SERFF.

(p) All variable language shall be identified by the use of brackets, accompanied by a statement of variability, and attached on the supporting document tab in SERFF which shall describe the full range of variability. Variable language shall not be approved if the variable language prevents review of the policy for compliance with minimum standards or the requirements of RSA 415:2.

(q) Complete revised forms including amendments shall be submitted with a distinguishing form number.

(r) All forms submitted shall be in final print.

(s) Forms shall be submitted with the exact content as intended for use by the company and shall bear facsimile signatures of corporate officers. However, facsimile signatures shall not be required on group certificates.

(t) Because of the many variations possible in group policies, their certificates and all of the intended insert pages reflecting possible variations shall be reviewed, provided that such filing is accompanied by a statement of variability describing all combinations used for the different types of policies.

(u) Every filing of a group policy or group policy page shall include the simultaneous filing of the corresponding group certificate page. In addition, every filing of a group certificate or group certificate page shall include the simultaneous filing of the corresponding group policy or group policy page.

(v) Any submission of a "blank" rider, amendment, or endorsement form shall in all instances be accompanied by a listing of all intended uses attached to the supporting document tab in SERFF.

(w) In the event that forms submitted to this department by an insurer are not approved, and such forms are thereafter corrected and resubmitted, the previous submission's SERFF number shall be given, and all previous correspondence shall be attached to the supporting document tab in SERFF. The filing description for the resubmission shall comply with all the provisions of Ins 401.13 and include a description of each correction made in reference to the prior submission. A copy of the new form showing each change highlighted or otherwise indicated shall also be attached to the supporting document tab in SERFF.

(x) Submissions that comply with the foregoing requirements of this rule, and the requirements of (ab) below if applicable, shall be accepted for filing and review by the commissioner.

(y) Submissions that do not comply with these requirements shall be immediately rejected.

(z) Policy forms that are resubmitted and disapproved 2 times by the department under (y) above due to non-compliance with statutes and rules shall not be given further consideration until a company representative personally attends a compliance conference at the department to discuss the form submission.

(aa) After a form has been filed with the commissioner, the company may withdraw that form from consideration if it has not already been approved or disapproved pursuant to this paragraph, provided written notice of such withdrawal is given to the commissioner.

(ab) When a company withdraws from use any form that it has used in this state, written notice of such withdrawal shall be provided to the commissioner advising the commissioner of the date of such withdrawal.

History

#8726, eff 9-18-06; ss by #9334, eff 12-5-08, EXPIRED: 12-5-16
#12126, eff 3-18-17 (from Ins 401.12); renumbered by #12882 (formerly Ins 401.13)

N.H. Code Admin. R. Ann. Ins 401.15 Penalty; Generally {#sec-ins-401.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.15}

If an insurer, producer, or any person, firm, association, or corporation violates the provisions of this part, the department shall assess that violation pursuant to the provisions of RSA 400-A:15, III.

History

#8726, eff 9-18-06, EXPIRED: 9-18-17
#12126, eff 3-18-17 (from Ins 401.13) renumbered by #12882 (formerly Ins 401.14)

N.H. Code Admin. R. Ann. Ins 401.16 Waiver or Suspension of Rules {#sec-ins-401.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 401.16}

(1) Applying the rule provision would result in a form that is inaccurate, would cause confusion, or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to or inconsistent with the form of policy;

(3) There are specific circumstances unique to the form such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

History

#12126, eff 3-18-17 renumbered by #12882 (formerly Ins 401.15)

Part Ins 402 Standards for Filings Providing a Return of Premium or Cash Benefits

N.H. Code Admin. R. Ann. Ins 402.01 Scope {#sec-ins-402.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 402.01}

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

N.H. Code Admin. R. Ann. Ins 402.02 Standards Required {#sec-ins-402.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 402.02}

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

N.H. Code Admin. R. Ann. Ins 402.03 Rate Filings {#sec-ins-402.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 402.03}

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

N.H. Code Admin. R. Ann. Ins 402.04 Nonconforming Forms Subject to This Part {#sec-ins-402.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 402.04}

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

N.H. Code Admin. R. Ann. Ins 402.05 Penalties {#sec-ins-402.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 402.05}

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

N.H. Code Admin. R. Ann. Ins 402.06 Separability {#sec-ins-402.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 402.06}

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

Part Ins 403 Standard Wellness Plan Rate and Form Filing Standards

N.H. Code Admin. R. Ann. Ins 403.01 Purpose {#sec-ins-403.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.01}

The purpose of this part is to establish guidelines and standards for the standard wellness plan under RSA 420-G:4-b.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.02 Applicability and Scope {#sec-ins-403.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.02}

This part applies to all rate and form filings for the standard wellness plan under RSA 420-G:4-b.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.03 Definitions {#sec-ins-403.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.03}

For the purposes of this chapter:

(a) "Care navigator" means an informed decision-making resource provided by the carrier that is designed to provide members with information about treatment options, identify and assist members in navigating through the healthcare system and to direct the member to related resources within the healthcare community.

(b) "Carrier" means any entity that offers health coverage in the small employer market in this state and has at least 1,000 covered lives as of the first day of the calendar year and that is subject to the requirement of offering the standard wellness plan.

(d) "Department" means the New Hampshire insurance department.

(e) "Health coverage plan target rate" means the health coverage plan rate that is set at or below 10 percent of the prior year's median wage based on the occupation employment statistics maintained by the U.S. Department of Labor and adjusted by the state department of labor to reflect the median hourly wage of full time New Hampshire employees.

(f) "HealthFirst benefit plan" means the HealthFirst standard benefit design, including the HealthFirst wellness incentives as set forth in the HealthFirst benefit description.

(g) "Prescription drugs" means covered medications, diabetic supplies and contraceptive devices purchased at a network pharmacy.

(h) "Preventive care services" mean:

(1) Immunizations;

(2) Lead screening;

(3) PSA tests;

(4) Routine physical exams, including family planning, pre-natal visits and well child care;

(5) Annual ob-gyn visits, including mammography;

(6) Routine hearing tests;

(7) Routine laboratory tests; and

(8) Annual care plan for chronic illnesses.

(i) "Standard wellness plan" means the benefit plan developed by the commissioner pursuant to RSA 420-G:4-b.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.04 Standard Wellness Plan {#sec-ins-403.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.04}

The standard wellness plan shall include the following benefit structure as described herein and as set forth in Appendix A:

(a) Benefits shall include:

(1) Full coverage for preventive care services;

(2) Primary care visits covered with a $20.00 per visit copay;

(3) Specialist visits covered with a $50.00 per visit copay;

(4) Full coverage for inpatient and outpatient hospital care, including diagnostic laboratory work, after the deductible has been met;

(5) Skilled nursing facility care for a period of up to 100 days within each policy year, subject to the deductible;

(6) Rehabilitation facility care for a period of up to 60 days within each policy year, subject to the deductible;

(7) Full coverage for diagnostic laboratory work;

(8) Diagnostic radiology, including x-rays, MRI's, CT scans, and PET scans, subject to the deductible, except for mammograms which are preventive care shall not be subject to the deductible;

(9) Outpatient surgery performed in a physician's office, subject to the office visit copay of $20 for a primary care provider and $50 for a specialist;

(10) Outpatient surgery performed in a hospital or surgical center, subject to the deductible;

(11) Urgent care facility care, subject to a $100 per visit copay for the facility charge with other covered services subject to the tier 1 or tier 2 deductible for facilities that are hospital owned. If the urgent care facility is not hospital owned, the services shall be subject to the tier 1 deductible;

(12) Emergency care facility care, subject to a $200 per visit copay for the emergency room facility charge. Other covered services, including radiology and laboratory work, delivered at the emergency room shall be subject to the tier 1 deductible;

(13) Ambulance services, subject to the deductible;

(14) Short-term therapy, including physical therapy, speech therapy, and occupational therapy, subject to a $50 per visit copay;

(15) Mental health and substance abuse services, subject to a $20 per visit copay for office visits and subject to the inpatient and outpatient deductible when the services are provided at a hospital or outpatient care facility;

(16) Durable medical equipment, subject to the deductible and limited to a calendar year maximum of $3,000;

(17) Prescription drugs including covered medications, diabetic supplies and contraceptive devices purchased at a network pharmacy, subject to:

a. The following copays:

A $10 copay for generic drugs;
A $35 copay for non-generic formulary drug brands; and
A $50 copay for non-formulary brand drugs.

b. Drugs that are considered maintenance shall be available for a supply greater than 30 days;

c. The copay shall be applied to each 30 day supply of the drugs except when drugs are purchased through a mail-order facility that offers a reduction of copay(s) for purchasing through the mail-order facility; and

d. For formulary brand and non-formulary brand at least 2 brand drugs shall be available for each therapeutic class covered under the HealthFirst benefit plan.

(18) Full coverage for screening and brief intervention for alcohol and drug abuse;

(19) Full coverage for body mass index screening; and

(20) Colonoscopy, subject to a $250 copay.

(b) The standard wellness plan shall use hospital tiering of acute care hospitals to determine the amount of the hospital deductible, so that:

(1) The deductible for tier 1 facilities shall be $2,500 per member and $5,000 per family; and

(2) The deductible for tier 2 facilities shall be $4,000 per member and $8,000 per family.

(c) The annual out of pocket maximum for the standard wellness plan shall be $5,000 per member and $10,000 per family. There shall not be a lifetime maximum amount.

(d) A separate annual out-of-pocket maximum for prescription drugs may be offered with an annual out-of-pocket of $5,000 per member and $10,000 per family. There shall not be a lifetime maximum amount.

(e) The standard wellness plan shall comply with all state laws and rules related to small group accident and health insurance coverage, including, but not limited to state mandated benefits in RSA 415, 420-B, 420-J and Ins 1900.

(f) The use of a telecommunications or telehealth system shall be defined by the insurer and may substitute for an in-person visit for consultations, office and outpatient visits, psychiatric diagnostic interviews, individual psychotherapy, individual medical nutrition therapy, end-stage renal disease (ESRD) services, and pharmacologic management. Telehealth shall not be used for group visits.

(g) The care navigator shall be included in the benefit design; and

(h) The care navigator shall specifically describe:

(1) The application of the care navigator in the HealthFirst benefit plan; and

(2) How the care navigator shall be used in each applicable benefit description.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.05 Wellness Incentive Plan {#sec-ins-403.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.05}

(a) The standard wellness plan shall include a standard wellness incentive program. In administering the standard wellness incentive program, a carrier may utilize existing programs to the extent practicable.

(b) The standard wellness program shall include the following incentives described herein and set forth in Appendix B:

(1) In year one, a cash payment of $200.00 shall be paid to both the subscriber and the spouse or civil union partner of a subscriber on a plan that covers 2 or more people when the subscriber and spouse or civil union partner:

a. Establish and maintain a relationship with a primary care provider;

b. Complete a health risk questionnaire;

c. Do not smoke or participate in a smoking cessation program;

d. Each have a body mass index measurement lower than 25 and a blood pressure reading lower than 140/90 or participate in a health management program for blood pressure or weight loss; and

e. Each have acceptable blood glucose and cholesterol levels as determined by the health carrier, or participate in a health management program;

(2) In years 2 and 3, the certificateholder who fulfills the requirements of Ins 403.05 (b) for year one shall receive a credit in the amount of $1,000 against the deductible for the product;

(3) To receive the amount of $1,000 per adult subscriber against the deductible in subsequent years, on a policy that covers 2 or more persons, the subscriber and spouse or civil union partner shall both be required to fulfill the requirements to obtain any benefit. A maximum credit of $2,000 shall be allowed on any policy that covers 2 or more people; and

(4) In the event that both the subscriber and the spouse or civil union partner covered by the policy fail to fulfill the requirements, there shall be no reduction of the deductible, and there shall be no payment of $200.00 in the first year.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.06 Hospital Tiering {#sec-ins-403.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.06}

(a) Hospital tiers shall be incorporated into the HealthFirst standard benefit design. The member deductible for hospital services shall be based on whether the member obtains services from a tier 1or a tier 2 hospital. A listing of the hospitals in each tier shall be provided in the HealthFirst benefit description.

(b) The HealthFirst standard benefit design shall require greater cost sharing for members seeking services from a tier 2 hospital than for those who obtain services from a tier 1 hospital.

(1) The department shall use the all payer claims data base for the previous calendar year, collected pursuant to RSA 420-G:11, and the New Hampshire health care facility data, collected pursuant to He-C 1500, to determine historical pricing and payment differences among hospitals;

(2) Assignment to a tier shall be based on relative payment differences among the hospitals as well as geographical proximity and access;

(3) A hospital in close proximity to a lower cost hospital that provides services within the same hospital service area may be assigned to tier 2 despite its overall cost ranking across all hospitals in the state. The assignment of a hospital to tier 2 shall be based on geographical location;

(4) All hospitals located out of state shall be assigned to tier 2; and

(5) The department shall publish the hospital tiering by December 1st of each year. The hospital tiers shall be effective on a calendar year basis beginning on January 1st of each year.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.07 Application for Carrier Specific Hospital Tiering {#sec-ins-403.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.07}

(a) A carrier may submit an application to the department to use carrier specific hospital tiering.

(b) The application for carrier specific tiering shall establish that carrier specific deviations from the department's tiering will result in reduced expenditures to the carrier based on the carrier's payment for specific services, admissions to hospitals, utilization of specific services and quality measures.

(1) Historical data as well as current information on contract reimbursement levels;

(2) A detailed explanation of the methodology used, including:

a. The time frame of the data;

b. The membership included; and

c. A description of the analytic tools used including:

Case-mix adjustment;
The number of observations;
The weighting used relative to outpatient and inpatient services;
Contact information for the analyst preparing the application; and
Hospital specific relative rankings for each hospital for which a tier change is requested; and

(3) The application may include a request for tier changes to out of state as well as in state hospitals.

(d) A carrier seeking approval for carrier specific hospital tiering shall submit the application to the department no more than 7 days following the publication date of the department's tiering.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.08 Standard for Approval of Tier Change {#sec-ins-403.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.08}

The department shall grant approval for carrier specific tiers when the department finds based on substantial evidence that the requested tier change is cost effective to the carrier requesting the change.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.09 Applications for Tier Changes {#sec-ins-403.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.09}

All applications for tier changes submitted by carriers shall be maintained as confidential documents by the department, and the information contained in the application shall not be released.

History

#9511, eff 7-10-09

N.H. Code Admin. R. Ann. Ins 403.10 Required Reporting {#sec-ins-403.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 403.10}

Each carrier shall submit to the department the following reports:

(a) Quarterly trend information on small group HealthFirst business and comparative small group trend information on other small group products no later than 30 days after the end of each calendar year quarter. Trend information shall include the total trend and detailed numerical information on utilization, cost, technology and other factors comprising total trend numbers.

(b) Quarterly total enrollment information on the HealthFirst product no later than 30 days after the end of the calendar year quarter. Enrollment information shall include the number of subscribers, the number of spouses or civil union partners, and the number of dependent children or other dependents by enrollment classification.

(c) Quarterly, no later than 30 days after the end of the calendar year quarter, the total premium earned and total paid claims for the preceding quarter.

Appendix A

NH HealthFirst Program Benefit Summary

Benefits

HealthFirst Plan

Preventive Care Services:

Immunizations, Lead Screenings, PSA, Routine Physical Exams (including family planning, pre-natal & well child care), annual ob-gyn visits (including mammography), Routine Hearing Laboratory and an Annual Care Plan for Chronic Illnesses

Covered in Full

Other Office Visits:

Primary Care Copay

Specialist Copay

Colonoscopy

$20 per visit

$50 per visit

Subject to $250 copay

Deductible (single family traditional)

Coinsurance

Max out of pocket (single/family traditional)

Tier 1 Facilities: $2,500/$5,000

Tier 2 Facilities: $4,000/$8,000

None

$5,000/$10,000

Lifetime Maximum

No maximum

In/Out Patient Hospital Care

Subject to deductible, including diagnostic lab

Skilled Nursing & Rehab Facilities:

SNF limited to 100 days/CY, Rehabilitation Facility limited to 60 days/CY

Subject to deductible

Diagnostic Labs and X-Rays:

Labs

X-Rays

MRI, CT and PET Scans

Covered in full

Subject to deductible

Outpatient Surgery:

Doctor's Office

Hospital/Surgical Day Care

$20/$50 per visit

Subject to deductible

Urgent/Emergency Room Care:

Urgent Care Facility Copay

Emergency Room Facility Copay

$100 per visit for the facility charge. All other services are subject to the Tier 1 or Tier 2 deductible.

$200 per visit

Ambulance (medically necessary)

Subject to deductible

Short Term Therapy (PT, OT, ST)

$50 per visit

Chiropractic

Not covered

Mental Health/Substance Abuse Services:

Office Visits

Facility

$20 per visit

Subject to deductible

Durable Medical Equipment:

Limited to $3,000/Mbr/CY

Subject to deductible

Prescription Drugs:

Covered medication, diabetic supplies and contraception devices purchased at a network pharmacy

Certain maintenance drugs are available for a supply greater than 30 days.

Maximum out-of-pocket (single/family traditional)

Important Notes:

If, due to medical necessity, your physicianprescribes a brand drug, you pay only the formulary or non-formulary brand copay shown on this summary.

For formulary brand and non-formulary brand at least 2 brand drugs shall be available for each covered benefit therapeutic class.

$10 copay/generic

$35 copay/formulary brand

$50 copay/non-formulary brand

No Max

Copayment applies to each 30 day supply.

$5,000/$10,000

Members are required to work with a care navigator for certain tests and procedures.

Members shall establish a relationship with a primary care provider.

The benefit plan shall additionally cover the following services:

Screening and Brief Intervention for Alcohol and Drug Abuse

Body Mass Index Screening

After-hours care

Appendix B

NH HealthFirst Wellness Design

Employees and Spouses Reward Per Adult

Year One

Establish and continue relationship with a Primary Care Provider

Complete a Health Risk Questionnaire

Remain Smoke-Free or Participate in a Smoking Cessation Program

Get a BMI measurement and Blood Pressure reading, and maintain a BMI of <25 and BP of <140/90 or participate in a health management program

Get your Blood Glucose and Cholesterol levels checked, and maintain acceptable levels or participate in a health management program

$200 for Meeting All Requirements

Year One -

Within 8 Months of Employee's Effective Date

Submit a Wellness Verification Form for Year 2 Deductible Credit

Year Two

Complete a Health Risk Questionnaire

Remain Smoke-Free or Participate in a Smoking Cessation Program

Maintain a BMI of <25 and a BP of <140/90 or participate in a health management program

Maintain acceptable Blood Glucose and Cholesterol levels or participate in a health management program

$1,000 Deductible Credit for Meeting All Requirements

Year Two - Within 8 Months of Benefit Year Start Date

Submit a Wellness Verification Form for Year 3 Deductible Credit

Year Three

Complete Health Risk Questionnaire

Remain Smoke-Free or Participate in Smoking Cessation Program

Maintain a BMI of <25 and BP of <140/90 or participate in a health management program

Maintain acceptable Blood Glucose and Cholesterol levels or participate in a health management program

$1,000 Deductible Credit for Meeting All Requirements

(1) $200 reward is granted to the subscriber, or to both the subscriber and the spouse or civil union partner, upon completion of all requirements and submission of the Wellness Verification Form. To receive the $200.00 reward for a family policy, both the subscriber and spouse or civil union partner shall establish compliance with all requirements.

(2) Deductible Credits are awarded for the benefit year period following submission of the form.

(3) For policies that cover 2 or more persons, the subscriber and spouse or civil union partner shall comply to obtain the deductible credit. If both satisfy the requirements, then the single deductible amount is reduced by 1 x the credit, and the family is reduced by 2 x the credit (i.e., one credit for each adult parent)

(4) The deductible for children covered under a family plan shall match that of the parents.

(5) The Form shall be submitted within 8 months of the benefit year start date to obtain the rewards.

APPENDIX C - State Statutes and Federal Requirements Implemented

Rule

Specific State or Federal Statute the Rule Implements

Ins 401.01

RSA 400-A:15, I; 408; 408-A; 408-D:17; 409-A; 415:1; 420-A; 420-B:21

Ins 401.02

RSA 400-A:15, I

Ins 401.03

RSA 400-A:15, I ; 415-A:2; 415-F:3

Ins 401.04

RSA 400-A:15, I; 408:2-b; 408:2-c; 408:16; 408:16-d; 408:16-e; 408-A:7; 415:2 and 3; 415:18, I

Ins 401.05

RSA 400-A:15, I; 408:9 and10; 408-E:8; 409-A:3 and 409-A:9, II; 415:14

Ins 401.06

RSA 400-A:15, I; 415; 415-A; 415-F:3; 420-G:5, IV; 420-G:6, VI and VII

Ins 401.07

RSA 400-A:15, I; 408:15 and 16

Ins 401.08

RSA 400-A:15, I; 415:18; 415-F:3; 420-G

Ins 401.09

RSA 400-A:15, I

Ins 401.10

RSA 400-A:15, I; 408:27-34 and 52

Ins 401.11

RSA 400-A:15, I; 408:29

Ins 401.12

RSA 400-A:15, I; 408:9; 415:1 and 6; 415-A:2; 417:3

Ins 401.13

RSA 400-A:15, I; RSA 400-A:37, III(d); RSA 408-D:17

Ins 401.14

RSA 400-A:15, I; RSA 400-A:35; RSA 400-A:37, III(d);

RSA 408; RSA 408-A; RSA 408-D; RSA 408-E; RSA 409;

RSA 415; RSA 415-A; RSA 415-D; RSA 415-F; RSA 415-H; RSA 420-A; RSA 420-B; RSA 420-F; RSA 420-G; RSA 420-J

Ins 401.15

RSA 400-A:15, I and III; 408:8 and 12; 408-A:14; 415:20

Ins 401.16

RSA 400-A:15, I; RSA 541-A:22, IV

Ins 403.01

RSA 400-A:15, I; 420-G:4-a; 420-G:4-b

Ins 403.02

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

Ins 403.03

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

Ins 403.04

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

Ins 403.05

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

Ins 403.06

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

Ins 403.07

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

Ins 403.08

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

Ins 403.09

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

Ins 403.10

RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

APPENDIX D – Rules Incorporated by Reference

Rule

Title

Obtain:

Ins 401.05(c)(2)a.

Moody’s Corporate Bond Yield Average – Monthly Averages Corporates

Online for no cost at:

https://www.moodys.com/

or by writing:

Moody's Investors Service, Inc.

One International Place

100 Oliver Street, Suite 1400

Boston, MA 02110

Ins 401.10(d)(6)a.2.

Annuity 2000 Mortality Table

Online for no cost at: http://mort.soa.org/

Ins 401.10(e)(7)a.2.

Annuity 2000 Mortality Table

Online for no cost at: http://mort.soa.org/

History

#9511, eff 7-10-09

Chapter Ins 600 Credit for Reinsurance

Part Ins 601 Credit for Reinsurance

N.H. Code Admin. R. Ann. Ins 601.01 Purpose {#sec-ins-601.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.01}

The purpose of this rule is to set forth rules and procedural requirements that the commissioner deems necessary to carry out the provisions of RSA 405:45, RSA 405:46, RSA 405:47, RSA 405:48, RSA 405:49, RSA 405:50, RSA 405:50-a, RSA 405:51, and RSA 405:52. The actions and information required by this rule are declared to be necessary and appropriate in the public interest and for the protection of the ceding insurers in this state.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13; ss by #13296, eff 11-24-21

N.H. Code Admin. R. Ann. Ins 601.02 Credit for Reinsurance - Reinsurer Licensed in This State {#sec-ins-601.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.02}

Pursuant to RSA 405:47, I, the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer that was licensed in this state as of any date on which statutory financial statement credit for reinsurance is claimed.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #10449, eff 11-1-13; ss by #13296, eff 11-24-21

N.H. Code Admin. R. Ann. Ins 601.03 Credit for Reinsurance - Accredited Reinsurers {#sec-ins-601.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.03}

(a) Pursuant to RSA 405:47, II, the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer that is accredited as a reinsurer in this state as of the date on which statutory financial statement credit for reinsurance is claimed. An accredited reinsurer shall:

(1) File a properly executed Form AR-1 (attached as an exhibit to this rule) as evidence of its submission to this state's jurisdiction and to this state's authority to examine its books and records;

(2) File with the commissioner a certified copy of a certificate of authority or other acceptable evidence that it is licensed to transact insurance or reinsurance in at least one state, or, in the case of a U.S. branch of an alien assuming insurer, is entered through and licensed to transact insurance or reinsurance in at least one state;

(3) File annually with the commissioner a copy of its annual statement filed with the insurance department of its state of domicile or, in the case of an alien assuming insurer, with the state through which it is entered and in which it is licensed to transact insurance or reinsurance, and a copy of its most recent audited financial statement; and

(4) Maintain a surplus as regards policyholders in an amount not less than $20,000,000, or obtain the affirmative approval of the commissioner upon a finding that it has adequate financial capacity to meet its reinsurance obligations and is otherwise qualified to assume reinsurance from domestic insurers.

(b) If the commissioner determines that the assuming insurer has failed to meet or maintain any of these qualifications, the commissioner may upon written notice and opportunity for hearing, suspend or revoke the accreditation. Credit shall not be allowed a domestic ceding insurer under this section if the assuming insurer's accreditation has been revoked by the commissioner, or if the reinsurance was ceded while the assuming insurer’s accreditation was under suspension by the commissioner.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13; ss by #13296, eff 11-24-21

N.H. Code Admin. R. Ann. Ins 601.04 Credit for Reinsurance - Reinsurer Domiciled in Another State {#sec-ins-601.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.04}

(a) Pursuant to RSA 405:47, III, the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer that as of any date on which statutory financial statement credit for reinsurance is claimed:

(1) Is domiciled in (or, in the case of a U.S. branch of an alien assuming insurer, is entered through) a state that employs standards regarding credit for reinsurance substantially similar to those applicable under RSA 405:45, RSA 405:46, RSA 405:47, RSA 405:48, RSA 405:49, RSA 405:50, and this rule.

(2) Maintains a surplus as regards policyholders in an amount not less than $20,000,000; and

(3) Files a properly executed Form AR-1 with the commissioner as evidence of its submission to this state's authority to examine its books and records.

(b) The provisions of this section relating to surplus as regards policyholders shall not apply to reinsurance ceded and assumed pursuant to pooling arrangements among insurers in the same holding company system. As used in this section, “substantially similar” standards means credit for reinsurance standards that the commissioner determines equal or exceed the standards of RSA 405 and this rule.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13; ss by #13296, eff 11-24-21

N.H. Code Admin. R. Ann. Ins 601.05 Credit for Reinsurance -Reinsurers Maintaining Trust Funds {#sec-ins-601.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.05}

(a) Pursuant to RSA 405:47, IV, the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer which, as of any date on which statutory financial statement credit for reinsurance is claimed, and thereafter for so long as credit for reinsurance is claimed, maintains a trust fund in an amount prescribed below in a qualified U.S. financial institution as defined in RSA 405:46, III, for the payment of the valid claims of its U.S. domiciled ceding insurers, their assigns and successors in interest. The assuming insurer shall report annually to the commissioner substantially the same information as that required to be reported on the National Association of Insurance Commissioners (NAIC) annual statement form by licensed insurers, to enable the commissioner to determine the sufficiency of the trust fund.

(b) The following requirements apply to the following categories of assuming insurer:

(1) The trust fund for a single assuming insurer shall consist of funds in trust in an amount not less than the assuming insurer's liabilities attributable to reinsurance ceded by U.S. domiciled insurers, and in addition, the assuming insurer shall maintain a trusteed surplus of not less than $20,000,000, except as provided in subparagraph (2) of this paragraph.

(2) At any time after the assuming insurer has permanently discontinued underwriting new business secured by the trust for at least 3 full years, the commissioner with principal regulatory oversight of the trust may authorize a reduction in the required trusteed surplus, but only after a finding, based on an assessment of the risk, that the new required surplus level is adequate for the protection of U.S. ceding insurers, policyholders and claimants in light of reasonably foreseeable adverse loss development. The risk assessment may involve an actuarial review, including an independent analysis of reserves and cash flows, and shall consider all material risk factors, including when applicable the lines of business involved, the stability of the incurred loss estimates and the effect of the surplus requirements on the assuming insurer’s liquidity or solvency. The minimum required trusteed surplus may not be reduced to an amount less than 30 percent of the assuming insurer’s liabilities attributable to reinsurance ceded by U.S. ceding insurers covered by the trust.

(3) a. The trust fund for a group including incorporated and individual unincorporated underwriters shall consist of:

For reinsurance ceded under reinsurance agreements with an inception, amendment, or renewal date on or after January 1, 1993, funds in trust in an amount not less than the respective underwriters’ several liabilities attributable to business ceded by U.S. domiciled ceding insurers to any underwriter of the group;
For reinsurance ceded under reinsurance agreements with an inception date on or before December 31, 1992, and not amended or renewed after that date, notwithstanding the other provisions of this rule, funds in trust in an amount not less than the respective underwriters’ several insurance and reinsurance liabilities attributable to business written in the United States; and
In addition to these trusts, the group shall maintain a trusteed surplus of which $100,000,000 shall be held jointly for the benefit of the U.S. domiciled ceding insurers of any member of the group for all the years of account.

b. The incorporated members of the group shall not be engaged in any business other than underwriting as a member of the group and shall be subject to the same level of regulation and solvency control by the group’s domiciliary regulator as are the unincorporated members. The group shall, within 90 days after its financial statements are due to be filed with the group’s domiciliary regulator, provide to the commissioner:

An annual certification by the group’s domiciliary regulator of the solvency of each underwriter member of the group; or
If a certification is unavailable, a financial statement, prepared by independent public accountants, of each underwriter member of the group.

(4) a. The trust fund for a group of incorporated insurers under common administration, whose members possess aggregate policyholders surplus of $10,000,000,000 (calculated and reported in substantially the same manner as prescribed by the annual statement instructions and Accounting

Practices and Procedures Manual of the NAIC) and which has continuously transacted an insurance business outside the United States for at least 3 years immediately prior to making application for accreditation, shall:

Consist of funds in trust in an amount not less than the assuming insurers' several liabilities attributable to business ceded by U.S. domiciled ceding insurers to any members of the group pursuant to reinsurance contracts issued in the name of such group;
Maintain a joint trusteed surplus of which $100,000,000 shall be held jointly for the benefit of U.S. domiciled ceding insurers of any member of the group; and
File a properly executed Form AR-1 as evidence of the submission to this state's authority to examine the books and records of any of its members and shall certify that any member examined will bear the expense of any such examination.

b. Within 90 days after the statements are due to be filed with the group's domiciliary regulator, the group shall file with the commissioner an annual certification of each underwriter member’s solvency by the member's domiciliary regulators, and financial statements, prepared by independent public accountants, of each underwriter member of the group.

(c) (1) Credit for reinsurance shall not be granted unless the form of the trust and any amendments to the trust have been approved by either the commissioner of the state where the trust is domiciled or the commissioner of another state who, pursuant to the terms of the trust instrument, has accepted responsibility for regulatory oversight of the trust. The form of the trust and any trust amendments also shall be filed with the commissioner of every state in which the ceding insurer beneficiaries of the trust are domiciled. The trust instrument shall provide that:

a. Contested claims shall be valid and enforceable out of funds in trust to the extent remaining unsatisfied 30 days after entry of the final order of any court of competent jurisdiction in the United States;

b. Legal title to the assets of the trust shall be vested in the trustee for the benefit of the grantor's U.S. ceding insurers, their assigns and successors in interest;

c. The trust shall be subject to examination as determined by the commissioner;

d. The trust shall remain in effect for as long as the assuming insurer, or any member or former member of a group of insurers, shall have outstanding obligations under reinsurance agreements subject to the trust; and

e. No later than February 28 of each year the trustee of the trust shall report to the commissioner in writing setting forth the balance in the trust and listing the trust's investments at the preceding year end, and shall certify the date of termination of the trust, if so planned, or certify that the trust shall not expire prior to the following December 31.

(2) a. Notwithstanding any other provisions in the trust instrument, if the trust fund is inadequate because it contains an amount less than the amount required by this subsection or if the grantor of the trust has been declared insolvent or placed into receivership, rehabilitation, liquidation or similar proceedings under the laws of its state or country of domicile, the trustee shall comply with an order of the commissioner with regulatory oversight over the trust or with an order of a court of competent jurisdiction directing the trustee to transfer to the commissioner with regulatory oversight over the trust or other designated receiver all of the assets of the trust fund.

b. The assets shall be distributed by and claims shall be filed with and valued by the commissioner with regulatory oversight over the trust in accordance with the laws of the state in which the trust is domiciled applicable to the liquidation of domestic insurance companies.

c. If the commissioner with regulatory oversight over the trust determines that the assets of the trust fund or any part thereof are not necessary to satisfy the claims of the U.S. beneficiaries of the trust, the commissioner with regulatory oversight over the trust shall return the assets, or any part thereof, to the trustee for distribution in accordance with the trust agreement.

d. The grantor shall waive any right otherwise available to it under U.S. law that is inconsistent with this provision.

(d) For purposes of this section, the term “liabilities” shall mean the assuming insurer’s gross liabilities attributable to reinsurance ceded by U.S. domiciled insurers excluding liabilities that are otherwise secured by acceptable means, and shall include:

(1) For business ceded by domestic insurers authorized to write accident and health, and property and casualty insurance:

a. Losses and allocated loss expenses paid by the ceding insurer, recoverable from the assuming insurer;

b. Reserves for losses reported and outstanding;

c. Reserves for losses incurred by not reported;

d. Reserves for allocated loss expenses; and

e. Unearned premiums.

(2) For business ceded by domestic insurers authorized to write life, health and annuity insurance:

a. Aggregate reserves for life policies and contracts net of policy loans and net due and deferred premiums;

b. Aggregate reserves for accident and health policies;

c. Deposit funds and other liabilities without life or disability contingencies; and

d. Liabilities for policy and contract claims.

(e) Assets deposited in trusts established pursuant to RSA 405:47 and this section shall be valued according to their fair market value and shall consist only of cash in U.S. dollars, certificates of deposit issued by a U.S. financial institution as defined in RSA 405:46 II, clean, irrevocable, unconditional and “evergreen” letters of credit issued or confirmed by a qualified U.S. financial institution as defined in RSA 405:46 II, and investments of the type specified in this subsection, but investments in or issued by any entity controlling, controlled by or under common control with either the grantor or beneficiary of the trust shall not exceed 5 percent of total investments. No more than 20 percent of the total of the investments in the trust may be foreign investments authorized under Ins 601.05 (e)(1)e., (3), (6)b., or (7), and no more than 10 percent of the total of the investments in the trust may be securities denominated in foreign currencies. For purposes of applying the preceding sentence, a depository receipt denominated in U.S. dollars and representing rights conferred by a foreign security shall be classified as a foreign investment denominated in a foreign currency. The assets of a trust established to satisfy the requirements of RSA 405:47 shall be invested only as follows:

(1) Government obligations that are not in default as to principal or interest, that are valid and legally authorized and that are issued, assumed or guaranteed by:

a. The United Sates or by any agency or instrumentality of the United States;

b. A state of the United States;

c. A territory, possession or other governmental unit of the United States;

d. An agency or instrumentality of a governmental unit referred to in clauses (e)(1)b. and c. above if the obligations shall be by law (statutory or otherwise) payable, as to both principal and interest, from taxes levied or by law required to be levied or from adequate special revenues pledged or otherwise appropriated or by law required to be provided for making these payments, but shall not be obligations eligible for investment under this paragraph if payable solely out of special assessments on properties benefited by local improvements; or

e. The government of any other country that is a member of the Organization for Economic Cooperation and Development and whose government obligations are rated A or higher, or the equivalent, by a rating agency recognized by the Securities Valuation Office of the NAIC;

(2) Obligations that are issued in the United States, or that are dollar denominated and issued in a non-U.S. market, by a solvent U.S. institution (other than an insurance company) or that are assumed or guaranteed by a solvent U.S. institution (other than an insurance company) and that are not in default as to principal or interest if the obligations:

a. Are rated A or higher (or the equivalent) by a securities rating agency recognized by the Securities Valuation Office of the NAIC, or if not so rated, are similar in structure and other material respects to other obligations of the same institution that are so rated;

b. Are insured by at least one authorized insurer (other than the investing insurer or a parent, subsidiary or affiliate of the investing insurer) licensed to insure obligations in this state and, after considering the insurance, are rated AAA (or the equivalent) by a securities rating agency recognized by the Securities Valuation Office of the NAIC; or

c. Have been designated as Class One or Class Two by the Securities Valuation Office of the NAIC;

(3) Obligations issued, assumed or guaranteed by a solvent non-U.S. institution chartered in a country that is a member of the Organization for Economic Cooperation and Development or obligations of U.S. corporations issued in a non-U.S. currency, provided that in either case the obligations are rated A or higher, or the equivalent, by a rating agency recognized by the Securities Valuation Office of the NAIC;

(4) An investment made pursuant to the provisions of subparagraph (1), (2), or (3) of this paragraph shall be subject to the following additional limitations:

a. An investment in or loan upon the obligations of an institution other than an institution that issues mortgage-related securities shall not exceed 5 percent of the assets of the trust;

b. An investment in any one mortgage-related security shall not exceed 5 percent of the assets of the trust;

c. The aggregate total investment in mortgage-related securities shall not exceed 25 percent of the assets of the trust; and

d. Preferred or guaranteed shares issued or guaranteed by a solvent U.S. institution are permissible investments if all of the institution’s obligations are eligible as investments under (e)(2)a. and (2)c. above, but shall not exceed 2 percent of the assets of the trust.

(5) As used in this rule:

a. “Mortgage-related security” means an obligation that is rated AA or higher (or the equivalent) by a securities rating agency recognized by the Securities Valuation Office of the NAIC and that either:

Represents ownership of one or more promissory notes or certificates of interest or participation in the notes (including any rights designed to assure servicing of, or the receipt or timeliness of receipt by the holders of the notes, certificates, or participation of amounts payable under, the notes, certificates or participation), that:

(i) Are directly secured by a first lien on a single parcel of real estate, including stock allocated to a dwelling unit in a residential cooperative housing corporation, upon which is located a dwelling or mixed residential and commercial structure, or on a residential manufactured home as defined in 42 U.S.C. Section 5402(6), whether the manufactured home is considered real or personal property under the laws of the state in which it is located; and

(ii) Were originated by a savings and loan association, savings bank, commercial bank, credit union, insurance company, or similar institution that is supervised and examined by a federal or state housing authority, or by a mortgagee approved by the Secretary of Housing and Urban Development pursuant to 12 U.S.C. Sections 1709 and 1715-b, or, where the notes involve a lien on the manufactured home, by an institution or by a financial institution approved for insurance by the Secretary of Housing and Urban Development pursuant to 12 U.S.C. Section 1703; or

Is secured by one or more promissory notes or certificates of deposit or participations in the notes (with or without recourse to the insurer of the notes) and, by its terms, provides for payments of principal in relation to payments, or reasonable projections of payments, or notes meeting the requirements of a.1.(i) and a.1.(ii) of this subparagraph;

b. “Promissory note” when used in connection with a manufactured home, shall also include a loan, advance or credit sale as evidenced by a retail installment sales contract or other instrument.

(6) Equity interests

a. Investments in common shares or partnership interests of a solvent U.S. institution are permissible if:

Its obligations and preferred shares, if any, are eligible as investments under this subsection; and
The equity interests of the institution (except an insurance company) are registered on a national securities exchange as provided in the Securities Exchange Act of 1934, 15 U.S.C. Sections 78a to 78kk, or otherwise registered pursuant to that Act, and if otherwise registered, price quotations for them are furnished through a nationwide automated quotations system approved by the Financial Industry Regulatory Authority, or successor organization. A trust shall not invest in equity interests under this paragraph an amount exceeding one percent of the assets of the trust even though the equity interests are not so registered and are not issued by an insurance company;

b. Investments in common shares of a solvent institution organized under the laws of a country that is a member of the Organization for Economic Cooperation and Development, if:

All its obligations are rated A or higher, or the equivalent, by a rating agency recognized by the Securities Valuation Office of the NAIC; and
The equity interests of the institution are registered on a securities exchange regulated by the government of a country that is a member of the Organization for Economic Cooperation and Development;

c. An investment in or loan upon any one institution’s outstanding equity interests shall not exceed one percent of the assets of the trust. The cost of an investment in equity interests made pursuant to this subparagraph, when added to the aggregate cost of other investments in equity interests then held pursuant to this subparagraph, shall not exceed 10 percent of the assets in the trust;

(7) Obligations issued, assumed or guaranteed by a multinational development bank, provided the obligations are rated A or higher, or the equivalent, by a rating agency recognized by the Securities Valuation office of the NAIC.

(8) Investment companies

a. Securities of an investment company registered pursuant to the Investment Company Act of 1940, 15 U.S.C. Section 80a, are permissible investments if the investment company:

Invests at least 90 percent of its assets in the types of securities that qualify as an investment under subparagraphs (e)(1), (2) and (3) above or invests in securities that are determined by the commissioner to be substantively similar to the types of securities set forth in subparagraphs (e) (1), (2) and (3); or
Invests at least 90 percent of its assets in the types of equity interests that qualify as an investment under subparagraph (e)(6)a. above;

b. Investments made by a trust in investment companies under this paragraph shall not exceed the following limitations:

An investment in an investment company qualifying under (8)a.1. above shall not exceed 10 percent of the assets in the trust and the aggregate amount of investment in qualifying investment companies shall not exceed 25 percent of the assets in the trust; and

2 Investments in an investment company qualifying under (8)a.2. above shall not exceed 5 percent of the assets in the trust and the aggregate amount of investment in qualifying investment companies shall be included when calculating the permissible aggregate value of equity interests pursuant to subparagraph (e)(6) a. above.

(9) Letters of Credit

a. In order for a letter of credit to qualify as an asset of the trust, the trustee shall have the right and the obligation pursuant to the deed of trust or some other binding agreement (as duly approved by the commissioner), to immediately draw down the full amount of the letter of credit and hold the proceeds in trust for the beneficiaries of the trust if the letter of credit will otherwise expire without being renewed or replaced.

b. The trust agreement shall provide that the trustee shall be liable for its negligence, willful misconduct or lack of good faith. The failure of the trustee to draw against the letter of credit in circumstances where such draw would be required shall be deemed to be negligence and/or willful misconduct.

(f) A specific security provided to a ceding insurer by an assuming insurer pursuant to Ins 601.09 of this rule shall be applied, until exhausted, to the payment of liabilities of the assuming insurer to the ceding insurer holding the specific security prior to, and as a condition precedent for, presentation of a claim by the ceding insurer for payment by a trustee of a trust established by the assuming insurer pursuant to this section.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13; ss by #13296, eff 11-24-21

N.H. Code Admin. R. Ann. Ins 601.06 Credit for Reinsurance – Certified Reinsurers {#sec-ins-601.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.06}

(a) Pursuant to RSA 405:47 IV-a., the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer that has been certified as a reinsurer in this state at all times for which statutory financial statement credit for reinsurance is claimed under this section. The credit allowed shall be based upon the security held by or on behalf of the ceding insurer in accordance with a rating assigned to the certified reinsurer by the commissioner. The security shall be in a form consistent with the provisions of RSA 405:47 IV-a., 405:50, and Ins 601.10, Ins 601.11, and Ins 601.12 of this rule. The amount of security required in order for full credit to be allowed shall correspond with the following requirements:

(1) Ratings Security Required

Secure – 1 0%

Secure – 2 10%

Secure – 3 20%

Secure – 4 50%

Secure – 5 75%

Vulnerable – 6 100%

(2) Affiliated reinsurance transactions shall receive the same opportunity for reduced security requirements as all other reinsurance transactions.

(3) The commissioner shall require the certified reinsurer to post 100 percent, for the benefit of the ceding insurer or its estate, security upon the entry of an order of rehabilitation, liquidation or conservation against the ceding insurer.

(4) In order to facilitate the prompt payment of claims, a certified reinsurer shall not be required to post security for catastrophe recoverables for a period of one year from the date of the first instance of a liability reserve entry by the ceding company as a result of a loss from a catastrophic occurrence as recognized by the commissioner. The one year deferral period is contingent upon the certified reinsurer continuing to pay claims in a timely manner. Reinsurance recoverables for only the following lines of business as reported on the NAIC annual financial statement related specifically to the catastrophic occurrence will be included in the deferral:

a. Line 1: Fire

b. Line 2: Allied Lines

c. Line 3: Farmowners multiple peril

d. Line 4: Homeowners multiple peril

e. Line 5: Commercial multiple peril

f. Line 9: Inland Marine

g. Line 12: Earthquake

h. Line 21: Auto physical damage

(5) Credit for reinsurance under this section shall apply only to reinsurance contracts entered into or renewed on or after the effective date of the certification of the assuming insurer. Any reinsurance contract entered into prior to the effective date of the certification of the assuming insurer that is subsequently amended after the effective date of the certification of the assuming insurer, or a new reinsurance contract, covering any risk for which collateral was provided previously, shall only be subject to this section with respect to losses incurred and reserves reported from and after the effective date of the amendment or new contract.

(6) Nothing in this section shall prohibit the parties to a reinsurance agreement from agreeing to provisions establishing security requirements that exceed the minimum security requirements established for certified reinsurers under this section.

(b) Certification Procedure.

(1) The commissioner shall post notice on the insurance department’s website promptly upon receipt of any application for certification, including instructions on how members of the public may respond to the application. The commissioner may not take final action on the application until at least 30 days after posting the notice required by this paragraph.

(2) The commissioner shall issue written notice to an assuming insurer that has made application and been approved as a certified reinsurer. Included in such notice shall be the rating assigned the certified reinsurer in accordance with subsection (a) of this section. The commissioner shall publish a list of all certified reinsurers and their ratings.

(3) In order to be eligible for certification, the assuming insurer shall meet the following requirements:

a. The assuming insurer shall be domiciled and licensed to transact insurance or reinsurance in a Qualified Jurisdiction, as determined by the commissioner pursuant to subsection (c) of this section.

b. The assuming insurer shall maintain capital and surplus, or its equivalent, of no less than $250,000,000 calculated in accordance with subparagraph (4)h. of this subsection. This requirement may also be satisfied by an association including incorporated and individual unincorporated underwriters having minimum capital and surplus equivalents (net of liabilities) of at least $250,000,000 and a central fund containing a balance of at least $250,000,000.

c. The assuming insurer shall maintain financial strength ratings from 2 or more rating agencies deemed acceptable to the commissioner. These ratings shall be based on interactive communication between the rating agency and the assuming insurer and shall not be based solely on publicly available information. These financial strength ratings will be one factor used by the commissioner in determining the rating that is assigned to the assuming insurer. Acceptable rating agencies include the following:

Standard & Poor’s;
Moody’s Investors Service;
Fitch Ratings;
A.M. Best Company; or
Any other Nationally Recognized Statistical Rating Organization.

d. The certified reinsurer shall comply with any other requirements reasonably imposed by the commissioner.

(4) Each certified reinsurer shall be rated on a legal entity basis, with due consideration being given to the group rating where appropriate, except that an association including incorporated and individual unincorporated underwriters that has been approved to do business as a single certified reinsurer may be evaluated on the basis of its group rating. Factors that may be considered as part of the evaluation process include, but are not limited to, the following:

a. The certified reinsurer’s financial strength rating from an acceptable rating agency. The maximum rating that a certified reinsurer may be assigned will correspond to its financial strength rating as outlined in the table below. The commissioner shall use the lowest financial strength rating received from an approved rating agency in establishing the maximum rating of a certified reinsurer. A failure to obtain or maintain at least 2 financial strength ratings from acceptable rating agencies shall result in loss of eligibility for certification:

Ratings

Best

S&P

Moody’s

Fitch

Secure – 1

A++

AAA

Aaa

AAA

Secure – 2

A+

AA+, AA, AA-

Aa1, Aa2, Aa3

AA+, AA, AA-

Secure – 3

A+, A

A1, A2

A+, A

Secure – 4

A-

Secure – 5

B++, B+

BBB+, BBB, BBB-

Baa1, Baa2, Baa3

BBB+, BBB, BBB-

Vulnerable – 6

B,B-C++, C+, C, C-, D, E, F

BB+, BB, BB-, B+, B, B-, CCC, CC, C, D, R

Ba1, Ba2, Ba3, B1, B2, B3, Caa, Ca, C

BB+, BB, BB-, B+, B, B1, CCC+, CC, CCC-, DD

b. The business practices of the certified reinsurer in dealing with its ceding insurers, including its record of compliance with reinsurance contractual terms and obligations;

c. For certified reinsurers domiciled in the U.S., a review of the most recent applicable NAIC Annual Statement Blank, either Schedule F (for property/casualty reinsurers) or Schedule S (for life and health reinsurers);

d. For certified reinsurers not domiciled in the U.S., a review annually of Form CR-F (for property/casualty reinsurers) or Form CR-S (for life and health reinsurers) (attached as exhibits to this rule);

e. The reputation of the certified reinsurer for prompt payment of claims under reinsurance agreements, based on an analysis of ceding insurers’ Schedule F reporting overdue reinsurance recoverables, including the proportion of obligations that are more than 90 days past due or are in dispute, with specific attention given to obligations payable to companies that are in administrative supervision or receivership;

f. Regulatory actions against the certified reinsurer;

g. The report of the independent auditor on the financial statements of the insurance enterprise, on the basis described in paragraph h. below;

h. For certified reinsurers not domiciled in the U.S., audited financial statements, regulatory filings, and actuarial opinion (as filed with the non-U.S. jurisdiction supervisor, with a translation into English). Upon the initial application for certification, the commissioner will consider audited financial statements for the last [3]2 years filed with its non-U.S. jurisdiction supervisor;

i. The liquidation priority of obligations to a ceding insurer in the certified reinsurer’s domiciliary jurisdiction in the context of an insolvency proceeding;

j. A certified reinsurer’s participation in any solvent scheme of arrangement, or similar procedure, which involves U.S. ceding insurers. The commissioner shall receive prior notice from a certified reinsurer that proposes participation by the certified reinsurer in a solvent scheme of arrangement; and

k. Any other information deemed relevant by the commissioner.

(5) Based on the analysis conducted under subparagraph (4)e. above of a certified reinsurer’s reputation for prompt payment of claims, the commissioner may make appropriate adjustments in the security the certified reinsurer is required to post to protect its liabilities to U.S. ceding insurers, provided that the commissioner shall, at a minimum, increase the security the certified reinsurer is required to post by one rating level under subparagraph (4)a. above, if the commissioner finds that:

a. More than 15 percent of the certified reinsurer’s ceding insurance clients have overdue reinsurance recoverables on paid losses of 90 days or more which are not in dispute and which exceed $100,000 for each cedent; or

b. The aggregate amount of reinsurance recoverables on paid losses which are not in dispute that are overdue by 90 days or more exceeds $50,000,000.

(6) The assuming insurer shall submit a properly executed Form CR-1 (attached as an exhibit to this rule) as evidence of its submission to the jurisdiction of this state, appointment of the commissioner as an agent for service of process in this state, and agreement to provide security for 100 percent of the assuming insurer’s liabilities attributable to reinsurance ceded by U.S. ceding insurers if it resists enforcement of a final U.S. judgment. The commissioner shall not certify any assuming insurer that is domiciled in a jurisdiction that the commissioner has determined does not adequately and promptly enforce final U.S. judgments or arbitration awards.

(7) The certified reinsurer shall agree to meet application information filing requirements as determined by the commissioner, both with respect to an initial application for certification and on an ongoing basis. All information submitted by certified reinsurers which are not otherwise public information subject to disclosure shall be exempted from disclosure under RSA 91-A and shall be withheld from public disclosure. The applicable information filing requirements are, as follows:

a. Notification within 10 days of any regulatory actions taken against the certified reinsurer, any change in the provisions of the domiciliary license or any change in rating by an approved rating agency, including a statement describing such changes and the reasons therefore;

b. Annually, Form CR-F or CR-S, as applicable (per the instructions to be developed as an exhibit to this model);

c. Annually, the report of the independent auditor on the financial statements of the insurance enterprise, on the basis described in subparagraph (7)d. below;

d. Annually, the most recent audited financial statements, regulatory filings, and actuarial opinion (as filed with the certified reinsurer’s supervisor, with a translation into English). Upon the initial certification, audited financial statements for the last 2 years filed with the certified reinsurer’s supervisor;

e. At least annually, an updated list of all disputed and overdue reinsurance claims regarding reinsurance assumed from U.S. domestic ceding insurers;

f. A certification from the certified reinsurer’s domestic regulator that a certified reinsurer is in good standing and maintains capital in excess of the jurisdiction’s highest regulatory action level; and

g. Any other information that the commissioner may reasonably require.

(8) Change in Rating or Revocation of Certification.

a. In the case of a downgrade by a rating agency or other disqualifying circumstance, the commissioner shall upon written notice assign a new rating to the certified reinsurer in accordance with the requirements of subparagraph (4)a. above.

b. The commissioner shall have the authority to suspend, revoke, or otherwise modify a certified reinsurer’s certification at any time if the certified reinsurer fails to meet its obligations or security requirements under this section, or if other financial or operating results of the certified reinsurer, or documented significant delays in payment by the certified reinsurer, lead the commissioner to reconsider the certified reinsurer’s ability or willingness to meet its contractual obligations.

c. If the rating of a certified reinsurer is upgraded by the commissioner, the certified reinsurer may meet the security requirements applicable to its new rating on a prospective basis, but the commissioner shall require the certified reinsurer to post security under the previously applicable security requirements as to all contracts in force on or before the effective date of the upgraded rating. If the rating of a certified reinsurer is downgraded by the commissioner, the commissioner shall require the certified reinsurer to meet the security requirements applicable to its new rating for all business in has assumed as a certified reinsurer.

d. Upon revocation of the certification of a certified reinsurer by the commissioner, the assuming insurer shall be required to post security in accordance with Ins 601.09 in order for the ceding insurer to continue to take credit for reinsurance ceded to the assuming insurer. If funds continue to be held in trust in accordance with Ins 601.05, the commissioner may allow additional credit equal to the ceding insurer’s pro rata share of such funds, discounted to reflect the risk of uncollectability and anticipated expenses of trust administration. Notwithstanding the change of a certified reinsurer’s rating or revocation of its certification, a domestic insurer that has ceded reinsurance to that certified reinsurer may not be denied credit for reinsurance for a period of 3 months for all reinsurance ceded to that certified reinsurer, unless the reinsurance is found by the commissioner to be at high risk of uncollectability.

(1) If, upon conducting an evaluation under this section with respect to the reinsurance supervisory system of any non-U.S. assuming insurer, the commissioner determines that the jurisdiction qualifies to be recognized as a qualified jurisdiction, the commissioner shall publish notice and evidence of such recognition in an appropriate manner. The commissioner may establish a procedure to withdraw recognition of those jurisdictions that are no longer qualified;

(2) In order to determine whether the domiciliary jurisdiction of a non-U.S. assuming insurer is eligible to be recognized as a qualified jurisdiction, the commissioner shall evaluate the reinsurance supervisory system of the non-U.S. jurisdiction, both initially and on an ongoing basis, and consider the rights, benefits and the extent of reciprocal recognition afforded by the non-U.S. jurisdiction to reinsurers licensed and domiciled in the U.S. The commissioner shall determine the appropriate approach for evaluating the qualifications of such jurisdictions, and create and publish a list of jurisdictions whose reinsurers may be approved by the commissioner as eligible for certification. A qualified jurisdiction shall agree to share information and cooperate with the commissioner with respect to all certified reinsurers domiciled within that jurisdiction. Additional factors to be considered in determining whether to recognize a qualified jurisdiction, in the discretion of the commissioner, include but are not limited to the following:

a. The framework under which the assuming insurer is regulated;

b. The structure and authority of the domiciliary regulator with regard to solvency regulation requirements and financial surveillance;

c. The substance of financial and operating standards for assuming insurers in the domiciliary jurisdiction;

d. The form and substance of financial reports required to be filed or made publicly available by reinsurers in the domiciliary jurisdiction and the accounting principles used;

e. The domiciliary regulator’s willingness to cooperate with U.S. regulators in general and the commissioner in particular;

f. The history of performance by assuming insurers in the domiciliary jurisdiction;

g. Any documented evidence of substantial problems with the enforcement of final U.S. judgments in the domiciliary jurisdiction. A jurisdiction will not be considered to be a qualified jurisdiction if the commissioner has determined that it does not adequately and promptly enforce final U.S. judgments or arbitration awards.

h. Any relevant international standards or guidance with respect to mutual recognition of reinsurance supervision adopted by the International Association of Insurance Supervisors or successor organization; and

i. Any other matters deemed relevant by the commissioner.

(3) A list of qualified jurisdictions shall be published through the NAIC Committee Process. The commissioner shall consider this list in determining qualified jurisdictions. If the commissioner approves a jurisdiction as qualified that does not appear on the list of qualified jurisdictions, the commissioner shall provide thoroughly documented justification with respect to the criteria provided under subparagraphs (c)(2)a. to i. above; and

(4) U.S. jurisdictions that meet the requirements for accreditation under the NAIC financial standards and accreditation program shall be recognized as qualified jurisdictions.

(d) Recognition of Certification Issued by an NAIC Accredited Jurisdiction.

(1) If an applicant for certification has been certified as a reinsurer in an NAIC accredited jurisdiction, the commissioner has the discretion to defer to that jurisdiction’s certification, and to defer to the rating assigned by that jurisdiction, if the assuming insurer submits a properly executed Form CR-1 and such additional information as the commissioner requires. The assuming insurer shall be considered to be a certified reinsurer in this State;

(2) Any change in the certified reinsurer’s status or rating in the other jurisdiction shall apply automatically in this State as of the date it takes effect in the other jurisdiction. The certified reinsurer shall notify the commissioner of any change in its status or rating within 10 days after receiving notice of the change;

(3) The commissioner may withdraw recognition of the other jurisdiction’s rating at any time and assign a new rating in accordance with subparagraph (b)(8) above; and

(4) The commissioner may withdraw recognition of the other jurisdiction’s certification at any time, with written notice to the certified reinsurer. Unless the commissioner suspends or revokes the certified reinsurer’s certification in accordance with subparagraph (b)(8) above, the certified reinsurer’s certification shall remain in good standing in this State for a period of 3 months, which shall be extended if additional time is necessary to consider the assuming insurer’s application for certification in this State.

(e) Mandatory Funding Clause. In addition to the clauses required under Ins 601.13, reinsurance contracts entered into or renewed under this section shall include a proper funding clause, which requires the certified reinsurer to provide and maintain security in an amount sufficient to avoid the imposition of any financial statement penalty on the ceding insurer under this section for reinsurance ceded to the certified reinsurer.

(f) The commissioner shall comply with all reporting and notification requirements that may be established by the NAIC with respect to certified reinsurers and qualified jurisdictions.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13 ; ss by #13296, eff 11-24-21

N.H. Code Admin. R. Ann. Ins 601.07 Credit for Reinsurance – Reciprocal Jurisdictions {#sec-ins-601.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.07}

(a) Pursuant to RSA 405:47, IV-b, the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer that is licensed to write reinsurance by, and has its head office or is domiciled in, a Reciprocal Jurisdiction, and which meets the other requirements of this regulation.

(b) A “Reciprocal Jurisdiction” is a jurisdiction, as designated by the commissioner pursuant to paragraph (d) below, that meets one of the following:

(1) A non-U.S. jurisdiction that is subject to an in-force covered agreement with the United States, each within its legal authority, or, in the case of a covered agreement between the United States and the European Union, is a member state of the European Union. For purposes of this subsection, a “covered agreement” is an agreement entered into pursuant to the Dodd-Frank Wall Street Reform and Consumer Protection Act, 31 U.S.C. §§ 313 and 314, that is currently in effect or in a period of provisional application and addresses the elimination, under specified conditions, of collateral requirements as a condition for entering into any reinsurance agreement with a ceding insurer domiciled in this state or for allowing the ceding insurer to recognize credit for reinsurance;

(2) A U.S. jurisdiction that meets the requirements for accreditation under the NAIC financial standards and accreditation program; or

(3) A qualified jurisdiction, as determined by the commissioner pursuant to RSA 405:47, IV-a(c) and Ins 601.06(c), which is not otherwise described in subparagraph (1) or (2) above and which the commissioner determines meets all of the following additional requirements:

a. Provides that an insurer which has its head office or is domiciled in such qualified jurisdiction shall receive credit for reinsurance ceded to a U.S.-domiciled assuming insurer in the same manner as credit for reinsurance is received for reinsurance assumed by insurers domiciled in such qualified jurisdiction;

b. Does not require a U.S.-domiciled assuming insurer to establish or maintain a local presence as a condition for entering into a reinsurance agreement with any ceding insurer subject to regulation by the non-U.S. jurisdiction or as a condition to allow the ceding insurer to recognize credit for such reinsurance;

c. Recognizes the U.S. state regulatory approach to group supervision and group capital, by providing written confirmation by a competent regulatory authority, in such qualified jurisdiction, that insurers and insurance groups that are domiciled or maintain their headquarters in this state or another jurisdiction accredited by the NAIC shall be subject only to worldwide prudential insurance group supervision including worldwide group governance, solvency and capital, and reporting, as applicable, by the commissioner or the commissioner of the domiciliary state and will not be subject to group supervision at the level of the worldwide parent undertaking of the insurance or reinsurance group by the qualified jurisdiction; and

d. Provides written confirmation by a competent regulatory authority in such qualified jurisdiction that information regarding insurers and their parent, subsidiary, or affiliated entities, if applicable, shall be provided to the commissioner in accordance with a memorandum of understanding or similar document between the commissioner and such qualified jurisdiction, including but not limited to the International Association of Insurance Supervisors Multilateral Memorandum of Understanding or other multilateral memoranda of understanding coordinated by the NAIC.

(c) Credit shall be allowed when the reinsurance is ceded from an insurer domiciled in this state to an assuming insurer meeting each of the conditions set forth below:

(1) The assuming insurer must be licensed to transact reinsurance by, and have its head office or be domiciled in, a Reciprocal Jurisdiction;

(2) The assuming insurer must have and maintain on an ongoing basis minimum capital and surplus, or its equivalent, calculated on at least an annual basis as of the preceding December 31 or at the annual date otherwise statutorily reported to the Reciprocal Jurisdiction, and confirmed as set forth in subparagraph (7) below according to the methodology of its domiciliary jurisdiction, in the following amounts:

a. No less than $250,000,000; or

b. If the assuming insurer is an association, including incorporated and individual unincorporated underwriters:

Minimum capital and surplus equivalents (net of liabilities) or own funds of the equivalent of at least $250,000,000; and
A central fund containing a balance of the equivalent of at least $250,000,000;

(3) The assuming insurer must have and maintain on an ongoing basis a minimum solvency or capital ratio, as applicable, as follows:

a. If the assuming insurer has its head office or is domiciled in a Reciprocal Jurisdiction as defined in paragraph (b)(1) above, the ratio specified in the applicable covered agreement;

b. If the assuming insurer is domiciled in a Reciprocal Jurisdiction as defined in paragraph (b)(2) above, a risk-based capital (RBC) ratio of 300 percent of the authorized control level, calculated in accordance with the formula developed by the NAIC; or

c. If the assuming insurer is domiciled in a Reciprocal Jurisdiction as defined in paragraph (b)(3) above, after consultation with the Reciprocal Jurisdiction and considering any recommendations published through the NAIC Committee Process, such solvency or capital ratio as the commissioner determines to be an effective measure of solvency;

(4) The assuming insurer must agree to and provide adequate assurance, in the form of a properly executed Form RJ-1 (attached as an exhibit to this regulation), of its agreement to the following:

a. The assuming insurer must agree to provide prompt written notice and explanation to the commissioner if it falls below the minimum requirements set forth in subparagraphs (2) or (3) above, or if any regulatory action is taken against it for serious noncompliance with applicable law;

b. The assuming insurer must consent in writing to the jurisdiction of the courts of this state and to the appointment of the commissioner as agent for service of process:

The commissioner may also require that such consent be provided and included each reinsurance agreement under the commissioner’s jurisdiction; and
Nothing in this provision shall limit or in any way alter the capacity of parties to a reinsurance agreement to agree to alternative dispute resolution mechanisms, except to the extent such agreements are unenforceable under applicable insolvency or delinquency laws;

c. The assuming insurer must consent in writing to pay all final judgments, wherever enforcement is sought, obtained by a ceding insurer, that have been declared enforceable in the territory where the judgment was obtained;

d. Each reinsurance agreement must include a provision requiring the assuming insurer to provide security in an amount equal to 100 percent of the assuming insurer’s liabilities attributable to reinsurance ceded pursuant to that agreement if the assuming insurer resists enforcement of a final judgment that is enforceable under the law of the jurisdiction in which it was obtained or a properly enforceable arbitration award, whether obtained by the ceding insurer or by its legal successor on behalf of its estate, if applicable;

e. The assuming insurer must confirm that it is not presently participating in any solvent scheme of arrangement, which involves this state’s ceding insurers, and agrees to notify the ceding insurer and the commissioner and to provide one hundred percent (100%) security to the ceding insurer consistent with the terms of the scheme, should the assuming insurer enter into such a solvent scheme of arrangement. Such security shall be in a form consistent with the provisions of RSA 405:47, IV-a, RSA 405:50, Ins 601.10, Ins 601.11, and Ins 601.12. For purposes of this rule, the term “solvent scheme of arrangement” means a foreign or alien statutory or regulatory compromise procedure subject to requisite majority creditor approval and judicial sanction in the assuming insurer’s home jurisdiction either to finally commute liabilities of duly noticed classed members or creditors of a solvent debtor, or to reorganize or restructure the debts and obligations of a solvent debtor on a final basis, and which may be subject to judicial recognition and enforcement of the arrangement by a governing authority outside the ceding insurer’s home jurisdiction; and

f. The assuming insurer must agree in writing to meet the applicable information filing requirements as set forth in subparagraph (5) below;

(5) The assuming insurer or its legal successor must provide, if requested by the commissioner, on behalf of itself and any legal predecessors, the following documentation to the commissioner:

a. For the 2 years preceding entry into the reinsurance agreement and on an annual basis thereafter, the assuming insurer’s annual audited financial statements, in accordance with the applicable law of the jurisdiction of its head office or domiciliary jurisdiction, as applicable, including the external audit report;

b. For the 2 years preceding entry into the reinsurance agreement, the solvency and financial condition report or actuarial opinion, if filed with the assuming insurer’s supervisor;

c. Prior to entry into the reinsurance agreement and not more than semi-annually thereafter, an updated list of all disputed and overdue reinsurance claims outstanding for 90 days or more, regarding reinsurance assumed from ceding insurers domiciled in the United States; and

d. Prior to entry into the reinsurance agreement and not more than semi-annually thereafter, information regarding the assuming insurer’s assumed reinsurance by ceding insurer, ceded reinsurance by the assuming insurer, and reinsurance recoverable on paid and unpaid losses by the assuming insurer to allow for the evaluation of the criteria set forth in subparagraph (6) below;

(6) The assuming insurer must maintain a practice of prompt payment of claims under reinsurance agreements. The lack of prompt payment will be evidenced if any of the following criteria is met;

a. More than 15 percent of the reinsurance recoverables from the assuming insurer are overdue and in dispute as reported to the commissioner;

b. More than 15 percent of the assuming insurer’s ceding insurers or reinsurers have overdue reinsurance recoverable on paid losses of 90 days or more which are not in dispute and which exceed for each ceding insurer $100,000, or as otherwise specified in a covered agreement; or

c. The aggregate amount of reinsurance recoverable on paid losses which are not in dispute, but are overdue by 90 days or more, exceeds $50,000,000, or as otherwise specified in a covered agreement;

(7) The assuming insurer’s supervisory authority must confirm to the commissioner on an annual basis that the assuming insurer complies with the requirements set forth in subparagraphs (2) and (3) above; and

(8) Nothing in this provision precludes an assuming insurer from providing the commissioner with information on a voluntary basis.

(d) The commissioner shall timely create and publish a list of Reciprocal Jurisdictions:

(1) A list of Reciprocal Jurisdictions is published through the NAIC Committee Process. The commissioner’s list shall include any Reciprocal Jurisdiction, as defined under paragraphs (b)(1) and (b)(2) above, and shall consider any other Reciprocal Jurisdiction included on the NAIC list. The commissioner may approve a jurisdiction that does not appear on the NAIC list of Reciprocal Jurisdictions as provided by applicable law, regulation, or in accordance with criteria published through the NAIC Committee Process; and

(2) The commissioner may remove a jurisdiction from the list of Reciprocal Jurisdictions upon a determination that the jurisdiction no longer meets one or more of the requirements of a Reciprocal Jurisdiction, as provided by applicable law, regulation, or in accordance with a process published through the NAIC Committee Process, except that the commissioner shall not remove from the list a Reciprocal Jurisdiction as defined under paragraphs (b)(1) and (b)(2) above. Upon removal of a Reciprocal Jurisdiction from this list, credit for reinsurance ceded to an assuming insurer domiciled in that jurisdiction shall be allowed, if otherwise allowed pursuant to RSA 405:45-52 or Ins 601.

(e) The commissioner shall timely create and publish a list of assuming insurers that have satisfied the conditions set forth in this section and to which cessions shall be granted credit in accordance with this section:

(1) If an NAIC accredited jurisdiction has determined that the conditions set forth in paragraph (c) above have been met, the commissioner has the discretion to defer to that jurisdiction’s determination, and add such assuming insurer to the list of assuming insurers to which cessions shall be granted credit in accordance with this subsection. The commissioner may accept financial documentation filed with another NAIC accredited jurisdiction or with the NAIC in satisfaction of the requirements of paragraph (c) above; and

(2) When requesting that the commissioner defer to another NAIC accredited jurisdiction’s determination, an assuming insurer must submit a properly executed Form RJ-1 and additional information as the commissioner may require. A state that has received such a request will notify other states through the NAIC Committee Process and provide relevant information with respect to the determination of eligibility.

(f) If the commissioner determines that an assuming insurer no longer meets one or more of the requirements under this section, the commissioner may revoke or suspend the eligibility of the assuming insurer for recognition under this section:

(1) While an assuming insurer’s eligibility is suspended, no reinsurance agreement issued, amended or renewed after the effective date of the suspension qualifies for credit except to the extent that the assuming insurer’s obligations under the contract are secured in accordance with Ins 601.09; and

(2) If an assuming insurer’s eligibility is revoked, no credit for reinsurance may be granted after the effective date of the revocation with respect to any reinsurance agreements entered into by the assuming insurer, including reinsurance agreements entered into prior to the date of revocation, except to the extent that the assuming insurer’s obligations under the contract are secured in a form acceptable to the commissioner and consistent with the provisions of Ins 601.09.

(g) Before denying statement credit or imposing a requirement to post security with respect to paragraph (f) above or adopting any similar requirement that will have substantially the same regulatory impact as security, the commissioner shall:

(1) Communicate with the ceding insurer, the assuming insurer, and the assuming insurer’s supervisory authority that the assuming insurer no longer satisfies one of the conditions listed in paragraph (c) of this section;

(2) Provide the assuming insurer with 30 days from the initial communication to submit a plan to remedy the defect, and 90 days from the initial communication to remedy the defect, except in exceptional circumstances in which a shorter period is necessary for policyholder and other consumer protection;

(3) After the expiration of 90 days or less, as set out in subparagraph (2) above, if the commissioner determines that no or insufficient action was taken by the assuming insurer, the commissioner may impose any of the requirements as set out in this subsection; and

(4) Provide a written explanation to the assuming insurer of any of the requirements set out in this paragraph.

(h) If subject to a legal process of rehabilitation, liquidation or conservation, as applicable, the ceding insurer, or its representative, may seek and, if determined appropriate by the court in which the proceedings are pending, may obtain an order requiring that the assuming insurer post security for all outstanding liabilities.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13 (from Ins 601.06); ss by #13296, eff 11-24-21

N.H. Code Admin. R. Ann. Ins 601.08 Credit for Reinsurance Required by Law {#sec-ins-601.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.08}

Pursuant to RSA 405:47, V, the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer not meeting the requirements of RSA 405:47, I, II, III, IV, IV-a, or IV-b, but only as to the insurance of risks located in jurisdictions where such reinsurance is required by the applicable law or regulation of that jurisdiction. As used in this section, "jurisdiction" means state, district or territory of the United States and any lawful national government.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13 (from Ins 601.07); ss by #13296, eff 11-24-21; ss by #13296, eff 11-24-21

N.H. Code Admin. R. Ann. Ins 601.09 Asset or Reduction From Liability for Reinsurance Ceded to an Unauthorized Assuming Insurer Not Meeting the Requirements of Ins 601.02 through Ins 601.08 {#sec-ins-601.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.09}

(a) Pursuant to RSA 405:50, the commissioner shall allow a reduction from liability for reinsurance ceded by a domestic insurer to an assuming insurer not meeting the requirements of RSA 405:47 in an amount not exceeding the liabilities carried by the ceding insurer. The reduction shall be in the amount of funds held by or on behalf of the ceding insurer, including funds held in trust for the exclusive benefit of the ceding insurer, under a reinsurance contract with such assuming insurer as security for the payment of obligations under the reinsurance contract. The security shall be held in the United States subject to withdrawal solely by, and under the exclusive control of, the ceding insurer or, in the case of a trust, held in a qualified United States financial institution as defined in RSA 405:46, III. This security may be in the form of any of the following:

(1) Cash;

(2) Securities listed by the Securities Valuation Office of the NAIC, including those deemed exempt from filing as defined by the Purposes and Procedures Manual of the Securities Valuation Office, and qualifying as admitted assets;

(3) Clean, irrevocable, unconditional and "evergreen" letters of credit issued or confirmed by a qualified United States institution, as defined in RSA 405:46, I, effective no later than December 31 of the year for which filing is being made, and in the possession of, or in trust for, the ceding insurer on or before the filing date of its annual statement. Letters of credit meeting applicable standards of issuer acceptability as of the dates of their issuance (or confirmation) shall, notwithstanding the issuing (or confirming) institution's subsequent failure to meet applicable standards of issuer acceptability, continue to be acceptable as security until their expiration, extension, renewal, modification or amendment, whichever first occurs; or

(4) Any other form of security acceptable to the commissioner.

(b) An admitted asset or a reduction from liability for reinsurance ceded to an unauthorized assuming insurer pursuant to this section shall be allowed only when the requirements of Ins 601.13 and the applicable portions of Ins 601.10, Ins 601.11 and Ins 601.12 of this rule have been satisfied.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13 ss by #13296, eff 11-24-21 (formerly Ins 601.08)

N.H. Code Admin. R. Ann. Ins 601.10 Trust Agreements Qualified Under Ins 601.09 {#sec-ins-601.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.10}

(a) As used in this section:

(1) "Beneficiary" means the entity for whose sole benefit the trust has been established and any successor of the beneficiary by operation of law. If a court of law appoints a successor in interest to the named beneficiary, then the named beneficiary includes and is limited to the court appointed domiciliary receiver (including conservator, rehabilitator or liquidator).

(2) "Grantor" means the entity that has established a trust for the sole benefit of the beneficiary. When established in conjunction with a reinsurance agreement, the grantor is the unlicensed, unaccredited assuming insurer.

(3) "Obligations," as used in subparagraph (b)(11) of this section means:

a. Reinsured losses and allocated loss expenses paid by the ceding company, but not recovered from the assuming insurer;

b. Reserves for reinsured losses reported and outstanding;

c. Reserves for reinsured losses incurred but not reported; and

d. Reserves for allocated reinsured loss expenses and unearned premiums.

(b) Required conditions.

(1) The trust agreement shall be entered into between the beneficiary, the grantor and a trustee, which shall be a qualified United States financial institution as defined in RSA 405:46, III.

(2) The trust agreement shall create a trust account into which assets shall be deposited.

(3) All assets in the trust account shall be held by the trustee at the trustee's office in the United States.

(4) The trust agreement shall provide that:

a. The beneficiary shall have the right to withdraw assets from the trust account at any time, without notice to the grantor, subject only to written notice from the beneficiary to the trustee;

b. No other statement or document is required to be presented to withdraw assets, except that the beneficiary may be required to acknowledge receipt of withdrawn assets;

c. It is not subject to any conditions or qualifications outside of the trust agreement; and

d. It shall not contain references to any other agreements or documents except as provided for in paragraphs (b)(11) and (b)(12) of this section.

(5) The trust agreement shall be established for the sole benefit of the beneficiary.

(6) The trust agreement shall require the trustee to:

a. Receive assets and hold all assets in a safe place;

b. Determine that all assets are in such form that the beneficiary, or the trustee upon direction by the beneficiary, may whenever necessary negotiate any such assets, without consent or signature from the grantor or any other person or entity;

c. Furnish to the grantor and the beneficiary a statement of all assets in the trust account upon its inception and at intervals no less frequent than the end of each calendar quarter;

d. Notify the grantor and the beneficiary within 10 days, of any deposits to or withdrawals from the trust account;

e. Upon written demand of the beneficiary, immediately take any and all steps necessary to transfer absolutely and unequivocally all right, title and interest in the assets held in the trust account to the beneficiary and deliver physical custody of the assets to the beneficiary; and

f. Allow no substitutions or withdrawals of assets from the trust account, except on written instructions from the beneficiary, except that the trustee may, without the consent of but with notice to the beneficiary, upon call or maturity of any trust asset, withdraw such asset upon condition that the proceeds are paid into the trust account.

(7) The trust agreement shall provide that at least 30 days, but not more than 45 days, prior to termination of the trust account, written notification of termination shall be delivered by the trustee to the beneficiary.

(8) The trust agreement shall be made subject to and governed by the laws of the state in which the trust is domiciled.

(9) The trust agreement shall prohibit invasion of the trust corpus for the purposes of paying commission to, or reimbursing the expenses of, the trustee. In order for a letter of credit to qualify as an asset of the trust, the trustee shall have the right and the obligation pursuant to the deed of trust or some other binding agreement (as duly approved by the commissioner), to immediately draw down the full amount of the letter of credit and hold the proceeds in trust for the beneficiaries of the trust if the letter of credit will otherwise expire without being renewed or replaced.

(10) The trust agreement shall provide that the trustee shall be liable for its own negligence, willful misconduct or lack of good faith. The failure of the trustee to draw against the letter of credit in circumstances where such draw would be required shall be deemed to be negligence and/or willful misconduct.

(11) Notwithstanding other provisions of this rule, when a trust agreement is established in conjunction with a reinsurance agreement covering risks other than life, annuities and accident and health, where it is customary practice to provide a trust agreement for a specific purpose, the trust agreement may provide that the ceding insurer shall undertake to use and apply amounts drawn upon the trust account, without diminution because of the insolvency of the ceding insurer or the assuming insurer, only for the following purposes:

a. To pay or reimburse the ceding insurer for the assuming insurer's share under the specific reinsurance agreement regarding any losses and allocated loss expenses paid by the ceding insurer, but not recovered from the assuming insurer, or for unearned premiums due to the ceding insurer if not otherwise paid by the assuming insurer;

b. To make payment to the assuming insurer of any amounts held in the trust account that exceed 102 percent of the actual amount required to fund the assuming insurer's obligations under the specific reinsurance agreement; or

c. Where the ceding insurer has received notification of termination of the trust account and where the assuming insurer's entire obligations under the specific reinsurance agreement remain unliquidated and undischarged 10 days prior to the termination date, to withdraw amounts equal to the obligations and deposit those amounts in a separate account, in the name of the ceding insurer in any qualified U.S. financial institution as defined in RSA 405:46, III, apart from its general assets, in trust for such uses and purposes specified in subparagraphs (11)a. and b. above as may remain executory after such withdrawal and for any period after the termination date.

(12) Notwithstanding other provisions of this rule, when a trust agreement is established to meet the requirements of Ins 601.09 in conjunction with a reinsurance agreement covering life, annuities or accident and health risks, where it is customary to provide a trust agreement for a specific purpose, the trust agreement may provide that the ceding insurer shall undertake to use and apply amounts drawn upon the trust account, without diminution because of the insolvency of the ceding insurer or the assuming insurer, only for the following purposes:

a. To pay or reimburse the ceding insurer for:

The assuming insurer's share under the specific reinsurance agreement of premiums returned, but not yet recovered from the assuming insurer, to the owners of policies reinsured under the reinsurance agreement on account of cancellations of the policies; and
The assuming insurer's share under the specific reinsurance agreement of surrenders and benefits or losses paid by the ceding insurer, but not yet recovered from the assuming insurer, under the terms and provisions of the policies reinsured under the reinsurance agreement;

b. To pay to the assuming insurer amounts held in the trust account in excess of the amount necessary to secure the credit or reduction from liability for reinsurance taken by the ceding insurer; or

c. Where the ceding insurer has received notification of termination of the trust and where the assuming insurer's entire obligations under the specific reinsurance agreement remain unliquidated and undischarged 10 days prior to the termination date, to withdraw amounts equal to the assuming insurer's share of liabilities, to the extent that the liabilities have not yet been funded by the assuming insurer, and deposit those amounts in a separate account, in the name of the ceding insurer in any qualified U.S. financial institution apart from its general assets, in trust for the uses and purposes specified in subparagraphs a. and b. of this paragraph as may remain executory after withdrawal and for any period after the termination date.

(13) Either the reinsurance agreement or the trust agreement shall stipulate that assets deposited in the trust account shall be valued according to their current fair market value and shall consist only of cash in United States dollars, certificates of deposited issued by a United States bank and payable in United States dollars, and investments permitted by the insurance code or any combination of the above, provided investments in or issued by an entity controlling, controlled by or under common control with either the grantor or the beneficiary of the trust shall not exceed 5 percent of total investments. The agreement may further specify the types of investments to be deposited. If the reinsurance agreement covers life, annuities or accident and health risks, then the provisions required by this paragraph shall be included in the reinsurance agreement.

(1) The trust agreement may provide that the trustee may resign upon delivery of a written notice of resignation, effective not less than 90 days after the beneficiary and grantor receive the notice and that the trustee may be removed by the grantor by delivery to the trustee and the beneficiary of a written notice of removal, effective not less than 90 days after the trustee and the beneficiary receive the notice, provided that no such resignation or removal shall be effective until a successor trustee has been duly appointed and approved by the beneficiary and the grantor and all assets in the trust have been duly transferred to the new trustee.

(2) The grantor may have the full and unqualified right to vote any shares of stock in the trust account and to receive from time to time payments of any dividends or interest upon any shares of stock or obligations included in the trust account. Any interest or dividends shall be either forwarded promptly upon receipt to the grantor or deposited in a separate account established in the grantor's name.

(3) The trustee may be given authority to invest, and accept substitutions of, any funds in the account, provided that no investment or substitution shall be made without prior approval of the beneficiary, unless the trust agreement specifies categories of investments acceptable to the beneficiary and authorizes the trustee to invest funds and to accept substitutions that the trustee determines are at least equal in current fair market value to the assets withdrawn and that are consistent with the restrictions in subparagraph Ins 601.10 (d)(1)b. below.

(4) The trust agreement may provide that the beneficiary may at any time designate a party to which all or part of the trust assets are to be transferred. Transfer may be conditioned upon the trustee receiving, prior to or simultaneously, other specified assets.

(5) The trust agreement may provide that, upon termination of the trust account, all assets not previously withdrawn by the beneficiary shall, with written approval by the beneficiary, be delivered over to the grantor.

(d) Additional conditions applicable to reinsurance agreements:

(1) A reinsurance agreement may contain provisions that:

a. Require the assuming insurer to enter into a trust agreement and to establish a trust account for the benefit of the ceding insurer, and specifying what the agreement is to cover;

b. Require the assuming insurer, prior to depositing assets with the trustee, to execute assignments or endorsements in blank, or to transfer legal title to the trustee of all shares, obligations or any other assets requiring assignments, in order that the ceding insurer, or the trustee upon the direction of the ceding insurer, may whenever necessary negotiate these assets without consent or signature from the assuming insurer or any other entity;

c. Require that all settlements of account between the ceding insurer and the assuming insurer be made in cash or its equivalent; and

d. Stipulate that the assuming insurer and the ceding insurer agree that the assets in the trust account, established pursuant to the provisions of the reinsurance agreement, may be withdrawn by the ceding insurer at any time, notwithstanding any other provisions in the reinsurance agreement, and shall be utilized and applied by the ceding insurer or its successors in interest by operation of law, including without limitation any liquidator, rehabilitator, receiver or conservator of such company, without diminution because of insolvency on the part of the ceding insurer or the assuming insurer, only for the following purposes:

To pay or reimburse the ceding insurer for:

(i) The assuming insurer's share under the specific reinsurance agreement of premiums returned, but not yet recovered from the assuming insurer, to the owners of policies reinsured under the reinsurance agreement because of cancellations of such policies;

(ii) The assuming insurer's share of surrenders and benefits or losses paid by the ceding insurer pursuant to the provisions of the policies reinsured under the reinsurance agreement; and

(iii) Any other amounts necessary to secure the credit or reduction from liability for reinsurance taken by the ceding insurer;

To make payment to the assuming insurer of amounts held in the trust account in excess of the amount necessary to secure the credit or reduction from liability for reinsurance taken by the ceding insurer.

(2) The reinsurance agreement may also contain provisions that:

a. Give the assuming insurer the right to seek approval from the ceding insurer, which shall not be unreasonably or arbitrarily withheld, to withdraw from the trust account all or any part of the trust assets and transfer those assets to the assuming insurer, provided:

The assuming insurer shall, at the time of withdrawal, replace the withdrawn assets with other qualified assets having a current fair market value equal to the market value of the assets withdrawn so as to maintain at all times the deposit in the required amount, or
After withdrawal and transfer, the current fair market value of the trust account is no less than 102 percent of the required amount.

b. Provide for the return of any amount withdrawn in excess of the actual amounts required for subparagraph Ins 601.10(d)(1)d. above, and for interest payments at a rate not in excess of the prime rate of interest on the amounts;

c. Permit the award by any arbitration panel or court of competent jurisdiction of:

Interest at a rate different from that provided in subparagraph Ins 601.10(c)(2)b. above;
Court or arbitration costs;
Attorney's fees; and
Any other reasonable expenses.

(3) Financial Reporting. A trust agreement may be used to reduce any liability for reinsurance ceded to an unauthorized assuming insurer in financial statements required to be filed with this department in compliance with the provisions of this rule when established on or before the date of filing of the financial statement of the ceding insurer. Further, the reduction for the existence of an acceptable trust account may be up to the current fair market value of acceptable assets available to be withdrawn from the trust account at that time, but such reduction shall be no greater than the specific obligations under the reinsurance agreement that the trust account was established to secure.

(4) Existing Agreements. Notwithstanding the effective date of this rule, any trust agreement or underlying reinsurance agreement in existence prior to the effective date of this rule shall continue to be acceptable until 6 months after the effective date of this rule, at which time the agreements will have to fully comply with this rule for the trust agreement to be acceptable.

(5) The failure of any trust agreement to specifically identify the beneficiary as defined in paragraph (a) of this section shall not be construed to affect any actions or rights that the commissioner may take or possess pursuant to the provisions of the laws of this state.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13 (from Ins 601.09); ss by #13296, eff 11-24-21 (formerly Ins 601.09)

N.H. Code Admin. R. Ann. Ins 601.11 Letters of Credit Qualified Under Ins 601.09 {#sec-ins-601.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.11}

(a) The letter of credit must be clean, irrevocable and unconditional and issued or confirmed by a qualified United States financial institution as defined in RSA 405:46, II. The letter of credit shall contain an issue date and expiration date and shall stipulate that the beneficiary need only draw a sight draft under the letter of credit and present it to obtain funds and that no other document need be presented. The letter of credit also shall indicate that it is not subject to any condition or qualifications outside of the letter of credit. In addition, the letter of credit itself shall not contain reference to any other agreements, documents or entities, except as provided in subparagraph Ins 601.11 (h)(1) below. As used in this section, "beneficiary" means the domestic insurer for whose benefit the letter of credit has been established and any successor of the beneficiary by operation of law. If a court of law appoints a successor in interest to the named beneficiary, then the named beneficiary includes and is limited to the court appointed domiciliary receiver (including conservator, rehabilitator or liquidator).

(b) The heading of the letter of credit may include a boxed section containing the name of the applicant and other appropriate notations to provide a reference for the letter of credit. The boxed section shall be clearly marked to indicate that such information is for internal identification purposes only.

(c) The letter of credit shall contain a statement to the effect that the obligation of the qualified United States financial institution under the letter of credit is in no way contingent upon reimbursement with respect thereto.

(d) The term of the letter of credit shall be for at least one year and shall contain an "evergreen clause" that prevents the expiration of the letter of credit without due notice from the issuer. The "evergreen clause" shall provide for a period of no less than 30 days notice prior to expiration date or nonrenewal.

(e) The letter of credit shall state whether it is subject to and governed by the laws of this state or the Uniform Customs and Practice for Documentary Credits of the International Chamber of Commerce Publication 600 (UCP 600) or International Standby Practices of the International Chamber of Commerce Publication 590 (ISP98), or any successor publication, and all drafts drawn thereunder shall be presentable at an office in the United States of a qualified United States financial institution.

(f) If the letter of credit is made subject to the Uniform Customs and Practice for Documentary Credits of the International Chamber of Commerce Publication 600 (UCP 600) or International Standby Practices of the International Chamber of Commerce Publication 590 (ISP98), or any successor publication, then the letter of credit shall specifically address and provide for an extension of time to draw against the letter of credit in the event that one or more of the occurrences specified in Article 36 of Publication 600 or any other successor publication, occur.

(g) If the letter of credit is issued by a financial institution authorized to issue letters of credit, other than a qualified United States financial institution as described in paragraph (a) above, then the following additional requirements shall be met:

(1) The issuing financial institution shall formally designate the confirming qualified United States financial institution as its agent for the receipt and payment of the drafts; and

(2) The "evergreen clause" shall provide for 30 days notice prior to expiration date for nonrenewal.

(h) Reinsurance agreement provisions.

(1) The reinsurance agreement in conjunction with which the letter of credit is obtained may contain provisions that:

a. Require the assuming insurer to provide letters of credit to the ceding insurer and specify what they are to cover;

b. Stipulate that the assuming insurer and ceding insurer agree that the letter of credit provided by the assuming insurer pursuant to the provisions of the reinsurance agreement may be drawn upon at any time, notwithstanding any other provisions in the agreement, and shall be utilized by the ceding insurer or its successors in interest only for one or more of the following reasons:

To pay or reimburse the ceding insurer for:

(i) The assuming insurer's share under the specific reinsurance agreement of premiums returned, but not yet recovered from the assuming insurers, to the owners of policies reinsured under the reinsurance agreement on account of cancellations of such policies;

(ii) The assuming insurer's share, under the specific reinsurance agreement, of surrenders and benefits or losses paid by the ceding insurer, but not yet recovered from the assuming insurers, under the terms and provisions of the policies reinsured under the reinsurance agreement; and

(iii) Any other amounts necessary to secure the credit or reduction from liability for reinsurance taken by the ceding insurer;

Where the letter of credit will expire without renewal or be reduced or replaced by a letter of credit for a reduced amount and where the assuming insurer's entire obligations under the specific reinsurance remain unliquidated and undischarged 10 days prior to the termination date, to withdraw amounts equal to the assuming insurer's share of the liabilities, to the extent that the liabilities have not yet been funded by the assuming insurer and exceed the amount of any reduced or replacement letter of credit, and deposit those amounts in a separate account in the name of the ceding insurer in a qualified U.S. financial institution apart from its general assets, in trust for such uses and purposes specified in subparagraph Ins 601.11(h)(1)b.1. as may remain after withdrawal and for any period after the termination date.

c. All of the provisions of subparagraph Ins 601.11(h)(1)b.1. shall be applied without diminution because of insolvency on the part of the ceding insurer or assuming insurer.

(2) Nothing contained in subparagraph Ins 601.11(h)(1)b.1. shall preclude the ceding insurer and assuming insurer from providing for:

a. An interest payment, at a rate not in excess of the prime rate of interest, on the amounts held pursuant to subparagraph Ins 601.11(h)(1)b.1.; or

b. The return of any amounts drawn down on the letters of credit in excess of the actual amounts required for the above or any amounts that are subsequently determined not to be due.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13 (from Ins 601.10); ); ss by #13296, eff 11-24-21 (formerly Ins 601.10)

N.H. Code Admin. R. Ann. Ins 601.12 Other Security {#sec-ins-601.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.12}

A ceding insurer may take credit for unencumbered funds withheld by the ceding insurer in the United States subject to withdrawal solely by the ceding insurer and under its exclusive control.

History

(See Revision Note at chapter heading for Ins 600) #6090, eff 9-7-95, EXPIRED: 9-7-03
#8240, eff 1-3-05; ss by #8827, eff 3-1-07; ss by #10449, eff 11-1-13 (from Ins 601.11); ss by #13296, eff 11-24-21 (formerly Ins 601.11)

N.H. Code Admin. R. Ann. Ins 601.13 Reinsurance Contract {#sec-ins-601.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.13}

(a) Credit shall not be granted, nor an asset or reduction from liability allowed, to a ceding insurer for reinsurance effected with assuming insurers meeting the requirements of Ins 601.02, Ins 601.03, Ins 601.04, Ins 601.05, Ins 601.06, and Ins 601.09 or otherwise in compliance with RSA 405:47 after the adoption of this rule unless the reinsurance agreement:

(1) Includes a proper insolvency clause, which stipulates that reinsurance is payable directly to the liquidator or successor without diminution regardless of the status of the ceding company, pursuant to RSA 405:47, VII(a);

(2) Includes a provision pursuant to RSA 405:47 whereby the assuming insurer, if an unauthorized assuming insurer, has submitted to the jurisdiction of an alternative dispute resolution panel or court of competent jurisdiction within the United States, has agreed to comply with all requirements necessary to give the court or panel jurisdiction, has designated an agent upon whom service of process may be effected, and has agreed to abide by the final decision of the court or panel; and

History

#10449, eff 11-1-13 (from Ins 601.12); ss by #13296, eff 11-24-21 (formerly Ins 601.12)

N.H. Code Admin. R. Ann. Ins 601.14 Contracts Affected {#sec-ins-601.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 601.14}

All new and renewal reinsurance transactions entered into after the effective date of this rule shall conform to the requirements of the chapter and this rule if credit is to be given to the ceding insurer for such reinsurance.

FORM AR-1

CERTIFICATE OF ASSUMING INSURER

I,__________________________________________________________________________________

(name of officer) (title of officer)

of_________________________________________________________________________________, (name of assuming insurer)

the assuming insurer under a reinsurance agreement with one or more insurers domiciled in

_________________________________________________, hereby certify that

(name of state)

___________________________________________________________("Assuming Insurer"):

(name of assuming insurer)

Submits to the jurisdiction of any court of competent jurisdiction in

(ceding insurer's state of domicile)

for the adjudication of any issues arising out of the reinsurance agreement, agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such court or any appellate court in the event of an appeal. Nothing in this paragraph constitutes or should be understood to constitute a waiver of Assuming Insurer's rights to commence an action in any court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any state in the United States. This paragraph is not intended to conflict with or override the obligation of the parties to the reinsurance agreement to arbitrate their disputes if such an obligation is created in the agreement.

Designates the Insurance Commissioner of _______________________________________________

(ceding insurer's state of domicile)

as its lawful attorney upon whom may be served any lawful process in any action, suit or proceeding arising out of the reinsurance agreement instituted by or on behalf of the ceding insurer.

Submits to the authority of the Insurance Commissioner of

________________________________________________________ to examine its books and records

(ceding insurer's state of domicile)

and agrees to bear the expense of any such examination.

Submits with this form a current list of insurers domiciled in

__________________________________________________________ reinsured by Assuming Insurer

(ceding insurer's state of domicile)

and undertakes to submit additions to or deletions from the list to the Insurance Commissioner at least once per calendar quarter.

Dated:__________________________________________

(name of assuming insurer)

By: ___________________________________________

(name of officer)

(title of officer)

FORM CR-1

CERTIFICATE OF CERTIFIED REINSURER

I, _____________________________________, _____________________________________________

(name of officer) (title of officer)

of ____________________________________________________, the assuming insurer

(name of assuming insurer)

under a reinsurance agreement with one or more insurers domiciled in ________________________

in order to be considered for approval in this state, hereby certify that (name of state)

____________________________________________________________(“Assuming Insurer”):

(name of assuming insurer)

Submits to the jurisdiction of any court of competent jurisdiction in ________________________

____________________________________ for the adjudication of any issues arising out of the reinsurance agreement, agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such court or any appellate court in the event of an appeal. Nothing in this paragraph constitutes or should be understood to constitute a waiver of Assuming Insurer’s rights to commence an action in any court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any state in the United States. This paragraph is not intended to conflict with or override the obligation of the parties to the reinsurance agreement to arbitrate their dispute if such an obligation is created in the agreement.

Designates the Insurance Commissioner of ____________________________________________

(ceding insurer’s state of domicile)

as its lawful attorney upon whom may be served any lawful process in any action, suit or proceeding arising out of the reinsurance agreement instituted by or on behalf of the ceding insurer.

Agrees to provide security in an amount equal to 100% of liabilities attributable to U.S. ceding insurers if it resists enforcement of a final U.S. judgment or properly enforceable arbitration award.
Agrees to provide notification within 10 days of any regulatory actions taken against it, any change in the provisions of its domiciliary license or any change in its rating by an approved rating agency, including a statement describing such changes and the reasons therefore.
Agrees to annually file information comparable to relevant provisions of the NAIC financial statement for use by insurance markets in accordance with Ins 600.
Agrees to annually file the report of the independent auditor on the financial statements of the insurance enterprise.
Agrees to annually file audited financial statements, regulatory filings, and actuarial opinion in accordance with Ins 600.
Agrees to annually file an updated list of all disputed and overdue reinsurance claims regarding reinsurance assumed from U.S. domestic ceding insurers.
Is in good standing as an insurer or reinsurer with the supervisor of its domiciliary jurisdiction.

Dated: ___________________________

(name of assuming insurer)

BY: ________________________________________

(name of officer)

(title of officer)

FORM RJ-1

CERTIFICATE OF REINSURER DOMICILED IN RECIPROCAL JURISDICTION

I, _____________________________________________, _________________________________

(name of officer) (title of officer)

of _____________________________________________________________________________,

(name of assuming insurer)

the assuming insurer under a reinsurance agreement with one or more insurers domiciled in

_____________________________________, in order to be considered for approval in this state,

(name of state)

hereby certify that ____________________________________________ (“Assuming Insurer”): (name of assuming insurer)

Submits to the jurisdiction of any court of competent jurisdiction in New Hampshire for the adjudication of any issues arising out of the reinsurance agreement, agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such court or any appellate court in the event of an appeal. The assuming insurer agrees that it will include such consent in each reinsurance agreement, if requested by the commissioner. Nothing in this paragraph constitutes or should be understood to constitute a waiver of assuming insurer’s rights to commence an action in any court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any state in the United States. This paragraph is not intended to conflict with or override the obligation of the parties to the reinsurance agreement to arbitrate their disputes if such an obligation is created in the agreement, except to the extent such agreements are unenforceable under applicable insolvency or delinquency laws.
Designates the Insurance Commissioner of New Hampshire as its lawful attorney in and for New Hampshire upon whom may be served any lawful process in any action, suit or proceeding in this state arising out of the reinsurance agreement instituted by or on behalf of the ceding insurer.
Agrees to pay all final judgments, wherever enforcement is sought, obtained by a ceding insurer, that have been declared enforceable in the territory where the judgment was obtained.
Agrees to provide prompt written notice and explanation if it falls below the minimum capital and surplus or capital or surplus ratio, or if any regulatory action is taken against it for serious noncompliance with applicable law.
Confirms that it is not presently participating in any solvent scheme of arrangement, which involves insurers domiciled in New Hampshire. If the assuming insurer enters into such an arrangement, the assuming insurer agrees to notify the ceding insurer and the commissioner, and to provide 100% security to the ceding insurer consistent with the terms of the scheme.
Agrees that in each reinsurance agreement it will provide security in an amount equal to 100% of the assuming insurer’s liabilities attributable to reinsurance ceded pursuant to that agreement if the assuming insurer resists enforcement of a final U.S. judgment, that is enforceable under the law of the territory in which it was obtained, or a properly enforceable arbitration award whether obtained by the ceding insurer or by its resolution estate, if applicable.
Agrees to provide the documentation in accordance with Ins 601.07(c), if requested by the commissioner.

Dated:___________________________________________

(name of assuming insurer)

BY: _____________________________________________

(name of officer)

(title of officer)

Form CR-F – PART 1

Assumed Reinsurance as of December 31, Current Year (000 Omitted)

Reinsurance On

Company Code or ID Number

Name of Reinsured

Domiciliary Jurisdiction

Assume Premium

Paid Losses and Loss Adjustment Expenses

Known Case Losses and LAE

Cols. 6+7

Contingent Commission Payable

Assume Premiums Receivable

Unearned Premium

Funds Held By or Deposited With Reinsured Companies

Letters of Credit Posted

Amount of Assets Pledged or Compensating Balances to Secure Letters of Credit

Amount

of Assets Pledged

Collateral Held in Trust

9999999 Totals

Form CR-F – PART 2

Ceded Reinsurance as of December 31, Current Year (000 Omitted)

Reinsurance Recoverable On

Reinsurance Payable

Company Code or ID Number

Name of Reinsurer

Domiciliary Jurisdiction

Reinsurance Contracts Ceding 70% or More of Direct Premiums Written

Reinsurance Premiums Ceded

Paid Losses

Paid LAE

Known Case Loss Reserves

Known Case LAE Reserves

IBNR Loss Reserves

IBNR LAE Reserves

Unearned Premiums

Contingent Commissions

Cols. 7 through 14 Totals

Ceded Balances Payable

Other Amounts Due to Reinsurers

Net Amount Recoverable From Reinsurance Cols. 15 – [16 + 17]

Funds Held by Company Under Reinsurance Treaties

9999999 Totals

Form CR-S – PART 1 – SECTION 1

Reinsurance Assumed Life Insurance, Annuities, Deposit Funds and Other Liabilities

Without Life or Disability Contingencies, and Related Benefits Listed by Reinsured Company as of December 31, Current Year

Company Code or ID Number

Effective Date

Name of Reinsured

Location

Type of Reinsurance Assume

Amount of In Force at End of Year

Reserve

Premiums

Reinsurance Payable on Paid and Unpaid Losses

Modified Coinsurance Reserve

Funds Withheld Under Coinsurance

Totals

Form CR-S – PART 1 – SECTION 2

Reinsurance Assumed Accident and Health Insurance Listed by Reinsured Company as of December 31, Current Year

Company Code or ID Number

Effective Date

Name of Reinsured

Domiciliary

Jurisdiction

Type of Reinsurance Assumed

Premiums

Unearned

Premiums

Reserve Liability Other Than for Unearned Premiums

Reinsurance Payable on Paid and Unpaid Losses

Modified Coinsurance Reserve

Funds Withheld Under Coinsurance

Totals

Form CR-S – PART 2

Reinsurance Recoverable on Paid and Unpaid Losses Listed by Reinsuring Company as of December 31, Current Year

Company Code or ID Number

Effective Date

Name of Company

Location

Paid Losses

Unpaid Losses

Totals – Life, Annuity and Accident and Health

Form CR-S – PART 3 – SECTION 1

Reinsurance Ceded Life Insurance, Annuities, Deposit Funds and Other Liabilities

Without Life or Disability Contingencies, and Related Benefits Listed by Reinsuring Company as of December 31, Current Year

Company Code or ID Number

Effective Date

Name of Company

Location

Type of Reinsurance Ceded

Amount in Force at End of Year

Reserve

Credit Taken

Premiums

Outstanding Surplus Relief

Modified Coinsurance Reserve

Funds Withheld Under Coinsurance

Current Year

Prior Year

Current Year

Prior Year

Totals

Form CR-S – PART 3 – SECTION 2

Reinsurance Ceded Accident and Health Insurance Listed by Reinsuring Company as of December 31, Current Year

Company Code or ID Number

Effective Date

Name of Company

Location

Type

Premiums

Unearned Premium (Estimated)

Reserve Credit Taken Other than for Unearned Premiums

Outstanding Surplus Relief

Modified Coinsurance Reserve

Funds Withheld under Coinsurance

Current Year

Prior Year

Totals

APPENDIX

Rule

Statute

Ins 601.01

RSA 400-A:15, I; RSA 405:45-52, inclusive

Ins 601.02

RSA 400-A:15, I; RSA 405:47, I; RSA 405:50-a

Ins 601.03

RSA 400-A:15, I; RSA 405:47, II; RSA 405:50-a

Ins 601.04

RSA 400-A:15, I; RSA 405:47, III; RSA 405:50-a

Ins 601.05

RSA 400-A:15, I; RSA 405:47, IV; RSA 405:50-a

Ins 601.06

RSA 400-A:15, I; RSA 405:47, IV-a; RSA 405:50-a

Ins 601.07

RSA 400-A:15, I; RSA 405:47, IV-a; RSA 405:47, IV-b;

RSA 405:50; RSA 405:50-a

Ins 601.08

RSA 400-A:15, I; RSA 405:46, III; RSA 405:48; RSA 405:50-a

Ins 601.09

RSA 400-A:15, I; RSA 405:47; RSA 405:50-a

Ins 601.10

RSA 400-A:15, I; RSA 405:46, II & VI; RSA 405:50-a

Ins 601.11

RSA 400-A:15, I; RSA 405:50, IV; RSA 405:50-a

Ins 601.12

RSA 400-A:15, I; RSA 405:47; RSA 405:49; RSA 405:50-a

Ins 601.13

RSA 400-A:15, I; RSA 405:47; RSA 405:49; RSA 405:50-a

Ins 601.14

RSA 400-A:15, I; RSA 405:47; RSA 405:49; RSA 405:50-a

History

#10449, eff 11-1-13 (from Ins 601.12); ss by #13296, eff 11-24-21 (formerly Ins 601.13)

Chapter Ins 800 Reporting of Statistical Data by Property and Casualty Insurance Companies

Part Ins 801 Reporting Requirements

N.H. Code Admin. R. Ann. Ins 801.01 Purpose {#sec-ins-801.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.01}

The purpose of this chapter is to set forth the manner of reporting data by insurers to statistical agents, to prescribe reports to be submitted by statistical agents to the commissioner, and to prescribe certain conduct in connection therewith. This chapter does not apply to data reported directly by insurers to the commissioner.

History

#4468, eff 8-5-88; ss by #5649, eff 7-1-93; ss by #7027, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7108, eff 10-29-99, EXPIRED: 10-29-07
#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.02 Scope {#sec-ins-801.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.02}

This chapter shall apply to all lines of insurance except life insurance, variable annuities, accident and health insurance, title insurance, reinsurance, ocean marine insurance, and aviation insurance.

History

#4468, eff 8-5-88; ss by #5649, eff 7-1-93; ss by #7027, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7108, eff 10-29-99, EXPIRED: 10-29-07
#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.03 Definitions {#sec-ins-801.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.03}

(a) "NAIC Statistical Handbook or Handbook" means the publication of the National Association of Insurance Commissioners (NAIC) that explains insurance statistical data and provides reporting requirements and report formats to be regularly furnished by statistical agents.

(b) "Statistical agent" means an entity that has been designated by the commissioner to collect statistics from insurers and provide reports developed from these statistics to the commissioner for the purpose of fulfilling the statistical reporting obligations of those insurers.

(c) "Statistical plan" means a statistical agent's system for collecting information from reporting insurers, including exposure, coverage, classification, territory, premium, loss, and other information.

History

#4468, eff 8-5-88; ss by #5649, eff 7-1-93; ss by #7027, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7108, eff 10-29-99, EXPIRED: 10-29-07
#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.04 Examination of Statistical Agents {#sec-ins-801.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.04}

To be designated to collect statistics from insurers for purposes of fulfilling the statistical reporting requirements of this chapter, any entity other than a licensed advisory organization shall be subject to the same examination provisions as licensed advisory organizations.

History

#4468, eff 8-5-88; ss by #5649, eff 7-1-93; ss by #7027, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7108, eff 10-29-99, EXPIRED: 10-29-07
#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.05 Filing of Statistical Plans by Statistical Agents {#sec-ins-801.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.05}

Every statistical agent shall file with the commissioner every statistical plan and every modification that it proposes to use to collect statistics to meet the requirements of this chapter. Such statistical plan filings shall be deemed to meet the requirements of this chapter unless disapproved by the commissioner within 30 days after filing for being inconsistent with the requirements of the statistical plan requested by the commissioner.

History

#4468, eff 8-5-88; ss by #5649, eff 7-1-93; ss by #7027, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7108, eff 10-29-99, EXPIRED: 10-29-07
#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.06 Statistical Plans and Reporting by Insurers {#sec-ins-801.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.06}

Every insurance company licensed in this state shall report its insurance statistical experience for lines of insurance covered by this chapter to a statistical agent designated by the commissioner. This data shall be submitted in accordance with statistical plans approved in accordance with Ins 801.05.

History

#4468, eff 8-5-88; ss by #5649, eff 7-1-93; ss by #7027, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7108, eff 10-29-99, EXPIRED: 10-29-07
#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.07 Statistical Agents' Compliance with the Statistical Handbook {#sec-ins-801.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.07}

For every line of insurance that it collects statistics in this state, every statistical agent shall, at a minimum, collect statistics and file reports and compilations in the form and detail provided in the NAIC Statistical Handbook, edition date 2012, as available in Appendix B.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.08 Multiple Statistical Agents for the Same Line of Insurance {#sec-ins-801.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.08}

For lines of insurance where more than one statistical agent has been designated and collects statistics in this state, the statistical agents shall, if so directed by the commissioner, arrange to file combined reports for all statistical agents collecting data for the affected lines of insurance. The statistical agents may make arrangements among themselves for the equitable sharing of the costs to produce combined reports.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.09 Edit and Control Procedures for Statistical Agents {#sec-ins-801.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.09}

Statistical agents shall adopt, edit, and control procedures to screen and check data for reasonableness, apparent accuracy, and completeness. These procedures shall, at a minimum, conform to the specifications provided in the NAIC Statistical Handbook, edition date 2012, as available in Appendix B.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.10 Insurer Edit and Audit Procedures {#sec-ins-801.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.10}

Insurers shall adopt, edit, and audit procedures to screen and check data required by this chapter to be reported to see that such data meets the standards for reasonableness and accuracy provided in the NAIC Statistical Handbook, edition date 2012, as available in Appendix B.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15; ss by #14505, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 801.11 Disclosure of Complying and Non-Complying Insurers {#sec-ins-801.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.11}

Statistical reports shall each contain a listing of insurers whose data are included. In addition, if data from an insurer or insurers that had agreed to have data included are, in fact, not included, then a listing of these insurers shall also be made with the statistical report as specified in the NAIC Statistical Handbook, edition date 2012, as available in Appendix B. For any insurer that is listed as not included in a statistical report, the statistical agent shall, upon the request of the commissioner, provide reasons for the exclusion.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15 (from Ins 801.11); ss by #14505, eff 2-7-26, EXPIRES: 2-7-36 (formerly Ins 801.12)

N.H. Code Admin. R. Ann. Ins 801.12 Access to Data {#sec-ins-801.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.12}

Statistical agents shall provide access to the commissioner of all statistical data that has been collected. Upon request by the commissioner, the statistical agent shall provide a copy of any report that it produces from data that the commissioner has required to be collected.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15 (from Ins 801.12); ss by #14505, eff 2-7-26, EXPIRES: 2-7-36 (formerly Ins 801.13)

N.H. Code Admin. R. Ann. Ins 801.13 Disclosure of Data {#sec-ins-801.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.13}

When data submitted to the insurance department by a statistical agent identify individual insurers, appear likely to identify individual claimants or insureds, or are asserted by the statistical agent or a reporting insurer to be subject to protection from disclosure, such data shall not be publicly disclosed unless, prior to such disclosure:

(a) The department notifies the statistical agent and any insurer which has asserted the data to be subject to protection from disclosure of the request for disclosure;

(b) The department then provides a 30 day period for any insurer that reported data to the statistical agent to assert that its data are trade secret or are otherwise protected from disclosure. The 30 day period shall run from the time that the statistical agent receives notification from the department;

(c) The department then provides insurers which have asserted their data to be trade secret or otherwise protected from disclosure with the opportunity to support their positions, which shall be governed by RSA 400-A:17 and Ins 200; and

(d) After the applicable adjudicative process is complete, there is a final decision that the data are not trade secret and are not otherwise subject to protection from disclosure.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15 (from Ins 801.13); ss by #14505, eff 2-7-26, EXPIRES: 2-7-36 (formerly Ins 801.14)

N.H. Code Admin. R. Ann. Ins 801.14 Exemption {#sec-ins-801.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.14}

(a) Upon application by a statistical agent or an individual insurer, the commissioner may allow the submission of a report or statistical data at a specified later date if the submission of the report or data on the date required by this chapter would create a substantial hardship on the statistical agent or insurer.

(b) In considering whether to grant such an exemption, the commissioner shall consider whether the delay is necessitated by an unusual or a one-time situation, or whether the delay is necessitated by a situation that is likely to reoccur. When the delay is necessitated by a situation that is likely to reoccur, the commissioner may condition the granting of an exemption on whether the insurer or statistical agent has a plan of action to address the situation in the future.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15 (from Ins 801.14); ss by #14505, eff 2-7-26, EXPIRES: 2-7-36 (formerly Ins 801.15)

N.H. Code Admin. R. Ann. Ins 801.15 Lines of Insurance Without a Statistical Agent {#sec-ins-801.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.15}

Any licensed insurer writing any line of insurance not exempted in Ins 801.02 that finds or believes to have found that it is writing a line or type of insurance for which no statistical agent will accept data shall notify the commissioner of this fact as soon as practicable.

History

#9053, eff 1-2-08; ss by #11008, eff 12-31-15 (from Ins 801.15); ss by #14505, eff 2-7-26, EXPIRES: 2-7-36 (formerly Ins 801.16)

N.H. Code Admin. R. Ann. Ins 801.16 Penalty {#sec-ins-801.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.16}

Failure to file the information required under this chapter shall result in a penalty in accordance with the provisions of RSA 412:40.

History

#11008, eff 12-31-15 (from Ins 801.16); ss by #14505, eff 2-7-26, EXPIRES: 2-7-36 (formerly Ins 801.17)

N.H. Code Admin. R. Ann. Ins 801.17 Waiver of Rules {#sec-ins-801.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 801.17}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX A Statutes Implemented

Rule

Statute

Ins 801.01

RSA 412:23; RSA 412:24; RSA 412:25

Ins 801.02

RSA 412:2

Ins 801.03

RSA 412:23; RSA 412:24; RSA 412:25

Ins 801.04

RSA 412:43

Ins 801.05

RSA 412:23; RSA 412:24; RSA 412:25

Ins 801.06

RSA 412:23; RSA 412:24; RSA 412:25; RSA 412:43

Ins 801.07

RSA 412:23; RSA 412:24; RSA 412:25

Ins 801.08

RSA 412:43

Ins 801.09

RSA 412:23; RSA 412:24; RSA 412:43

Ins 801.10

RSA 412:43

Ins 801.11

RSA 412:23; RSA 412:24; RSA 412:43

Ins 801.12

RSA 412:23; RSA 412:24; RSA 412:43

Ins 801.13

RSA 400-A:17; RSA 400-A:25; RSA 412:43

Ins 801.14

RSA 412:43

Ins 801.15

RSA 412:43

Ins 801.16

RSA 412:40

Ins 801.17

RSA 400-A:15, I; RSA 541-A:22, IV

APPENDIX B Incorporation by Reference Information

Rule

Title

Publisher; How to Obtain; and Cost

Ins 801.07

Ins 801.09

Ins 801.10

Ins 801.11

“NAIC Statistical Handbook,” Statistical Handbook of Data Available to Insurance Regulators, (edition 2012)

Copyrighted by the National Association of Insurance Commissioners; Available from the National Association of Insurance Commissioners, 2301 McGee Street, Suite 301, Kansas City, Missouri 64108; telephone: 816-842-3600; www.naic.org; download free PDF

History

#14505, eff 2-7-26, EXPIRES: 2-7-36

Chapter Ins 900 Actuaries

Part Ins 901 Qualification of Actuaries

N.H. Code Admin. R. Ann. Ins 901.01 Scope {#sec-ins-901.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 901.01}

The provisions of this part shall apply to all reports, statements, and other documents filed with or provided to the insurance department or issued to the public in connection with the business of insurance.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #7028, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7123, eff 10-29-99; ss by #8965, eff 9-1-07; ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 901.02 Definitions {#sec-ins-901.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 901.02}

“Qualified actuary” means “qualified actuary” as defined in RSA 410:2, X.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #7028, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7123, eff 10-29-99; ss by #8965, eff 9-1-07; ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 901.03 Restriction on Use of Terms “Actuary” or “Actuarial” {#sec-ins-901.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 901.03}

(a) No person shall represent themselves as an actuary to the insurance department unless such person is a qualified actuary.

(b) No person shall make any representation to the insurance department in which the term "actuary" or "actuarial" is used to indicate a degree of professional competence unless such representation was prepared or approved by a qualified actuary.

(c) No person who is a qualified actuary shall make any representations using the terms “actuary” or “actuarial” to the insurance department unless they are qualified to give the actuarial advice therein contained.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #7028, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7123, eff 10-29-99; ss by #8965, eff 9-1-07; ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

Part Ins 902 Actuarial Review of Rate Filings

N.H. Code Admin. R. Ann. Ins 902.01 Scope {#sec-ins-902.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 902.01}

The provisions of this part shall apply to rate filings for classes of insurance that are now or shall hereafter be written in this state, submitted to the commissioner.

History

#4498(E), eff 9-30-88; ss by #4576, eff 2-6-89; ss by #5649, eff 7-1-93; ss by #7028, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7123, eff 10-29-99; ss by #8965, eff 9-1-07; ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 902.02 Review of Rate Filings {#sec-ins-902.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 902.02}

The commissioner shall, for the purpose of examining and analyzing rate filings, contract with a qualified actuary or actuarial firm employing qualified actuaries. The examination and analysis of any rate filing shall be undertaken by a contracting actuary or actuarial firm only when the insurance department is unable to provide the resources necessary to review such filings. The contracting actuary or actuarial firm shall provide advice to the commissioner on the rate filing and perform other actuarial services related to the rate filing as required.

History

#4498(E), eff 9-30-88; ss by #4576, eff 2-6-89; ss by #5649, eff 7-1-93; ss by #7028, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7123, eff 10-29-99; ss by #8965, eff 9-1-07; ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 902.03 Expense {#sec-ins-902.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 902.03}

The expense of the actuarial review required by this part and all other expenses associated with any actuarial services performed related to a rate filing shall be borne by the insurer or insurance advisory organization submitting the rate filing in accordance with RSA 400-A:37, III (d).

History

#4498(E), eff 9-30-88; ss by #4576, eff 2-6-89; ss by #5649, eff 7-1-93; ss by #7028, INTERIM, eff 7-1-99, EXPIRES: 10-29-99; ss by #7123, eff 10-29-99; ss by #8965, eff 9-1-07; ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

Part Ins 903 Other Requisite Reports and Documents

N.H. Code Admin. R. Ann. Ins 903.01 Signature of Actuary Required for Annual Statements {#sec-ins-903.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 903.01}

All annual statements of foreign, domestic, and alien life and accident and health insurance companies, fraternal benefit societies, hospital service corporations, and medical service corporations, which are required to be filed with the insurance commissioner, as well as other periodic financial statements of such companies as the insurance commissioner requires, shall be signed by a qualified actuary.

History

#8965, eff 9-1-07 (formerly Ins 901.04); ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 903.02 Actuarial Certification {#sec-ins-903.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 903.02}

All requisite actuarial certifications shall be prepared and signed by a qualified actuary.

History

#8965, eff 9-1-07; ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

Part Ins 904 Limitations

N.H. Code Admin. R. Ann. Ins 904.01 Limitations {#sec-ins-904.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 904.01}

Nothing in this chapter shall be construed to:

(a) Require any insurer or insurance advisory organization to employ an actuary;

(b) Require that rate filings be prepared or submitted by a qualified actuary; or

(c) Prohibit the strictly internal use by insurers or insurance advisory organizations of job titles containing the words “actuary” or “actuarial.”

History

#8965, eff 9-1-07; ss by #10919, eff 9-1-15; ss by #14511, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 904.02 Waiver of Rules {#sec-ins-904.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 904.02}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX

RULE

STATUTE IMPLEMENTED

Ins 901.01

RSA 410:2

Ins 901.02

RSA 402-E:1; RSA 402-F:11; RSA 410:2, X

Ins 901.03

RSA 410:2

Ins 902.01

RSA 412; RSA 420-A; RSA 420-B; RSA 420-F: RSA 420-G

Ins 902.02

RSA 412; RSA 420-A; RSA 420-B

Ins 902.03

RSA 400-A:36-a

Ins 903.01

RSA 410:2

Ins 903.02

RSA 410:2

Ins 904.01

RSA 410:2

Ins 904.02

RSA 400-A:15, I; RSA 541-A:22, IV

History

#14511, eff 2-7-26, EXPIRES: 2-7-36

Chapter Ins 1000 Claim Settlement

Part Ins 1001 Claim Settlement for All Insurers, Except Property and Casualty

N.H. Code Admin. R. Ann. Ins 1001.01 Communications Time Limit {#sec-ins-1001.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.01}

(a) Every insurer, upon notice of a claim, shall acknowledge the receipt of such notice in writing within 10 working days. This requirement of written acknowledgment shall not preclude a speedier method of acknowledgment where the circumstances warrant. Notification given to an agent of an insurer shall be to the insurer if such agent notifies the claimant within 5 working days that the agent is not notification to the insurer. If the notification is given to the agent of an insurer, such agent may acknowledge receipt of such notice. Unless otherwise provided by law or contract, notice to an agent of an insurer shall not be notice authorized to receive notices of claims.

(b) Every insurer shall reply within 10 working days to all claims communications from insureds, claimants, or authorized representatives of either.

(c) Every insurer, upon receipt of an inquiry from the insurance department, shall within 10 working days furnish the department with a complete and accurate written response to the inquiry.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #6999, eff 5-24-99, EXPIRED: 5-24-07
#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1001.02 Claims {#sec-ins-1001.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.02}

Settlement Time Limits.

(a) A complete decision regarding member payment or coverage or denial shall be made by the insurer within 30 days of receipt of any health insurance claim. In the event of extenuating circumstances, if a complete coverage decision is not made within 30 days, the insurer shall provide a written explanation to the member claimant justifying such delay. This provision shall not apply to provider-submitted claims for reimbursement for services which have been provided to members.

(b) Unless otherwise provided by law, every insurer shall establish procedures to commence an investigation of any claim filed by an insured, claimant, or authorized representative of either within 5 working days upon receipt of notice of loss. The procedures established shall anticipate the seasonal changes in the volume of claims. Every insurer shall mail to every insured, claimant, policyholder, or their authorized representative a notification of all items, statements, or forms as well as blank copies of all statements or forms which the insurer reasonably believes will be required in the settlement of the claim.

(c) Unless otherwise provided by law, within 10 working days after acknowledgment of the receipt of a notice of a claim from the insured, claimant, or authorized representative of either, the insurer shall advise the insured, claimant, or authorized representative of either in writing of the acceptance or rejection of the claim. If the insurer needs more time to determine whether the claim should be accepted or rejected, the insurer shall so notify the insured, claimant, or authorized representative of either within 10 working days after acknowledgement of the loss and provide the reasons for the delay.

(d) The insurer shall within 30 days from the date of the letter setting forth a need for further time and every 30 days thereafter, send to the insured, claimant, or authorized representative of either a letter setting forth the reasons for the delay in the claim settlement, unless the insured, claimant, or authorized representative otherwise agrees.

(e) An insurer shall not justify a delay in processing or paying a claim on the grounds of suspected fraud unless the insurer has notified the department and has provided the department with specific reasons to support its suspicions.

(f) Whenever the insurer denies a claim on the basis of no coverage or the amount of loss is below the deductible, the insurer shall inform the insured in writing the reason for the denial and include the department’s toll-free telephone number.

(g) Any letter setting forth the need for further time after the first 30-day period shall contain the following statement:

"We will, of course, be available to you to discuss the position we have taken and answer your questions. You may reach us by calling the customer service number located in this notice or the number on the back of your member identification card, if you have one.

If you have been unable to resolve your concern and are a resident of New Hampshire or have a New Hampshire issued policy, you may take this matter up with the New Hampshire insurance department, as it maintains a service division to investigate complaints at 21 South Fruit Street, Suite 14, Concord, NH, 0330l. The New Hampshire insurance department can be reached, toll-free, by dialing 1-800-852-3416.”

(h) Unless otherwise provided by law, every insurer shall pay any amount finally agreed upon in settlement of all or part of a claim not later than 5 working days from the date of such agreement or from the date of the performance by the insured, claimant, or authorized representative of either of all conditions set forth by such agreement.

(i) An insurer shall not request of a claimant or insured a waiver of insurer obligations under Ins 1000, except to request a waiver of the 30 day delay letter provision of this rule. This waiver shall be in writing and signed by the insured or claimant. The signed waiver shall be retained in the claim file.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #6999, eff 5-24-99, EXPIRED: 5-24-07
#8900, eff 7-1-07, EXPIRED: 10-26-15
#10962, eff 10-26-15; ss by #13173, eff 4-26-21

N.H. Code Admin. R. Ann. Ins 1001.03 Additional Information Required in Accepting or Rejecting Claims {#sec-ins-1001.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.03}

(a) If a claim is denied in whole or in part the insured, claimant or authorized representative of either shall be given the reason for the denial. In any case where coverage is denied the insurer shall notify the insured, claimant, or authorized representative of either of the applicable policy provision upon which denial is based.

(b) Statements setting forth benefits included within claim payments shall be in writing and in sufficient detail so that the insured, claimant, or authorized representative of either can reasonably understand the benefits included within the claim payment.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #6999, eff 5-24-99, EXPIRED: 5-24-07
#8900, eff 7-1-07 (from Ins 1001.04), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1001.04 Undisputed Amounts {#sec-ins-1001.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.04}

In any case where there is no dispute as to one or more elements of the claim, an offer of settlement for such undisputed elements shall be made without prejudice to either party notwithstanding the existence of disputes as to other elements of the claim.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.05), EXPIRED: 5-24-07
#8900, eff 7-1-07 (from Ins 1001.05), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1001.05 Required Notice of Insurance Department {#sec-ins-1001.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.05}

Any notice rejecting a claim in whole or in part shall contain the following statement:

If you have been unable to resolve your concern and are a resident of New Hampshire or have a New Hampshire issued policy, you may take this matter up with the New Hampshire insurance department, it maintains a service division to investigate complaints at 21 South Fruit Street, Suite 14, Concord, NH, 0330l. The New Hampshire insurance department can be reached, toll-free, by dialing 1-800-852-3416.”

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.06) ), EXPIRED: 5-24-07
#8900, eff 7-1-07 (from Ins 1001.06), EXPIRED: 7-1-15
#10962, eff 10-26-15; ss by #13173, eff 4-26-21

N.H. Code Admin. R. Ann. Ins 1001.06 Advance Payments {#sec-ins-1001.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.06}

No insurer shall refuse to grant advance payments on a claim because the claimant, insured or authorized representative of either has retained an attorney for the purpose of facilitating recovery on his behalf.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.07) ), EXPIRED: 5-24-07
#8900, eff 7-1-07 (from Ins 1001.07), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1001.07 Physician's Examination {#sec-ins-1001.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.07}

Unless otherwise provided by law, when a disability benefits claim has been accepted by an insurer under either an individual accident and health policy or group policy, the insurer shall not require additional reports from the insured's or beneficiary's physician to substantiate disability which has already been established by a prior report.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.08), EXPIRED: 5-24-07
#8900, eff 7-1-07 (from Ins 1001.08), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1001.08 Insurers Use of Unlicensed Adjusters Prohibited {#sec-ins-1001.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.08}

No insurer shall employ or otherwise utilize the services of an adjuster unless that adjuster has complied with all the appropriate licensing provisions of RSA 402-B or has been granted a temporary license pursuant to RSA 402-B:11. However, any claim adjusted to the satisfaction of an insurer and the claimant by an unlicensed adjuster shall bind the insurer.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.09), EXPIRED: 5-24-07
#8900, eff 7-1-07 (formerly Ins 1001.13), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1001.09 Telephone Communications With Claims Department {#sec-ins-1001.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.09}

Every insurer shall provide telephone facilities whereby the insured, claimant, or authorized representative of either can, without expense, contact the company claims office handling the particular claim. If the company has no claims office located in New Hampshire or in the region, then provision shall be made so that the company home office can be contacted by the insured, claimant, or authorized representative of either without expense. Notice of the fact that free telephone service is available along with the appropriate phone number shall be indicated on company claims forms.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.10), EXPIRED: 5-24-07
#8900, eff 7-1-07 (formerly Ins 1001.14), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1001.10 Other Insurer Responsibilities {#sec-ins-1001.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.10}

(a) If, under the provisions of RSA 417:4, XV(a)(12), the insured fails or refuses to submit a report of the loss to the insurer, this shall be considered to be a request by the insured not to pay the claim.

(b) The insurer shall adjust all claims in accordance with the provisions of the New Hampshire insurance laws and these rules.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.11), EXPIRED: 5-24-07
#8900, eff 7-1-07), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1001.11 Penalty {#sec-ins-1001.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 1001.11}

Any insurer or representative thereof who shall knowingly violate any provision of this part shall be subject to the provisions of RSA 400-A;15, III.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.12), EXPIRED: 5-24-07
#8900, eff 7-1-07 (formerly Ins 1001.16), EXPIRED: 7-1-15
#10962, eff 10-26-15

Part Ins 1002 Claim Settlement for Property & Casualty Insurance

N.H. Code Admin. R. Ann. Ins 1002.01 Purpose and Scope {#sec-ins-1002.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.01}

(a) The purpose of this part, unless otherwise provided by law, is to establish claim settlement standards for all property and casualty insurance, except workers' compensation and policies for large commercial policyholders as defined in RSA 412:3, XI.

(b) This part shall apply to all claims on property and casualty insurance policies written on any combination of risks or operations located in this state under the provisions of RSA 401:1, I, II, V, VII, and VIII and any miscellaneous insurance under RSA 401:1-a that is designated by the commissioner to be regulated under RSA 412.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15; ss by #13173, eff 4-26-21

N.H. Code Admin. R. Ann. Ins 1002.02 Definitions {#sec-ins-1002.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.02}

(a) "Claim file" means the complete and specific claim file record of events and dates maintained to show clearly the inception, handling, and disposition of each claim.

(b) "Claimant" means any person who sustains bodily injury or property damage and who asserts a right to recover for damages against an insured. The term "claimant" includes the claimant's authorized representative acting on behalf of the claimant.

(c) "Communications" means all correspondence and contact(s), regardless of source or type, that is materially related to the handling of the claim.

(d) "Documentation" means all communications, transactions, notes, work papers, claim forms, bills, statement of loss and other similar materials relative to the claim.

(e) "Fair market value" means the price at which an asset would change hands between a willing buyer and a willing seller when neither is under compulsion to act and both have knowledge of all facts relevant to the sale.

(f) "Independent repair shop or facility" means any entity that:

(1) Provides automobile repair services; and

(2) Has no arrangement with respect to repair prices or services with the insurer making a payment for settlement of the damaged motor vehicle; but which might have arrangements with respect to repair prices or services with other insurers.

(g) "Insured" means, for the purposes of this rule only, a person or persons who are included in the definition of an insured as set forth in the insurance policy. The term "insured" includes the insured's authorized representative acting on behalf of the insured.

(h) "Investigation" means the initial contact or documented attempted contact with the insured or claimant and all activities of an insurer directly or indirectly related to the determination of liabilities under coverages afforded by an insurance policy.

(i) "Local market area" means a maximum distance of 75 miles surrounding the area where the motor vehicle is principally garaged and not limited to the geographic boundaries of the state of New Hampshire.

(j) "Motor vehicle" means motor vehicle as defined in RSA 259:60, III.

(k) "Notice of a claim" means any notification, whether in writing or other means acceptable under the terms of an insurance policy, to an insurer or its appointed producer, by an insured or claimant, that apprises the insurer of the facts pertinent to a claim.

(l) "Uninsured motor vehicle" means a motor vehicle that is:

(1) Not insured under any insurance policy;

(2) An insured motor vehicle for which the insurer is unable to make payment within the insured liability limits due to insolvency; or

(3) An insured motor vehicle that at the time of the accident had limits of liability insurance that were lower than the minimum limits required for a motor vehicle liability policy pursuant to applicable law.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.03 Computation of Time {#sec-ins-1002.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.03}

(a) Unless otherwise specified, all time periods referenced in this part shall be calendar days.

(b) Computation of any period of time referred to in this part shall begin with the day after the action which sets the time period in motion, and shall include the last day of the period so computed.

(c) If the last day of the period so computed falls on a Saturday, Sunday or legal holiday, then the time period shall be extended to include the first business day following the Saturday, Sunday, or legal holiday.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.04 Communications Time Limit {#sec-ins-1002.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.04}

(a) Notice of a claim given by an insured or claimant to an insurer’s appointed producer shall be considered notification to the insurer, unless:

(1) Otherwise provided by law or the policy; or

(2) The appointed producer notifies the insured or claimant within 5 working days of receipt of notice of a claim that the appointed producer is not authorized to receive notices of claims.

(b) Every insurer shall reply in no later than 10 working days to all claims communications from insureds or claimants. Receipt of documentation or information by an insurer that was requested of the insured or claimant is a communication subject to response under this section.

(c) Every insurer, upon receipt of an inquiry from the insurance department, shall within 10 working days furnish the department with a complete and accurate written response to the inquiry.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.05 Claims Settlement Time Limits {#sec-ins-1002.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.05}

(a) Unless otherwise provided by law, every insurer shall establish procedures to:

(1) Commence an investigation of any notice of a claim filed by an insured or claimant not later than 5 working days from receipt of the notice of a claim; and

(2) Anticipate the seasonal changes in the volume of claims in order to comply with this section.

(b) Every insurer, upon receipt of notice of a claim, shall acknowledge the receipt of such notice to the insured or claimant, within 10 working days, as follows:

(1) By written correspondence, including facsimile or e-mail if acceptable to both parties; or

(2) By telephone or face-to-face communication if the insurer provides the insured or claimant with the toll free telephone number of the insurer's claims office handling the claim. Thereafter, should the insured or claimant request a written acknowledgment, the insurer shall provide written acknowledgment within 5 working days from the request of the insured or claimant.

(c) Unless otherwise provided by law, within 30 days from the receipt of the notice of claim, the insurer shall make a complete decision regarding coverage, acceptance, denial, or payment of a claim and communicate this to the insured or claimant with the following exceptions:

(1) If a decision cannot be made because the insurer needs more time to make a decision, the insurer shall provide the insured or claimant, in writing, a delay letter setting forth the specific factual or legal reasons that the insurer needs more time to determine whether the claim will be covered, accepted, paid, or denied;

(2) The insurer shall, within 30 days from the date of the delay letter in (c)(1) above, and every 30 days thereafter, send a letter setting forth the specific factual or legal reasons for the continued delay in the claim settlement process;

(3) If the reason the claim remains open is that the insurer is waiting for documentation or information requested of the insured or claimant, then the insurer shall send a letter to the insured or claimant requesting the particular documentation or information necessary to accept, pay, or deny the claim, but shall not be required to send the delay letter(s) to the insured or claimant as required in (c)(1) or (c) (2) above; and

(4) If either party has filed suit, and the settlement of the claim is being litigated in a court of law, the delay letter in (c)(1) or (c)(2) above shall not be required.

(d) Unless otherwise provided by law or court order, every insurer shall pay all or part of the claim:

(1) Within 5 working days from date of agreement with an insured or claimant; or

(2) Within 5 working days after receipt from the insured or claimant, of documentation needed to process the claim for payment as requested by the insurer.

(e) In any claim in which the insurer cannot make a decision within 5 working days from the date of agreement or of receipt of the requested documentation, the insurer shall send a delay letter to the insured or claimant explaining the reasons for the delay in the claim settlement process.

(f) The insurer shall, within 30 days from the date of the delay letter in (e) above, and every 30 days thereafter, send a letter setting forth the specific reasons for the continued delay in the claim settlement process.

(g) When the reason for delay is suspected fraud a delay letter issued pursuant to (c) or (d) above shall be deemed sufficient if it indicates that the reason for the delay is that further investigation is needed to determine the validity of the claim.

(h) Whenever the insurer denies a claim, in whole or in part, including on the basis of no coverage or that the amount of the loss is below the deductible, or issues a reservation of rights letter, or when sending a second or subsequent delay letter(s) as provided in (c)(2) and (f) above, the insurer shall include the following statement in at least 12-point font bold type:

“We will, of course, be available to you to discuss the position we have taken. You may reach us at (insurance company toll free telephone number). If you are a New Hampshire resident; if your policy insures property located in New Hampshire; or if you have been injured/your property has been damaged by a New Hampshire resident and you wish to take this matter up with the New Hampshire Insurance Department, it maintains a consumer services division to assist consumers with complaints at 21 South Fruit Street, Suite 14, Concord, NH, 03301. The New Hampshire Insurance Department can be reached, toll free, by dialing 1-800-852-3416.

(i) An insurer shall not request of an insured or claimant a waiver of the insurer's obligations under this part, except to request a waiver of the 30 day delay letter provision of (c)(2) and (f) above. The waiver shall be in writing and signed by the insured or claimant. The signed waiver shall be retained in the claim file.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.06 Additional Information Required in Accepting or Denying Claims {#sec-ins-1002.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.06}

(a) In addition to the provisions of Ins 1002.05, if a claim is denied in whole or in part, the insured or claimant shall be given a written notice of the reason for the denial and any applicable policy provision upon which denial is based, provided, however, that if the reason for the denial is fraud, the notification shall be deemed sufficient if it provides a general statement explaining that the damage did not occur in the manner reported by the insured and/or claimant.

(b) Every insurer shall provide with each claim payment, either on the check, draft or in a letter, the reason for the payment and the date of loss, for example, “collision payment for your accident on (date), homeowner contents payment for your fire loss on (date) or property damage loss to your motor vehicle as the result of an accident on (date).”

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.07 Undisputed Amounts {#sec-ins-1002.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.07}

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.08 Claims Payments {#sec-ins-1002.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.08}

(a) No insurer shall refuse to grant advance payments on a claim because the insured or claimant has retained an attorney for the purpose of facilitating recovery on his or her behalf.

(b) The form of payment of a claim shall allow the claimant or insured ready access to claim funds and comply with one of the following methods:

(1) Delivery of payment by paper check or draft to the insured or claimant;

(2) With the prior verifiable authorization of the insured or claimant, direct deposit to a claimant's or insured's financial account; or

(3) With the prior verifiable authorization of the insured or claimant, delivery of a debit card, bank card, or other similar card, procured by arrangement between the insurer and financial institution, whereby the claim payment to the consumer is transferred from the insurer to the financial institution and held in an account at the financial institution, provided:

a. Prior to securing the verifiable authorization of the insured or claimant for payment by such card, the insurer shall provide a written disclosure including:

All options for withdrawal of funds; and
An itemized list of any transaction or other fees or charges that may be assessed to the insured or claimant using the card, including those by third parties;

b. The contract between the insurer and financial institution shall ensure that the insured or claimant will receive written advance notice of any change to the terms and conditions of the card until such time as the claimant or insured has expended all funds on the card;

c. Authorization to receive claim payments by one of the methods set out in (b)(1), (b)(2) or (b)(3) shall be established for each claim at or after the time of the claim, and the selection of that method of payment shall not prohibit the insured or claimant from changing the method of payment for future claim payments arising from the same claim nor shall it bind the insured or claimant to selection of the same method of payment for future claims;

d. The card:

Shall permit the claimant or insured at least one opportunity to withdraw the full amount provided on the card without charge; or
If the card does not provide for at least one opportunity to withdraw the full amount without charge as described in d.1. above, the insurer shall:

(i) Obtain an express written waiver from the insured or claimant of the right to a single, free opportunity to withdraw the card funds; or

(ii) Upon the request of the insured or claimant, send the consumer without charge, by overnight delivery, a check for the lesser of:

i. The full amount issued on the card; or

ii. The remaining balance;

e. Upon delivery of the card the insurer shall provide the insured or claimant:

A written statement confirming the amount available on the card as issued, to include information provided on the card itself indicating the amount available on the card as issued; or
A toll free number and secure internet site where the consumer can confirm the amount available on the card as issued; and

f. If the insured or claimant has not fully withdrawn or expended all funds in the card account:

Prior to the expiration of the card, a replacement card shall be issued at no cost to the insured or claimant; or
Upon the expiration of the card, any remaining funds shall be transferred to the consumer using the methods described in (b)(1) or (2) of this paragraph.

History

#8900, eff 7-1-07; ss by #10210, eff 12-1-12; ss by #10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.09 Value of Total Losses – Other than Motor Vehicle {#sec-ins-1002.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.09}

When the insured's or claimant's property has been determined to be a total loss, and there is no dispute concerning liability or coverage, and the provisions of RSA 407:11 do not apply, insurers attempting to establish the value of the property shall:

(a) Value the property in the community where the total loss property is located;

(b) Be prohibited from using arbitrary methods to establish the value of the property that do not take into consideration the specific characteristics of the property, however, this shall not preclude the insurer from making an offer of settlement on property based upon the fair market value of like kind and quality property wherever situated.

(d) Comply with Ins 1002.18 for every total loss settlement made or offered by the insurer to replace lost or damaged jewelry, watches, precious, or semi-precious stones, under applicable property insurance.

History

#8900, eff 7-1-07; amd by #9495, eff 6-29-09; ss by #10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.10 Insurers Use of Unlicensed Adjusters Prohibited {#sec-ins-1002.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.10}

No insurer shall employ or otherwise utilize the services of an adjuster unless that adjuster has complied with all the appropriate licensing provisions of RSA 402-B or has been granted a temporary license pursuant to RSA 402-B:11, however, any claim adjusted to the satisfaction of an insurer and the insured or claimant by an unlicensed adjuster shall bind the insurer.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.11 Communications With Claims Department {#sec-ins-1002.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.11}

To facilitate communication, every insurer shall provide a toll-free telephone number on all forms or correspondence, and if it chooses to do so, a facsimile number and/or e-mail address whereby the insured or claimant can contact the company claims office, independent adjuster, or appraiser handling the particular claim.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.12 Other Insurer Responsibilities {#sec-ins-1002.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.12}

(a) Prior to concluding that there is no coverage for the loss as a result of the insured's failure to comply with any obligation imposed on the insured under the policy, the insurer shall:

(1) Establish that the breach was a material breach that excuses the insurer from performance under the insurance policy; and

(2) Document the basis for concluding that the breach is material in the claim file.

(b) An insurer shall not refuse to make an evaluation of the insured's liability in any claim because the insured requests that the insurer not make a claim payment for a reported loss.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.13 Loss of Use {#sec-ins-1002.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.13}

In all motor vehicle property damage liability claims when liability has become clear the insurer shall immediately inform the claimant that coverage exists for the rental of a motor vehicle that is of like kind and quality for the time period necessary for repair, provided however that the insurer:

(a) Not be required to provide coverage for that portion of the motor vehicle rental that the insurer establishes is required due to an unreasonable delay in the repair caused by the direct action or inaction of the claimant.

(b) Document the basis for the finding of unreasonable delay pursuant to (a) above in the claim file.

(c) Be able to deduct the costs that would have been incurred in the operation of the claimant's own motor vehicle from the total costs of renting and operating the rented motor vehicle. If the claimant does not have insurance coverage as required by the rental company, the insurer shall pay the reasonable cost of the required coverage.

(d) Specifically document the claim file with evidence to show that a rental was offered to the claimant.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.14 Estimates {#sec-ins-1002.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.14}

The insured or claimant shall only be responsible for the cost of one damage estimate for motor vehicle property damage liability and collision and comprehensive claims. The insurer shall be responsible for any charge incurred by the insured or claimant for any subsequent damage estimates required by the insurer.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.15 Determining {#sec-ins-1002.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.15}

Amount of Motor Vehicle Total Loss Claims.

(a) In adjusting motor vehicle total loss property damage liability and collision and comprehensive damage claims for actual cash value, insurers shall determine total losses consistent with the RSA 261:22, VI standards and settlements based upon the motor vehicle’s fair market value using one of the following methods:

(1) The fair market value derived from the application of a methodology that the department accepts as a statistically valid method of establishing fair market value in the local market area; or

(2) The fair market value derived from documented sales costs of no fewer than 2 motor vehicles of the same make, model, and year as the total loss motor vehicle that have occurred within the previous 90 days within the local market area. If documented sales costs information of a motor vehicle of the same make, model, and year as the total loss motor vehicle is unavailable, then the insurer shall use:

a. Documented sales costs of no fewer than 2 motor vehicles of like, kind, and quality that have occurred within the previous 90 days within the local market area; or

b. An average sales price derived from written quotations for a motor vehicle that is the same make, model, and year as the total loss motor vehicle, obtained by the insurer from at least 2 different licensed dealerships located within the local market area, that engage in the buying and selling of motor vehicles of like kind and quality in the ordinary

course of their business.

(b) The following deviations from the valuation methods in (a)(1) through (a)(2) shall be permitted:

(1) For construction equipment as defined in RSA 259:42 and commercial motor vehicles as defined in RSA 259:12-e, data may be collected from outside the local market area but only to the extent necessary to obtain sufficient data as required in (a)(1) through (a)(2) above; and

(2) If the insurer can demonstrate that the motor vehicle is a make or model vehicle not customarily found in the local market area, data may be collected from outside the local market area but only to the extent necessary to obtain sufficient data as required in (a)(1) through (a)(2) above.

(c) If the insured or claimant disagrees with the value derived from (a) through (b) above and can demonstrate that disagreement by presenting to the insurer, within 20 days of receipt of the settlement payment, evidence from 2 reliable sources that the motor vehicle would have a higher fair market value in the local market area or deviation under (b) than the settlement payment, then the insurer shall recalculate a new fair market value considering this reliable evidence in determining a revised total loss settlement. Reliable evidence shall be limited to the sources listed in (a)(2) or deviation under (b). However, the reliable evidence right of the insured or claimant shall not apply if the insurer included in its documentation at the time of settlement a written notification of the availability and location in the local market area of a specified and comparable vehicle of the same manufacturer, same year, similar body style, and similar options, in as good or better condition as the total loss vehicle, which could have been purchased for an amount equal or less than the fair market value of the total loss vehicle as determined by the insurer. The documentation shall include the vehicle identification number.

(d) In conjunction with a total loss settlement offer, the insurer shall provide to the insured or claimant a report which explains the basis for the valuation underlying the offer.

(e) Fair market value as determined in (a)(1) through (2) above shall be adjusted to reflect motor vehicle condition, mileage, accessories, and options. Insurers shall consider usual and customary documentary preparation fees in determining fair market value.

(f) The insured or claimant has the right to a rental for at least the applicable insurance policy period for insureds or 5 business days after the insurer makes an offer consistent with RSA 417:4, XV(a)(4), whichever is earlier.

(g) If the insured or claimant chooses to keep the motor vehicle, the settlement payment shall be the difference between the total loss value as determined in (a) through (e) above and the salvage value for a motor vehicle of like, kind, and quality. Salvage value shall be calculated based on the salvage value available in the northeast of the United States or upon the salvage value available to the insurer from any salvage facility that is utilized by the insurer in the normal course of the insurer's business. Any costs that the insurer would have incurred for storage or transportation to any salvage facility shall be deducted from the salvage value.

(h) The methodology required by (a)(1) above shall be developed and submitted according to the following:

(1) In order for a methodology to be acceptable, the insurer, or vendor on behalf of the insurer, shall submit to the department a description of its methodology or model accompanied by supporting details. Supporting details shall include a discussion of how the valuation process or model is designed and an analytical or statistical validation of the assumptions, parameters, data elements, and results of the process or model. Any methodology that is not analytically or statistically valid shall be rejected;

(2) The department shall publish a list annually, at the beginning of the calendar year, of accepted valuation guides and methodologies. Insurers shall be required to use one of the department’s accepted methodologies;

(3) If there are any changes made to the process or methodology provided to the department pursuant to (a)(1) above, the insurer or vendor shall provide the department with details as to the changes being made so that the department can determine whether the process or method shall remain on the accepted list; and

(4) Information submitted to the department pursuant to this section shall be:

a. Considered confidential and commercial information under RSA 91-A:5, not subject to disclosure; and

b. Treated as confidential by the commissioner, pursuant to RSA 400-A:25.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15; ss by #13173, eff 4-26-21

N.H. Code Admin. R. Ann. Ins 1002.16 Willing and Able Contractors and Repairers; Other Than Motor Vehicle {#sec-ins-1002.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.16}

(a) Every settlement offer that is based upon an appraisal conducted on behalf of the insurer relative to property and liability insurance shall:

(1) Include a written statement that, if the claimant or insured cannot find a contractor or repairer to do the repair or replace the damage property for the price quoted, then the insured or claimant may request that the insurer supply the insured or claimant with the name and address of any known recognized, competent and conveniently located contractor or repairer who is willing and able to repair or replace the damaged property with other property of like kind and quality within a reasonable time for the price quoted in the appraisal or as otherwise provided for in the insurance policy;

(2) If the insurer provides the insured or claimant with the name of a contractor or repairer as set forth in (a)(1) above, the insurer shall also provide a written disclosure that any contractor or repairer may be used at the discretion of the insured or claimant; and

(3) If the insurer is unable to provide the name of a contractor or repairer upon request, then any fair and reasonable cost incurred to repair or replace the damage as set forth in the appraisal, in excess of the insurer's appraisal price, shall be at the expense of the insurer. If the insurer has provided the insured or claimant with the name of a contractor or repairer who is willing and able to repair or replace the damaged property with other property of like kind and quality within a reasonable time for the price quoted in the appraisal and the insured or claimant uses another contactor or repairer, then any cost in excess of the insurer's appraisal prices shall not be at the expense of the insurer.

(b) The insured or claimant shall be entitled to the usual and customary guarantees as to materials and workmanship relative to the property that is being repaired or replaced.

(c) In processing any claim for damage to a home, dwelling, or other property, the insurer shall not require as a condition to the payment of such claims that repairs be made by a particular contractor or repairer.

(d) Any settlement made based upon an agreement negotiated by an adjuster on behalf of the insurer with a contractor or repairer shall include a provision for coverage of hidden damage that is determined to be connected with the claim in question.

(e) For all claims, insurers and their adjusters, whether hired under contract or employed, shall not make any coercive, threatening, or intimidating statements at any time, orally or in writing, to an insured or claimant for the purpose of influencing the insured’s or claimant's choice of a particular contractor or repairer.

(f) In addition to the above requirements, every settlement made or offered by the insurer to repair or replace damaged jewelry, watches, precious, or semi-precious stones, under applicable property insurance, shall comply with the provisions of Ins 1002.18.

History

#8900, eff 7-1-07; amd by #9495, eff 6-29-09; ss by #10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.17 Willing and Able Repair Facilities; Motor Vehicle Insurance {#sec-ins-1002.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.17}

(a) Every settlement offer that is based upon an appraisal conducted on behalf of the insurer relative to property and liability insurance shall:

(1) Represent the fair and reasonable price in the area charged by repair shops or facilities providing similar services with the usual and customary guarantees as to materials and workmanship;

(2) Include a written statement that the insurer shall supply to the insured or claimant the name and address of a recognized, competent, and conveniently located repair shop or facility who is willing and able to repair or replace the damaged motor vehicle with another of like kind and quality within a reasonable time for the price quoted in the appraisal; and

(3) Include in the written statement a disclosure that any repair shop or facility may be used at the discretion of the insured or claimant.

(b) The insured or claimant shall be entitled to the usual and customary guarantees as to materials and workmanship relative to the motor vehicle that is being repaired or replaced.

(c) If the insurer is unable to provide the name of a repair shop or facility upon request, any additional repair or replacement costs incurred in excess of the insurer’s appraisal price shall be at the expense of the insurer.

(d) In processing any claim for any damage to a motor vehicle, the insurer shall not require as a condition to the payment of such claims, that repairs be made in a particular repair shop or facility.

(e) Insurers specifying the use of after-market parts shall:

(1) Pursuant to RSA 407-D:4, not require the use of after-market parts unless the parts are at least equal in like, kind, and quality to the original part in terms of fit, quality, and performance;

(2) Not require the use of after-market parts unless the insurer states or certifies in writing that the part is of like, kind, and quality; and

(3) Consider the cost of any modifications, re-repairs, or delays that might become necessary when making the repair.

(f) Any settlement made based upon an agreement negotiated by an appraiser or an adjuster on behalf of the insurer with a repair shop or facility shall include a provision providing for coverage of hidden damage that is determined to be connected with the claim in question.

(g) If an independent repair shop or facility and an insurer are unable to agree on a price, and the insurer has complied with (a) through (f) above, then:

(1) The price shall be the price available from any other recognized, competent, and conveniently located independent repair shop or facility that is willing and able to repair the damaged motor vehicle within a reasonable time; and

(2) The insurer shall furnish to the insured or claimant a written statement containing the following disclosure:

“Under New Hampshire law, you are always entitled to use the repair shop or facility of your choice. Unfortunately, we have been unable to agree on price with the facility you have chosen. In this situation, New Hampshire law provides that our payment for repair cost may be limited to the price available from a recognized, competent, and conveniently located independent repair shop or facility that is willing and able to repair the damaged motor vehicle within a reasonable time. You may be responsible for the difference between our payment and the price charged to you by the facility you have chosen. Upon your request, we will furnish a written disclosure of the factual basis for our determination of the fair and reasonable price. If you are our insured and disagree with our determination of the amount of loss, you are entitled to exercise the appraisal provision of your policy."

(h) For all claims, insurers and their appraisers and adjusters, whether hired under contract or employed, shall not make any coercive, threatening, or intimidating statements at any time, orally or in writing, to insureds or claimants for the purpose of influencing the insureds’ or claimants’ choice of repair shop or facility.

History

#8900, eff 7-1-07, EXPIRED: 7-1-15
#10962, eff 10-26-15; ss by #13173, eff 4-26-21

N.H. Code Admin. R. Ann. Ins 1002.18 Additional Requirements, Settlement of Jewelry Claims {#sec-ins-1002.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.18}

(a) In addition to any other requirements set forth in this part, every settlement made or offered by the insurer to replace or repair lost or damaged jewelry, watches, precious, or semi-precious stones, under applicable property insurance, shall also:

(1) Be based upon an appraisal which reflects values of such property of like kind and quality found in the local market area; and

(2) Include a notice to the insured or claimant that they may request an appraisal from an appraiser having no arrangement with the insurer, and of their choosing, in order to receive validation that the insurer's settlement offer reflects a fair market value and that the resulting repaired or replaced property will be of like kind and quality.

(b) If the insurer provides the insured or claimant with the name of the seller or repairer as set forth pursuant to Ins 1002.16 (a)(1), the insurer shall also provide a written disclosure as to the nature of any business arrangement between the insurer and the seller or repairer.

History

#9495, eff 6-29-09, EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.19 Miscellaneous Provisions {#sec-ins-1002.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.19}

(a) Pursuant to RSA 412:8, III, an insurer shall not apply an insured's collision deductible when the damage is:

(1) Caused by an uninsured motor vehicle;

(2) The operator of the uninsured motor vehicle has been positively identified; and

(3) The operator of the uninsured motor vehicle is solely at fault.

(b) Every insurer shall exercise due diligence in determining whether the requirements in (a) above have been met and shall make payment of the collision deductible as soon as practicable and not later than 30 days from the determination.

(c) Every insurer shall exercise due diligence in the pursuit of subrogation on behalf of the insured. Upon receipt of the final subrogation recovery, the insurer shall return the insured’s portion as soon as practical but not later than 30 days from receipt of the final recovery.

History

#8900, eff 7-1-07; renumbered by #9495 (from Ins 1002.18), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.20 Insurer Documentation {#sec-ins-1002.20 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.20}

Every insurer shall maintain in its files, in either written or electronic form, physical evidence of compliance with all of the provisions of this part and RSA 400-B.

History

#8900, eff 7-1-07; renumbered by #9495 (from Ins 1002.19), EXPIRED: 7-1-15
#10962, eff 10-26-15

N.H. Code Admin. R. Ann. Ins 1002.21 Penalty {#sec-ins-1002.21 omnilex-key=us-nh-regs-official--agency-ins--Ins 1002.21}

Any insurer or representative thereof who shall knowingly violate any provision of this part shall be subject to the provisions of RSA 400-A:15, III.

APPENDIX

RULE

SPECIFIC STATE OR FEDERAL STATUTE THE RULE IMPLEMENTS

Ins 1001.01

RSA 400-A:15, I.; 417:4, XV.

Ins 1001.02

RSA 400-A:15, I; RSA 417:3; RSA 417:4, XV

Ins 1001.03

RSA 400-A:15, I.; 417:4, XV.; 417:4, XVII.

Ins 1001.04

RSA 400-A:15, I.; 407:12-a; 417:4, XV.

Ins 1001.05

RSA 400-A:15, I; RSA 417:3

Ins 1001.06

RSA 400-A:15, I.; 417:4, XV.

Ins 1001.07

RSA 400-A:15, I.; 412:12

Ins 1001.08

RSA 400-A:15, I.; 402-B

Ins 1001.09

RSA 400-A:15, I.; 417:4, XVII.

Ins 1001.10

RSA 400-A:15, I.; 417:4, XV.

Ins 1001.11

RSA 400-A:15, I.; 417:6; 417:10

Ins 1002.01

RSA 400-A:15, I; RSA 412:3, XI; RSA 417:4, XV

Ins 1002.02

RSA 400-A:15, I.

Ins 1002.03

RSA 400-A:15, I.; 417:4, XV.; 417:4, XVII.

Ins 1002.04

RSA 400-A:15, I.; 417:4, XV.; 417:4, XVII.

Ins 1002.05

RSA 400-A:15, I.; 407:12; 417:4, XV.; 417:4, XVII.

Ins 1002.06

RSA 400-A:15, I.; 407:15; 417:4, XV.

Ins 1002.07

RSA 400-A:15, I.; 407:12-a; 417:4, XV.

Ins 1002.08

RSA 400-A:15, I..; 417:4, XV. (a)(10)

Ins 1002.09

RSA 400-A:15, I.; 407:11; 417:4, XV.

Ins 1002.09 (d)

RSA 400-A:15, I.; 417:4 XVII

Ins 1002.10

RSA 400-A:15, I.; 402-B

Ins 1002.11

RSA 400-A:15, I.; 417:4, XVII.

Ins 1002.12

RSA 400-A:15, I.; 417:4, XV.; 417:4, XVII.

Ins 1002.13

RSA 400-A:15, I.; 417:4, XV.

Ins 1002.14

RSA 400-A:15, I.; 417:4, XV.

Ins 1002.15

RSA 400-A:15, I; RSA 417:4, XV and XX

Ins 1002.16

RSA 400-A:15, I.; 407:12

Ins 1002.16 (f)

RSA 400-A:15, I.; 407:12

Ins 1002.17

RSA 400-A:15, I; RSA 407-D:3; RSA 407:3-a; RSA 407-D:4; RSA 417:4, XX

Ins 1002.18

RSA 400-A:15, I.; 417:4, XV.

Ins 1002.19

RSA 400-A:15, I.; 412:8, III

Ins 1002.20

RSA 400-A:15, I.; 417-A:11

Ins 1002.21

RSA 400-A:15, I.; 400-B

History

#8900, eff 7-1-07; renumbered by #9495 (from Ins 1002.20), EXPIRED: 7-1-15
#10962, eff 10-26-15

Chapter Ins 1100 Confidentiality of Hiv Tests

Part Ins 1101 Purpose and Scope

N.H. Code Admin. R. Ann. Ins 1101.01 Purpose {#sec-ins-1101.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1101.01}

The purpose of this chapter is to establish rules whereby all human immunodeficiency virus test results and records pertaining to such test results are maintained as confidential and be protected against inadvertent or unwarranted intrusion. This chapter also gives effect to the charge given the insurance commissioner by RSA 417:4, XIX(f), which is to adopt rules relative to recordkeeping designed to maintain the confidentiality of an individual tested by an insurer or other person subject to this part and to prescribe rules relative to access to such records and the conditions of such access.

History

#4583, eff 1-24-89; ss by #5650, eff 7-1-93; ss by #6953, eff 3-1-99, ss by #8826, eff 3-1-07, EXPIRED: 3-1-15
#10866, eff 7-1-15; ss by #14512, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 1101.02 Scope {#sec-ins-1101.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1101.02}

This chapter shall apply to all insurers, their producers, and any other person engaged in the business of insurance in this state who requires an individual applying for insurance or for any increased or additional insurance benefits to be tested for an antibody or antigen to a human immunodeficiency virus.

History

#4583, eff 1-24-89; ss by #5650, eff 7-1-93; ss by #6953, eff 3-1-99, ss by #8826, eff 3-1-07, EXPIRED: 3-1-15
#10866, eff 7-1-15; ss by #14512, eff 2-7-26, EXPIRES: 2-7-36

Part Ins 1102 Definitions

N.H. Code Admin. R. Ann. Ins 1102.01 Definitions {#sec-ins-1102.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1102.01}

(a) "Antibody" means a protein produced by the body in response to specific foreign substances such as bacteria or viruses.

(b) "Antigen" means a substance that stimulates the production of antibodies.

(c) "Human immunodeficiency virus" (HIV) means the virus, or its variants, which are the causative agents of acquired immune deficiency syndrome (AIDS), AIDS related conditions (ARC), and other clinical manifestations.

(d) "Insurer" means any person as defined in RSA 417:2, I included in or subject to Title XXXVII of the New Hampshire Revised Statutes Annotated. The term includes any health service corporation, and any health maintenance organization, as well as the producers of any insurer, health service corporation, or health maintenance organization.

(e) “Medical Information Bureau (MIB)” means a membership association of insurance companies, or any similar entity, which acts as a clearinghouse for confidential data on insurance applicants.

(f) “Positive test result” means the presence in an individual, as detected by laboratory testing, of an antibody or antigen to the human immunodeficiency virus.

History

#6953, eff 3-1-99 (formerly Ins 1101.03), ss by #8826, eff 3-1-07, EXPIRED: 3-1-15
#10866, eff 7-1-15; ss by #14512, eff 2-7-26, EXPIRES: 2-7-36

Part Ins 1103 Maintaining the Confidentiality of and Protecting the Privacy of Human Immunodeficiency Virus Test Results

(a) No insurer shall test any individual in connection with an application for insurance or for any increased or additional benefits for the presence of an antibody or antigen to a human immunodeficiency virus unless such individual gives written consent on a form created by the commissioner of health and human services and approved by the insurance commissioner pursuant to RSA 417:4, XIX(a).

(b) Insurers shall use the approved “HIV Antibody Testing Consent Form” the requirements of which are found in (d) below and is attached hereto as Appendix A when requesting receipt of an applicant’s HIV Antibody test results as part of the insurance application process.

(c) Insurers shall not use any form to obtain the consent required by (a), above, other than one that meets the requirements of (d), below.

(d) Insurers may add their own name, address, logo, and form number to the consent form, but the form shall include the following text and signatures exactly as they appear below:

“HIV Antibody Testing Consent Form

The insurance company to which you have applied may request a blood, urine or oral fluid sample from you for testing. One test will be to detect the presence of antibodies to the Human Immunodeficency Virus (HIV). HIV is the virus which causes Acquired Immune Deficiency Syndrome (AIDS). The New Hampshire Unfair Insurance Trade Practices Act (RSA 417) provides for an insurance company to test for the presence of an antibody or antigen to HIV only upon your written consent. The results of this test may determine your eligibility to acquire insurance. By signing this form you have consented to the HIV test and the reporting of the test results to the insurance company taking your application. Positive test results will not be disclosed except as authorized by you in writing. Negative and indeterminate (inconclusive) test results may be disclosed to reinsurers, contractually retained medical personnel and insurance affiliates or subsidiaries that are involved in necessary underwriting decisions regarding your application. The insurance company and any other party receiving the negative or indeterminate tests results will maintain the results of your HIV antibody test as confidential.

If your test results indicate the presence of antibodies to HIV or if your test results cannot be accurately determined, the insurance company will report a “nonspecific abnormality” to the Medical Information Bureau or any similar entity, if the insurance company reports these test results to third parties. The Medical Information Bureau contains the names and computerized medical records of insurance applicants nationally. The report will not identify you as having an abnormal HIV antibody test because many abnormalities are reported to the Bureau under the same classification.

The HIV antibody test is extremely accurate. However, in rare instances the test may be positive in persons who are not infected with the virus. Additionally, the test may occasionally be negative in persons who are infected with HIV (a false negative). If your HIV antibody test is positive, it does not mean that you have AIDS. A positive test indicates that you have been infected with HIV. It also means that HIV is present in your body fluids (such as blood, semen, vaginal secretions) and that you could infect other people through sexual contact, by sharing intravenous needles, by having a baby, or by donating blood, semen or body organs. Persons who have a positive HIV antibody test should see a physician as soon as possible. A negative test result indicates that no antibodies to the HIV virus were found. Absence of HIV antibodies does not mean that you have not been infected with the virus. Nor does absence of HIV antibodies mean that you are immune to the virus.

Public health authorities urge that everyone become educated about how to protect themselves from HIV infection. If you have questions, please consult your own physician or contact the Centers for Disease Control and Prevention at 1-800-232-4636 or visit their website at http://www.cdc.gov/hiv/default.html/.

The insurance company will notify you if your test results are positive or if your results cannot be accurately determined. At your request, the company will also send your results to a physician or other person. You should request that your results be sent to your private physician so that he/she can interpret them for you. In the event of a positive or indeterminate test result, I authorize disclosure to the following physician or other person or entity:

Name of Physician or other person/entity

Street Address

City State ZIP

Informed Consent

I have read and understand this information. I voluntarily consent to provide a sample of my blood, urine or oral fluid, the testing of that blood, urine or oral fluid and the disclosure of the test results as described above.

Proposed Insured Date of birth

Signature of Proposed Insured Date Signed State of Residence

Signature of Witness”

History

#6953, eff 3-1-99 (formerly Ins 1101.04); ss by #8826, eff 3-1-07, EXPIRED: 3-1-15
#10866, eff 7-1-15; amd by #12411, eff 10-27-17; ss by #14512, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 1103.02 Confidentiality and Disclosure of Test Results {#sec-ins-1103.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1103.02}

(a) All information in the possession of or available to an insurer regarding the results of any test for the human immunodeficiency virus shall be maintained as confidential information and shall be protected against inadvertent or unwarranted intrusion. The insurer shall take all necessary measures to maintain and assure the confidentiality and privacy of an individual applicant's test results.

(b) Insurers shall establish written policies and procedures to govern the internal dissemination of test results among their officers, employees, and producers. These policies and procedures shall be designed to assure compliance with the duties imposed by (a) above. Such policies and procedures shall also be designed to assure that only those officers, employees, or producers of the company whose official duties establish a definite, operational need for information regarding test results shall have access to such information.

(c) With respect to positive test results, each insurer's policies and procedures established in order to comply with (b) above shall:

(1) State that laboratory reports shall be routinely received from the laboratory only by the company physician(s), designated underwriting executive(s), or both retained or employed by the company;

(2) State that the company physician(s), designated underwriting executives(s), or both that were authorized to initially receive the report shall designate who shall see each report on a strict "need-to-know" basis;

(3) State that each referral of a file shall be documented;

(4) Be distributed to all persons with access to positive test results:

a. Upon adoption of the policy; and

b. If an employee is hired after the date of adoption, at the time such employee is hired; and

(5) Contain a statement about specific penalties to be enforced for willful or negligent abuse of its requirements.

(d) Each insurer currently engaged in the business of life insurance or health insurance shall submit a copy of its written policies and procedures designed to safeguard the confidentiality of human immunodeficiency virus test results to the insurance commissioner for review. Filings shall be made each time the insurer makes a change to such policies or procedures. Insurers authorized to do life or health insurance business but who are not currently engaged in either shall submit a statement to that effect.

(e) An insurer may disclose any test result, other than a positive test result, to its reinsurers, contractually retained medical personnel, laboratories, and insurance affiliates. However, such disclosure shall only be made if, and to the extent that, it is necessary to the making of underwriting decisions regarding the particular individual's application. Under no circumstances shall any such disclosure be made to the producers of the insurer.

(f) The insurer shall not submit positive test results to the MIB in any way that would identify a particular individual applicant as having had a positive test result for the human immunodeficiency virus. If an individual has a positive test result, the insurer may disclose to the MIB that the individual had an abnormal laboratory test, but shall not disclose the type of test, which was abnormal.

(g) Each insurer shall maintain data enabling it to report the number of New Hampshire applicants for insurance tested for antibodies or antigens to the human immunodeficiency virus and the number of such applicants denied insurance as a result of such test results. This information shall be made available to the insurance commissioner upon request.

(h) In the event of a positive test result, an insurer shall disclose the positive test result only to the individual tested or to such other person or entity as authorized in the approved consent form by the individual tested.

(i) Disclosure to the individual tested shall include the following language prominently displayed:

“A positive test result means that HIV is present in your body fluids (such as blood, semen, vaginal secretions) and that you could infect other people through sexual contact, by sharing intravenous needles, by having a baby, or by donating blood, semen or body organs. Persons who have a positive HIV antibody test should see a physician as soon as possible and refrain from close personal contact with other persons.”

(j) Test result information obtained by subpoena or any other method of discovery shall not be released or made public outside of the proceedings for which the information was obtained.

History

#6953, eff 3-1-99 (formerly Ins 1101.05); ss by #8826, eff 3-1-07, EXPIRED: 3-1-15
#10866, eff 7-1-15; ss by #14512, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 1103.03 Penalties {#sec-ins-1103.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1103.03}

Any insurer, producer, or any other person violating any of the provisions of this chapter shall be subject to the penalties provided in RSA 400-A:15, III.

History

#6953, eff 3-1-99 (formerly Ins 1101.07); ss by #8826, eff 3-1-07, EXPIRED: 3-1-15
#10866, eff 7-1-15; ss by #14512, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 1103.04 Disclosure to the Department of Health and Human Services {#sec-ins-1103.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1103.04}

Nothing in this chapter shall be construed to prohibit physicians, laboratory officials, hospital officials, or other health providers from reporting laboratory test results or other medical information on persons diagnosed with HIV and AIDS infection to the New Hampshire department of health and human services as provided under RSA 141-C:7.

APPENDIX A

State of New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301

HIV Antibody Testing Consent Form

Name of Physician or other person/entity

Street Address

City State ZIP

Informed Consent

Proposed Insured Date of birth

Signature of Proposed Insured Date Signed State of Residence

Signature of Witness

APPENDIX B

Rule

Statute

Ins 1101.01

RSA 400-A:15, I; RSA 417:4, XIX

Ins 1101.02

RSA 400-A:15, I; RSA 417:4, XIX

Ins 1102.01

RSA 400-A:15, I; RSA 417:2, I;RSA 417:4, XIX

Ins 1103.01

RSA 400-A:15, I; RSA 417:4, XIX

Ins 1103.02

RSA 400-A:15, I; RSA 417:4, XIX

Ins 1103.03

RSA 400-A;15, I; RSA 417:4, XIX

Ins 1103.04

RSA 400-A:15, I; RSA 417:4, XIX

History

#6953, eff 3-1-99 (formerly Ins 1101.06); ss by #8826, eff 3-1-07, EXPIRED: 3-1-15
#10866, eff 7-1-15; ss by #14512, eff 2-7-26, EXPIRES: 2-7-36

Chapter Ins 1200 Credit Insurance

Part Ins 1201 Credit Life and Credit Accident and Health Insurance

N.H. Code Admin. R. Ann. Ins 1201.01 Purpose {#sec-ins-1201.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.01}

(a) The purpose of this part is to protect the interests of debtors and the public in this state by providing a system of rate, policy form, and operating standards for the transaction of credit life and credit accident and health insurance.

(b) Creditors of various types participate in the marketing of credit insurance. Where this is the case, credit insurance is an incidental part of the credit transaction. The debtor constitutes a captive prospect for insurance and is frequently ill-equipped and poorly situated to judge whether the insurance offered by the creditor is reasonably priced. If the charge for the insurance is passed on to the debtor, as is usually the case, it would be to the advantage of creditors for them to seek to have the insurer charge premium rates in excess of those which would prevail were creditors charged with a fiduciary responsibility to seek out low cost credit insurance for their customers. This is because such creditors are able to recoup substantially all of the excess through administrative allowances, dividends, experience refunds, and other arrangements. Further, the larger the premium, the greater the finance charge added to it. In such a market climate, the need for premium rate regulation in credit insurance is apparent. In addition, the inferior position of the debtor requires that all other aspects of credit insurance be closely supervised.

(c) Credit insurance premium rate standards set forth in this part are designed to assure debtors that such insurance will be freely available at reasonable cost, to maintain a relationship between benefits and premiums consistent with other kinds of insurance sold in this state, and to provide reasonable compensation to the creditor.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.02 Scope {#sec-ins-1201.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.02}

(a) This part shall apply to all life insurance and accident and health insurance, whether group or individual, sold in connection with loans or other credit transactions, except such insurance sold in connection with:

(1) A loan or other credit transaction of more than 15 years' duration;

(2) A first real estate mortgage; or

(3) A loan secured by a filing under the Uniform Commercial Code pursuant to RSA 477:44, IV.

(b) The scope of this part shall be identical to that of RSA 408-A as stated in RSA 408-A:2.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; amd by #3196, eff 2-5-86; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.03 Definitions {#sec-ins-1201.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.03}

(a) "Account" means the aggregate credit life insurance or credit accident and health insurance coverage for a single plan of benefits and for a single class of business written through a single creditor.

(b) "Actual premium rate (APR)" means, with respect to each class of business and each plan of benefits, the maximum premium rate permitted to be charged by any insurer writing credit insurance in this state, whether it be new or renewed business, unless a rate deviation has been approved by the commissioner pursuant to Ins 1201.13.

(c) "Actual premium rate factor (APRF)" means the factor resulting when the actual premium rate for any plan of benefits or any class of business as determined pursuant to this part is divided by the corresponding nominal rate for the same plan of benefits as shown under Ins 1201.08 or Ins 1201.09.

(d) "Average number of life years" means the average number of group certificates or individual policies in force during the experience period, without regard to multiple coverage, times the number of years in the experience period for which experience is shown, or an equivalent calculation.

(e) "Calendar year" means January 1 through December 31.

(f) "Class of business" means any of the following:

(1) Credit unions;

(2) Commercial and savings banks;

(3) Finance companies;

(4) Motor vehicle dealers;

(5) Other sales finance; and

(6) Any other creditor.

(g) "Commissioner" means “commissioner” as defined in RSA 408-A:2, III(f), namely the insurance commissioner of the state of New Hampshire.

(h) "Credibility factor" means the extent to which the past experience of any given block of credit insurance business can be expected to recur in the future, and is found by reference to the credibility table as shown in Table 1200-1.

(i) "Credit insurance" means both credit life and credit accident and health insurance, as defined in RSA 408-A:2, III(a).

(j) "Creditor" means “creditor” as defined in RSA 408-A:2, III(c).

(k) “Critical period coverage” means accident and health coverage where the insurance coverage benefit period is stated as a period certain not necessarily coterminous with the remaining term of a loan.

(l) "Debtor" means “debtor” as defined in RSA 408-A:2, III(d).

(m) "Earned premiums" means actual earned premiums, that is, the premiums earned at the premium rates actually charged and in force during the experience period in accordance with the instructions and method of calculation for reporting on Form A or Form B.

(n) "Experience" means collectively all items of data which are shown on or reported on Form A or Form B as found on either a single Form A or Form B or any combination of the data from some or all Form A's and Form B's received.

(o) "Experience period" means, as of the date an annual experience report is due pursuant to Ins 1201.11, the 3 most recently completed calendar years.

(p) "Experience year" means any one of the 3 calendar years included in an experience period.

(q) "Form A" means the credit insurer annual experience report described in Ins 1201.12(a).

(r) "Form B" means the credit insurer annual experience report described in Ins 1201.12(b).

(s) "Incurred claim count" means the number of claims incurred during the experience period.

(t) “Incurred claims" means total claims paid during the experience period, adjusted for the change in the unreported claims and the claim reserve in accordance with the instructions and method of calculation for reporting on Form A or Form B.

(u) "Indebtedness" means “indebtedness” as defined in RSA 408-A:2, III(e).

(v) "Investment income" means the earnings derived from premium reserves arising out of single premiums charged the debtor.

(w) "Nominal rates" means those rates not adjusted by actual premium rate factors.

(x) "Plan of insurance" means:

(1) Credit life insurance for each combination of:

a. Single or joint lives;

b. Single or outstanding balance premiums; and

c. Decreasing or level coverage; and

(2) Credit accident and health insurance for each combination of:

a. Single or joint lives;

b. Single or outstanding balance premiums;

c. Waiting period; and

d. Retroactive or nonretroactive.

(y) “Policy year” means the 12-month period beginning on a policy’s anniversary date.

(z) “Pro rata method” means a method using the ratio of the number of months remaining in the term of coverage to the total number of months of coverage.

(aa) “Pure premium method” means the method used to calculate premium refunds for credit accident and health insurance described in Ins 1201.05(c).

(ab) “Rule of 78” means the method used to calculate premium refunds for credit life insurance described in Ins 1201.05(b).

(ac) "Target loss ratio (TLR)" means the standard used to establish the reasonableness of the relationship between benefits paid and premiums collected by an insurer.

(ad) “Truncated gross indebtedness” means that the insurance coverage is based on the sum total of the payments necessary to amortize the loan and includes both principal and interest.

(ae) “Truncated net indebtedness” means that the insurance coverage is based on the amount necessary to satisfy the loan obligation at any specific point in time.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.04 Rights and Treatment of Debtors {#sec-ins-1201.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.04}

(a) Limits on the amounts of credit life insurance and credit accident and health insurance permitted by statute shall be as stated in RSA 408-A:4.

(b) If a creditor makes available to the debtors more than one plan of credit life insurance or more than one plan of credit accident and health insurance, each debtor shall be informed of all such plans applicable to the type of loan or transaction involving that debtor.

(c) When a creditor requires credit life insurance, credit accident and health insurance, or both, as additional security for an indebtedness, the debtor shall be given the option of furnishing the required amount of insurance through existing policies of insurance owned or controlled by him or her or procuring and furnishing the required coverage through any insurer authorized to transact insurance business in this state. If this paragraph is applicable, the debtor shall be informed by the creditor of his or her right to provide alternative coverage before the transaction is completed.

(d) All credit insurance claims shall be processed in accordance with RSA 408-A:10.

(e) Termination of coverage shall be conducted as follows:

(1) If a debtor is covered by a group credit insurance policy providing for the payment of single premiums to the insurer, then provision shall be made by the insurer that in the event of termination of the policy for any reason, insurance coverage with respect to any debtor insured under such policy shall be continued for the entire period for which the single premium has been paid, subject to the debtor's right to cancel the insurance at any time by express action and subject to individual terminations as set forth in (i) and (j) below; or

(2) If a debtor is covered by a group credit insurance policy providing for the payment of premiums to the insurer on a monthly outstanding balance basis, then the policy shall provide that, in the event of termination of such policy for whatever reason, the insured debtor shall be notified that coverage will continue for 30 days from the date of notice, except where replacement of the coverage by the same or another insurer in the same or greater amount takes place without lapse of coverage; and

(3) The notice required in subparagraph (e)(2) shall be given by the insurer or, at the option of the insurer, by the creditor.

(f) If the creditor adds identifiable insurance charges or premiums for credit insurance to the indebtedness, and any direct or indirect finance, carrying, credit, or service charge is made to the debtor on such insurance charges or premiums, the creditor shall remit and the insurer shall collect such premium within 60 days after it is added to the indebtedness.

(g) If the indebtedness is discharged due to renewal or refinancing prior to the scheduled maturity date, the insurance in force shall be terminated before any new insurance may be issued in connection with the renewed or refinanced indebtedness. In all cases of such termination prior to scheduled maturity, a refund shall be paid or credited to the debtor as provided in Ins 1201.04(i) below. In any renewal or refinancing of the indebtedness, the effective date of the coverage as respects any policy provision shall be deemed to be the first date on which the debtor became insured under the policy covering the indebtedness which was renewed or refinanced, at least to the extent of the amount and term of the indebtedness outstanding at the time of renewal and refinancing of the debt.

(h) A provision in a policy or certificate that sets a maximum limit on total payments shall apply only to that policy or certificate.

(i) If a debtor prepays his or her indebtedness other than as a result of his or her death or through a lump sum disability payment, the following shall apply:

(1) Any credit life insurance covering such indebtedness shall be terminated, and an appropriate refund of the credit life insurance premium shall be paid to the debtor in accordance with Ins 1201.05;

(2) Any credit accident and health insurance covering such indebtedness shall be terminated, and an appropriate refund of the credit accident and health insurance premium shall be paid to the debtor in accordance with Ins 1201.05;

(3) If a claim under such coverage is in progress at the time of prepayment, the policy shall not terminate until the claim terminates, therefore such claim shall continue as if there had been no prepayment, but payment of the refund may be delayed until the claim terminates;

(4) The amount of refund may be determined as if the prepayment did not occur until the payment of benefits terminates;

(5) No refund shall have to be paid during any period of disability for which credit accident and health benefits are payable as the policy shall not terminate until such benefits are no longer payable; and

(6) A refund shall be computed as if prepayment occurred at the end of the disability period.

(j) If an indebtedness is prepaid by the proceeds of a credit life insurance policy covering the debtor or by a lump sum payment of a disability claim under a credit accident and health insurance policy covering the debtor, then it shall be the responsibility of the insurer to see that the following refunds are paid to the insured debtor, if living, or the beneficiary, other than the creditor, named by the debtor or to the debtor's estate:

(1) In the case of prepayment by the proceeds of a credit life insurance policy or by the proceeds of a lump sum total and permanent disability benefit under credit life coverage, an appropriate refund of the credit accident and health insurance premium in accordance with Ins 1201.05;

(2) In the case of prepayment by a lump sum disability claim, an appropriate refund of credit life insurance premium in accordance with Ins 1201.05; and

(3) In either case, the amount of the benefits in excess of the amount required to repay the indebtedness after crediting any unearned interest or finance charges.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; amd by #3196, eff 2-5-86; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.05 Premium Refunds {#sec-ins-1201.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.05}

(a) In the event of termination of the insurance prior to the scheduled maturity date of the indebtedness, other than as a result of the death of the insured, a refund of the unearned insurance premium or charge without any deduction whatsoever shall be made or credited promptly to the debtor in accordance with the methods in (b) through (h) below.

(b) In the case of all credit life insurance which decreases uniformly so as to cover the scheduled indebtedness at any time during the term of the indebtedness, the following method, known as the "rule of 78", shall apply:

(1) The refund shall be calculated as the product of the original premium times the ratio of

(2) Where “t” means the number of months remaining under the terms of the coverage; and

(3) Where “n” means the total number of coverage months.

(c) In the case of credit accident and health insurance, the following method, known as the “pure premium" method, shall apply. The refund under this method shall be computed as the premium which would have been charged for such insurance at the time originally purchased except for the amount of the total remaining benefits and for the remaining term of the indebtedness outstanding at the date of termination.

(d) As an alternative to the pure premium method, an insurer may elect for a particular account or accounts to refund an amount equal to the average of the refunds computed by the “rule of 78" method and the pro rata method. If this alternative method is elected, all refunds thereafter shall be calculated consistent with this alternative method.

(e) In the case of level credit life insurance, the refund shall be determined by the pro rata method.

(f) Under methods (a) through (e) above, if 16 days or more of a loan month have been earned, the refund may be computed from the end of the loan month provided that, if 15 days or less of a loan month have been earned, the refund is computed from the beginning of the loan month. Alternatively, the refund for partial months of coverage may be computed on a pro rata basis.

(g) No refund of $1.00 or less shall have to be made.

(h) Credit insurance policies and group certificates shall specify the method that will be used to compute refunds for each plan of insurance provided by the policy or group certificate. Compliance with the above requirement shall be considered to fulfill the requirements in RSA 408-A that refund formulas be filed with the commissioner where either the rule of 78, the pro rata, or the pure premium method is in use.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

(a) Credit life and credit accident and health insurance shall be issued only in forms described in RSA 408-A:3.

(b) All policy forms, certificates of insurance, notices of proposed insurance, applications for insurance, endorsements, and riders to be delivered or issued for delivery in this state and the schedules of premium rates pertaining thereto shall be filed with the commissioner as required by RSA 408-A:7 and RSA 408-A:8. All filings under this part shall be accompanied by supporting information which establishes that the rates to be used conform to the standards of reasonableness set forth in Ins 1201.07.

(1) To the extent that such procedures are not inconsistent with RSA 408-A:7, credit insurance forms which are required to be filed with the commissioner as indicated in (b) above shall be submitted in accordance with the procedures specified in Ins 401.04. Such submissions shall further comply with all other applicable provisions of Ins 401 which are not inconsistent with this part;

(2) Certificates of insurance to be delivered in this state under group policies issued in other states shall be filed with the commissioner and the premium rates to be used shall be filed with and approved by the commissioner as set forth in this part;

(3) Insurers using rates that do not exceed the actual premium rates established by this part as shown in Table 1200-2 shall satisfy the requirements of RSA 408-A:7 with respect to the filing of premium rates by:

a. Submitting to the commissioner for his or her approval a complete table of such premium rates; or

b. Submitting a written statement signed by an authorized official certifying that the premium rates to be used by the insurer will not exceed the actual premium rates shown in Ins 1201.18; and

(4) Insurers who wish to use premium rates that will exceed the actual premium rates shown in Ins 1201.18 shall file such premium rates in accordance with the procedures shown in Ins 1201.13.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; amd by #4369, eff 3-1-88; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.07 Determination of Reasonableness of Premiums in Relation to Benefits {#sec-ins-1201.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.07}

(a) Under RSA 408-A, premiums charged for credit insurance shall not be excessive in relation to benefits provided. This requirement shall be deemed to be satisfied if the premium rates to be charged are no greater than the rates specified in Ins 1201.18 and where the benefits provided correspond to those described in Ins 1201.08(c) and (d) or Ins 1201.09(d) and (e).

(b) If any insurer files for approval any form providing coverage which varies from that for which nominal rates are specified in Ins 1201.08 and Ins 1201.09, the insurer shall demonstrate to the commissioner that:

(1) The premium rates to be charged for such coverage are derived from actuarial assumptions equivalent to or consistent with the actuarial assumptions from which the closest comparable nominal rates were derived; and

(2) Such premium rates can be expected to produce a loss ratio not less than the appropriate target loss ratio defined in Ins 1201.03.

(c) If no specific charge is made to the debtor for credit insurance, the rate standards set forth in (a) and (b) above shall not be required to be used. For purposes of this paragraph, it shall be considered that the debtor is charged a specific amount for insurance if an identifiable charge for insurance is disclosed in the credit or other instrument furnished the debtor which sets out the financial elements of the credit transactions, or if there is a differential in finance, interest, service, or other similar charge made to debtors who are in like circumstances, except for their insured or non-insured status.

(d) With respect to either credit life or credit accident and health insurance, if the creditor pays premiums on the single premium basis, and if the interest or finance charge in a credit transaction is computed on an amount which does not include the identifiable charge for such credit insurance, such identifiable charge shall be computed as follows:

(1) Use the formulas in Ins 1201.08(b)(2) and Ins 1201.09(b)(1), eliminating from such formulas the expression:

(2) Then multiply such altered nominal rate by the appropriate actual premium rate factor specified in Ins 1201.18.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; amd by #4369, eff 3-1-88; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.08 Nominal Rates for Credit Life Insurance {#sec-ins-1201.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.08}

(a) The premium rates in (b) below shall be used to determine the single lives credit life insurance earned premiums at the nominal rate level which are to be reported by each insurer pursuant to Ins 1201.11.

(b) Where the insured portion of an indebtedness is repayable in equal monthly installments, the nominal premium rate for credit life insurance shall be as set forth in (1) and (2) below while subparagraphs (3) through (6) below shall apply to premium rates for other types of benefits either alone or in combination with the type of benefits applicable to (1) and (2) below:

(1) If premiums are payable on a monthly outstanding balance basis, the nominal rate shall be $.74 per month per $1000 of outstanding indebtedness;

(2) If premiums are payable on a single premium basis, the nominal rates stated under subparagraph (1) above shall be used to compute nominal single premium rates as the present value of the coverage cost as if the decreasing coverage was provided on an outstanding monthly balance basis throughout the term of coverage, as in the following formulae:

a. Where the coverage is provided on a gross indebtedness basis:

b. Where the coverage is provided on a truncated gross indebtedness basis:

c. Where the coverage is provided on a net indebtedness basis:

d. Where the coverage is provided on a truncated net indebtedness basis:

e. Where “SPn” and “t SPn” mean “single premium rate” per $100 of initial indebtedness repayable in “n” equal monthly installments;

f. Where “OP” means The nominal monthly outstanding “balance premium rate” per $1,000;

g. Where “n” means “original repayment period”, in months;

h. Where “” means the present value at an interest rate of i for n monthly payments of $1.00, first payable at the end of the month;

i. Where “i” means 1%, or the equivalent monthly compound interest rate associated with the covered loan; and

j. Where “t” means the coverage period in months;

(3) The nominal rate for level term life insurance shall be $.74 per month per $1000 if premiums are payable on a monthly outstanding balance basis;

(4) If level term life insurance premiums are payable on a single premium basis, they shall be calculated as the present value of the coverage cost as if the level coverage was provided on an outstanding monthly basis throughout the term of coverage, as in the following formula:

b. Where “LSPn” means “single premium rate” per $100 of initial indebtedness;

c. Where “” means the present value at 1/2% per month of n monthly payments of $1.00, first payable immediately;

d. Where “n” means the term of insurance, in months; and

e. Where “OP” means $.74 per month per $1000;

(5) A combination of the appropriate nominal rate for level term and the appropriate nominal rate for decreasing term, with equal decrements, shall be used if the coverage provided is a combination of level term and decreasing term, with equal decrements; and

(6) If the benefits provided are other than those described in subparagraphs (1) through (5) above, the nominal rate for the benefits that are provided shall be the actuarial equivalent of the nominal rates stated in or determined by the above subparagraphs, (1) through (5).

(c) The premium rates in paragraph (b) above shall apply to policies providing credit life insurance to be issued with or without evidence of insurability, to be offered to all debtors of a creditor.

(d) The premium rates in paragraph (b) above shall contain:

(1) No exclusions other than suicide within one year of the incurred indebtedness; and

(2) Either no age restrictions or age restrictions that are no less favorable to insured debtors than age restrictions making ineligible for coverage debtors 65 or over at the time indebtedness is incurred or debtors having attained age 66 or over on the maturity date of the indebtedness.

(e) An insurer may require that a debtor be actively-at-work at the time the indebtedness is incurred in order to be eligible for insurance.

(f) If premiums are to be determined according to the age of the insured debtor or by age brackets, the nominal rates for each age or age bracket shall be derived by adjustments in the appropriate nominal rate stated in Ins 1201.08(b)(1) through(6) above so that the nominal rates arrived at will be actuarially consistent with the nominal rates set out in subsection (b)(1) through (6). All such rates shall be filed with and shall be approved by the commissioner, if actuarially consistent according to generally accepted actuarial principles, prior to use.

(g) The premium rates for joint lives credit life insurance earned premiums at the nominal rate level shall be calculated by multiplying the single lives credit life insurance earned premiums by a factor of 1.55.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.09 Nominal Rates for Credit Accident and Health Insurance {#sec-ins-1201.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.09}

(a) The premium rates in (b) below shall be used to determine the single lives credit accident and health insurance earned premiums at the nominal rate level which are to be reported by each insurer pursuant to Ins 1201.11.

(b) The nominal credit accident and health insurance premium rates for the insured portion of an indebtedness repayable in equal installments shall be as set forth in (1) and (2) below for the benefits described in paragraph (e) below:

(1) If premiums are payable on a single premium basis, the nominal premium rates shall be calculated as follows:

a. Where the benefit period is coterminous with the remaining loan term, the nominal rates shall be calculated as the present value of the claim costs plus an allowance for administrative costs as in the following formula:

b. For critical period coverage, the nominal premium rates shall be calculated by multiplying the single premium calculated in a. above by the ratio of single claim costs for the critical period and the term of the loan as indicated by the following formula:

c. Where “SPn” and “CPSPn” mean the nominal single premium for $100 of initial insured indebtedness;

d. Where “SSCen” and “SSCeCP” mean the single claim cost per $100 initial insured indebtedness from the two-table “Credit Accident and Health Morbidity Study, 1968 NAIC Proceedings, Volume II, p. 638” and “1970 NAIC Proceedings, Volume I, p. 332”, incorporated herein, for retroactive or non-retroactive coverage as the case may be, with an elimination period of "e" and a loan term of “n”;

e. Where “n” means the term of the indebtedness in months; and

f. Where “e” means the elimination period, either 14 or 30 days; and

(2) If premiums are paid on the basis of a premium rate per month per $1000 of outstanding indebtedness, the nominal monthly outstanding balance premium rate shall be calculated as the amount that would amortize the single premium rate over the term of coverage, as in the following formula:

b. Where “SPn” means the nominal single premium per $100 of initial insured indebtedness repayable in n equal monthly installments;

c. Where “OPn” means the nominal monthly outstanding balance premium per $1000; and

d. Where “n” means the original repayment period in months.

(c) If the insurance provided is a different form of coverage than the forms of coverage for which appropriate nominal rates are specified in paragraph (a) above, other methods of determining nominal premium rates for such different forms of credit accident and health insurance may be used provided the resulting rates shall be actuarially consistent in the aggregate with the nominal premium rates determined by (a)(1) above.

(d) The nominal premium rates determined by paragraphs (a) and (b) shall apply to policies providing credit accident and health insurance that is offered to all debtors, which is to be issued with or without evidence of insurability.

(e) The nominal premium rate referenced in (c) above shall contain:

(1) A definition of disability no more restrictive during the first year of disability than requiring that the insured debtor be unable to perform the substantial duties of his or her occupation, and, thereafter, the substantial duties of any occupation for which the insured is reasonably fitted by education, training, or experience;

(2) No provisions excluding or denying a claim for disability resulting from pre-existing conditions except for those conditions manifesting themselves to the insured debtor by requiring medical treatment or diagnosis within 6 months preceding the effective date of the debtor's coverage and which caused loss within 6 months following the effective date of coverage;

(3) No other provision which excludes or restricts liability in the event of disability caused in a specified manner except that it may contain provisions excluding or restricting coverage in the event of pregnancy, intentionally self-inflicted injuries, and flight in non-scheduled aircraft;

(4) No age restrictions or only age restrictions that are no less favorable to the insured debtors than age restrictions making ineligible for coverage debtors 65 or over at the time the indebtedness is incurred or debtors who will have attained age 66 or over on the maturity date of the indebtedness;

(5) A daily benefit equal in amount to 1/30 of the scheduled monthly payments on the indebtedness; and

(6) No actively-at-work test that requires that the debtor be employed more than 30 hours per week.

(f) Subparagraph (e)(1) shall not apply to lump sum disability coverage.

(g) If premiums are to be determined according to the age of the insured debtor or by age brackets, the nominal rates for each age or age bracket shall be derived by adjustments in the appropriate nominal rate stated in Ins 1201.08(b) through (d) above so that the nominal rates arrived at shall be actuarially consistent with the nominal rates set out in paragraphs (b) or (c) above.

(h) All such rates in (g) above shall be filed with and approved by the commissioner, if actuarially consistent, prior to use.

(i) The premium rates for joint lives credit accident and health insurance earned premiums at the nominal rate level shall be calculated by multiplying the single lives credit accident and health insurance premiums by a factor of 1.64.

(j) Insurers may use a rate for the nominal monthly outstanding balance premium rate that is independent of the term of the loan.

(k) In calculating a rate that is independent of the loan term, the insurer shall:

(1) Calculate the rate as the weighted average of the prescribed nominal monthly outstanding balance premium rates;

(2) Use the outstanding principal amounts as weights; and

(3) Demonstrate that this composite term premium rate is revenue neutral compared to the term specific rates otherwise prescribed.

(l) Insurers may use an alternative rate development methodology for calculating nominal monthly outstanding balance premium rates that are independent of the term of the loan, with the commissioner's approval, provided that such rates are actuarially equivalent to the actual premium rates produced by Ins 1201.10.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; amd by #3196, eff 2-5-86; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00; amd by #7789, eff 11-1-02; ss by #9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.10 Actual Premium Rates for Credit Insurance {#sec-ins-1201.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.10}

(a) The actual premium rates applicable upon the effective date of this part shall be those shown in Ins 1201.19. Unless a rate deviation has been granted, beginning on the effective date of this part, it shall be unlawful for any insurer to issue any new business with premium rates that exceed the actual premium rates shown in Table 1200-2. With respect to any group credit insurance policy issued before the effective date of this part, the premium rates charged under such policy shall not exceed the actual premium rates shown in Table 1200-2 beginning with the first anniversary date of such policy occurring on or after the effective date of this part, unless a rate deviation has been approved with respect to such policy for an effective date on or after the effective date of this part.

(b) When there is a change in the actual premium rate for any plan of benefits of any class of business, the new actual premium rate table is to be produced by multiplying the corresponding table of nominal rates by the "actual premium rate factor."

(c) For the purposes of this part, the credibility factor may be based on either the number of claims incurred, the "average number of life years," or these 2 items combined. When reporting its experience for any experience period, an insurer may report credibility data, showing either "claim count" or "life year" data. If "claim count" or "life year" data is not available, reasonable methods of approximation may be used until such data is developed.

(d) The credibility table, cited as table 1200-1, shall be as follows:

Table 1200-1 Credibility Table

Average Number of Life Years

Credit Life

Credit Accident and Health Plans Retroactive and Nonretroactive

Incurred Claim Count

Credibility Factor

Waiting Periods

7 Day

14 Day

30 Day

.00

1,800

141

209

.25

2,400

126

188

279

.30

3,000

158

234

349

.35

3,600

189

281

419

.40

4,600

242

359

535

.45

5,600

295

438

651

.50

6,600

347

516

767

.55

7,600

400

594

884

.60

9,600

505

750

1,116

.65

11,600

611

906

1,349

.70

14,600

768

1,141

1,698

.75

17,600

926

l,375

2,047

.80

20,600

1,084

1,609

2,395

103

.85

25,600

1,347

2,000

2,977

128

.90

30,600

1,611

2,391

3,558

153

.95

40,000

2,106

3,125

4,651

200

1.00

(e) The above integral numbers in table 1200-1 represent the lower end of the bracket for each “Z” factor as defined in (m)(4)d. below. The upper end shall be one less than the lower end for the next highest Z.

(f) Reasonable methods of approximations may be used in arriving at the amount to be reported on Form A or Form B.

(g) Incurred claim count shall be the total number of claims reported during the experience period, whether paid or in the process of payment plus any incurred but not reported (IBNR) at the end of the experience period less the number of claims incurred but not reported at the beginning of the experience period. If a debtor has been issued more than one certificate for the same plan of insurance, only one claim shall be counted. If a debtor receives disability benefits, only the initial claim payment for that period of disability shall be counted.

(h) If the finance or interest charge is computed on an amount which includes the charge for insurance, a single premium shall be deemed to have been paid, regardless of how the creditor pays premiums to the insurer.

(i) The amount of investment income (I) shall be calculated as the amount of interest that would be earned in one year’s time on a fund equal to the average of the beginning premium reserve and the ending premium reserve, as in the following formula:

(1)

(2) Where “i” means .055;

(3) Where “A” means premium reserve, beginning of period; and

(4) Where “B” means premium reserve, end of period.

(j) The actual premium rates shall be as shown in Ins 1201.19. The commissioner shall determine new actual premium rates for each succeeding biennium which shall continue in effect until amended or repealed.

(k) Any change in actual premium rates implemented by the commissioner shall be promulgated as an amendment to this part pursuant to RSA 541-A. First notice of the commissioner's intent to adopt new actual premium rates shall appear in the register of rulemaking proceedings maintained by the director of legislative services of this state. The commissioner shall issue such notice of new actual premium rates at least 90 days before any such new actual premium rates are to be effective.

(l) In determining new actual premium rates, the commissioner shall analyze the experience data for the most recently completed experience period as reported to him or her by the insurers.

(m) The new actual premium rate factor for each class of business and each plan of benefits shall be derived from the following analyses:

(1) If CLR is less than TLR for credit life insurance or for credit accident and health insurance then the following formula shall apply:

APRF(Allowed) = APRF(Current)*(1-(TLR-CLR));

(2) If CLR is greater than TLR for credit life insurance then the following formula shall apply:

APRF(Allowed) = APRF(Current)(1+1.1(CLR-TLR));

(3) If CLR is greater than TLR for credit accident and health insurance then the following formula shall apply:

APRF(Allowed) = APRF(Current)(1+1.2(CLR-TLR));

(4) The symbols used in the above formulas represent the following:

a. “APRF(Allowed)” means actual premium rate factor allowed by formula;

b. “APRF(Current)” means actual premium rate factor currently approved;

c. “CLR” means the credibility adjusted preliminary loss ratio derived from the formula CLR = Z*(PLR) + (1 –Z)*(TLR);

d. “Z” means the credibility factor appropriate to the experience being considered as obtained from the credibility table;

e. “PLR” means the preliminary loss ratio obtained by dividing the incurred claims by a divisor consisting of the earned premiums plus the investment income; and

f. “TLR” means the target loss ratio of 50 percent for all plans of credit life insurance and 60 percent for all credit accident and health insurance plans.

(n) Before implementing new actual premium rates, the commissioner shall consider the overall impact of the indicated new rates and shall modify the actual formula results so that no modification would result in a rate change in excess of 20 percent.

(o) If the application of the formulas in (m) above produces new actual premium rates that differ from the actual premium rates currently in effect by less than 5 percent, the commissioner shall continue the current actual premium rates that are in use.

(p) Insurers shall be prohibited from charging credit insurance premium rates in excess of the actual premium rates that are in effect unless approval for a rate deviation is obtained from the commissioner. Insurers, at their option, may charge an account a premium rate for credit insurance that is less than the actual premium rate in effect.

(q) Whenever new actual premium rates are adopted by the commissioner, the new actual premium rates shall not be applied to existing group credit insurance policies until the first anniversary date of such policy occurring on or after the effective date of the new actual premium rates. The adoption of new actual premium rates shall not void existing rate deviations approved by the commissioner.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; amd by #3196, eff 2-5-86; ss by #4287, eff 7-1-87; amd by #4369, eff 3-1-88; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.11 Annual Experience Reports {#sec-ins-1201.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.11}

(a) On or before June 1 of each year, each insurer doing credit insurance business in this state during any part of the just completed experience period shall submit its annual experience report.

(b) The reports required by this section shall be submitted on either Form A or Form B. Insurers shall reproduce Forms A and B for use according to their needs.

(c) Form A shall be used to report the experience of all accounts of the insurer except those accounts which are to be reported on Form B as required in (d) below. When Form A is the proper form for reporting, a separate Form A shall be submitted for each plan of benefits written for each class of business. No single Form A submitted shall combine the experience of any 2 or more classes of business or any 2 or more plans of benefits. Following these directions, each insurer shall submit as many forms as is necessary to include all of their experience in the state within the experience period, except that which is to be reported on Form B.

(d) Form B shall be used to report the experience of these accounts of the insurer where any one of the following conditions apply:

(1) An approved rate deviation was applicable to the account throughout or during any part of the just completed experience period;

(2) The current premium rates of the account involve an approved rate deviation; or

(3) The insurer is requesting approval for a proposed rate deviation.

(e) A separate Form B shall be submitted for each account for which a Form B is required pursuant to (d) above. No single Form B, however, shall combine the experience of 2 or more classes of business or any 2 or more plans of benefits.

(f) Each insurer shall restrict the experience reported pursuant to this section to that insurer's experience in this state only.

(g) All individual policy experience shall be reported on a calendar year basis. Group insurance business shall be reported on either a calendar year basis or a policy year basis at the option of the insurer provided the insurer reports on a consistent basis from year to year. Where the insurer reports on a policy year basis, each policy year of experience shall be included in the calendar year during which the policy year ended.

(h) The experience reports submitted pursuant to this section shall not include the experience of those accounts where no identifiable charge for the insurance is made to the debtor.

(i) All reports submitted pursuant to this subsection shall be addressed to the attention of the life, accident, and health division.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; amd by #4369, eff 3-1-88; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.12 Description of Forms A and B {#sec-ins-1201.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.12}

(a) The annual experience report required by Ins 1201.11 above and designated as Form A shall contain the following:

(1) Identification of the class of business reported;

(2) Identification of the plans of benefits offered;

(3) Credibility data for the 3 year experience period reported, including:

a. Number of life years; and

b. Incurred claim count; and

(4) Company experience for the 3 year period reported and totals including:

a. Actual earned premiums at rates in use, including:

Gross premium written;
Refund on termination;
Gross premium written minus refund on termination, identified as net;
Premiums due but unpaid at the beginning of the period;
Premiums due but unpaid at the end of the period;
Premium reserve at the beginning of the period;
Premium reserve at the end of the period; and
Earned premiums, which shall be the final result of the net of gross premium written minus refund on termination, minus premiums due but unpaid at the beginning of the period, plus premiums due but unpaid at the end of the period, plus the result of premium reserve at the beginning of the period minus premium reserve at the end of the period;

b. Incurred claims, including:

Claims paid;
Unreported claims at the beginning of the period;
Unreported claims at the end of the period;
Claim reserve at the beginning of the period;
Claim reserve at the end of the period; and
Incurred claims, which shall be the final result of claims paid minus unreported claims at the beginning of the period, plus unreported claims at the end of the period, plus the result of claim reserve at the beginning of the period minus claim reserve at the end of the period; and

c. Investment income.

(b) The annual experience report required by Ins 1201.11 above and designated as Form B shall contain the following:

(1) Identification of the class of business reported;

(2) Identification of the plans of benefits offered;

(3) Credibility data for the 3 year experience period reported, including:

a. Number of life years; and

b. Incurred claim count;

(4) Company experience for the 3 year period reported and totals including:

a. Actual earned premiums at rates in use, including:

Gross premium written;
Refund on termination;
Gross premium written minus refund on termination, identified as net;
Premiums due but unpaid at the beginning of the period;
Premiums due but unpaid at the end of the period;
Premium reserve at the beginning of the period;
Premium reserve at the end of the period; and
Earned premiums, which is the final result of the net of gross premium written minus refund on termination, minus premiums due but unpaid at the beginning of the period, plus premiums due but unpaid at the end of the period, plus the result of premium reserve at the beginning of the period minus premium reserve at the end of the period;

b. Incurred claims, including:

Claims paid;
Unreported claims at the beginning of the period;
Unreported claims at the end of the period;
Claim reserve at the beginning of the period;
Claim reserve at the end of the period; and
Incurred claims, which is the final result of claims paid minus unreported claims at the beginning of the period, plus unreported claims at the end of the period, plus the result of claim reserve at the beginning of the period minus claim reserve at the end of the period; and

c. Investment income;

(5) Whether the experience in (4) above was included in an experience report filed by the company on Form A; and

(6) If a rate deviation is requested or rate deviation used at any time during the reported experience period, rate calculations, including:

a. Incurred claims from (4)b.6. above;

b. Investment income from (4)c. above;

c. Earned premium from (4)a.8. above;

d. PLR, which shall be the incurred claims divided by the result of investment income plus earned premiums;

e. Credibility factor from Table 1200-1;

f. TLR;

g. CLR;

h. Deviated APRF previously approved;

i. Formula deviated APRF Allowed;

j. The APRF deviation requested; and

k. The proposed effective date of the requested rate deviation.

(c) With respect to the insurer’s credit insurance experience that is to be reported on Form A or Form B, respectively, each company shall submit a separate form for each plan of benefits that is written for each separate class of business.

(d) Form A shall not include any experience reported in the same year on Form B.

(e) Form B shall not include any of the experience reported in the same year on Form A.

(f) For both Form A and Form B, the 3 year reporting period shall be the 3 calendar years preceding the year in which the report is due.

(g) For both Form A and Form B, New Hampshire only experience shall be shown.

(h) Statutory reserves shall not be used on either Form A or Form B in calculating investment income.

(i) The beginning and ending premiums to be reported as required in (a)(4)a.6., (a)(4)a.7., (b)(4)a.6., and (b)(4)a.7. above shall be the unearned premium reserves attributable to single premiums paid.

(j) A list of all applicable accounts shall be attached to both Form A and Form B.

(k) Form A and Form B shall indicate the name and telephone number of the contact person.

(l) Form A and Form B shall be signed and include the title of the person signing and date of signature.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.13 Rate Deviation Procedures {#sec-ins-1201.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.13}

(a) If an insurer desires to use a premium rate or schedule of premium rates that is higher than the actual premium rates established by this part and which are shown in Ins 1201.18, an insurer may at any time file a request for a rate deviation with the commissioner.

(b) Eligibility criteria for rate deviations shall be as follows:

(1) An insurer may request a rate deviation for any one single account or for any combination of single accounts of the insurer;

(2) Insurers who are seeking approval of the third or more rate deviation for an account or accounts having the same plan of benefits within the same class of business, shall include in the rate deviation request a request for a rate deviation based on all of the insurer’s accounts belonging to the class of business and plan of benefits for which a rate deviation has or is being requested. Unless the experience is 100% credible, any rate deviation request where the deviated rate exceeds the calculated deviated rate based on all of the insurer’s accounts belonging to the class of business and plan of benefits for which a rate deviation has or is being requested by more than 25% shall be disapproved;

(3) Rate deviations shall be considered by the commissioner only if the experience reported in support of a requested rate deviation can be assigned a credibility factor of 50 percent or more; and

(4) A rate deviation request shall not be considered if the experience submitted in support of the request covers a period of less than one complete experience year.

(1) Rate deviation requests that are submitted to the commissioner shall be submitted on Form B;

(2) All information and calculations required for Form B shall be completed for rate deviation requests;

(3) As an exception to (1) above, if an insurer desires to request a rate deviation that is based on considerations or methods of calculation other than those contemplated by Form B, the insurer shall advise the commissioner of this intention upon submission of such a deviation request;

(4) In such cases as in (3) above, the insurer shall provide a completed Form B, but may also provide any other data or method of calculation to support its request that the requested rate deviation will or can reasonably be expected to produce the appropriate target loss ratio as defined in Ins 1201.03(ac);

(5) If any part of the experience submitted in support of a requested rate deviation was included in the experience considered by the commissioner in approving any other rate deviation request, the insurer shall also submit a rate deviation request appropriately modified or appropriately adjusted to reflect the proposed bifurcation;

(6) Notwithstanding Ins 1201.11(f), if an insurer desires to request a rate deviation for an account or combination of accounts and where the experience of the account or combination of accounts in this state alone is less than 50 percent credible, the insurer may combine the New Hampshire experience with that of other jurisdictions;

(7) In such cases in (6) above, the commissioner shall give greater weight to New Hampshire experience that is combined with contiguous states as compared to combinations involving broader geographical areas;

(8) When requesting a rate deviation and especially where necessary to establish sufficient credibility, an insurer may include the experience produced by the account with previous insurers;

(9) The procedure in (8) above may also be used with a combination of accounts provided the combination accounts for at least 90% of the earned premiums as the combination of the previous insurers; and

(10) In no event shall the commissioner approve a rate deviation request if any of the supporting experience was obtained from an experience period prior to the most recently completed experience period.

(d) Implementation and use of rate deviations shall be as follows:

(1) Upon the approval of any rate deviation request by the commissioner, the premium rate filing requirements of RSA 408-A:7 which are applicable to said deviated rates shall be deemed to be satisfied;

(2) The commissioner shall have 30 days after the receipt of any rate deviation request to disapprove the request as submitted;

(3) If the commissioner fails to disapprove the deviation requested within 30 days of his or her receipt of the request, the request shall be deemed approved and the insurer may implement the rate deviation beginning on the effective date requested on Form B;

(4) No approved rate deviation shall be implemented prior to the effective date requested on Form B;

(5) The insurer shall notify the commissioner in the event an approved rate deviation is implemented at a date later than the date requested as the effective date on Form B;

(6) The approval for any rate deviation shall automatically expire following the completion of the period of time corresponding to the period of experience in years used to establish support for the rate deviation; and

(7) An insurer may request a continuance of or a new rate by submitting their request at least 30 days before the date upon which approval for any rate deviation expires; however, a rate deviation may not be changed more often than once during any 12-month period.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.14 Supervision of Credit Insurance Operations {#sec-ins-1201.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.14}

(a) Each insurer transacting credit insurance in this state shall conduct a thorough inspection of each creditor with respect to the first year of credit insurance business with such creditor and as often thereafter as is necessary to assure compliance with the insurance laws of this state and rules promulgated by the commissioner.

(b) The inspection required in paragraph (a) shall include but not be limited to:

(1) A determination that proper rate charts and refund charts are being used by the creditor;

(2) A determination that:

a. Insurance charges to debtors are computed on the same or lesser basis as premiums paid to the insurer by the creditor; and

b. Claims paid to the creditor are on the same basis as premiums paid to the insurer;

(3) A determination that upon termination of the insurance other than by death of the insured, the proper refunds of unearned insurance premiums are being made;

(4) A determination that all claims are being filed and properly handled;

(5) A determination that upon death of the insured, the appropriate refunds required under Ins 1201.04(i) are made;

(6) A determination that the creditor, upon request of the debtor for a quotation of the net amount necessary to prepay the debt, includes in the quotation the amount of the applicable unearned insurance premiums which could be required to be refunded; and

(7) A determination that the creditor has established a procedure for handling complaints from debtors concerning credit insurance coverage and a procedure for maintaining records of the complaints received and their disposition.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; amd by #4369, eff 3-1-88; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.15 Prohibited Transactions {#sec-ins-1201.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.15}

(a) The following practices, when engaged in by insurers in connection with the sale or placement of credit insurance, or as an inducement thereto, shall constitute unfair methods of competition and shall be subject to the Unfair Trade Practices Act, RSA 417:

(1) Agreement by an insurer to deposit with a bank or financial institution money or securities of the insurer with the design or intent that the same shall affect or take the place of a deposit of money or securities which otherwise would be required of the creditor by such bank or financial institution as a compensating balance or offsetting deposit for a loan or other advancement; and

(2) Deposit by an insurer of money or securities without interest or at a lesser rate of interest than is currently being paid by the creditor, bank, or financial institution to other depositors of like amounts.

(b) The prohibition in (a)(2) above shall not be construed to prohibit the maintenance by an insurer of such demand deposits or premium deposit accounts as are reasonably necessary for use in the ordinary course of the insurer's business.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.16 Special Rules For Open-End Credit Transactions {#sec-ins-1201.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.16}

(a) The procedures in this section shall govern the sale of credit insurance sold in connection with open-end credit transactions, which are sometimes called revolving charge accounts and similar names. Where not inconsistent, other sections of this part shall also apply to this category of credit insurance.

(b) Coverage may be provided only under group insurance policies.

(d) Disclosure to debtor shall include:

(1) If a certificate of insurance is not furnished to the debtor immediately when the account is opened, a notice of proposed insurance shall be given to the debtor, and a certificate shall be delivered to him or her within 30 days;

(2) The notice, certificate, or both, shall show the effective date of the insurance;

(3) The notice, certificate, or both shall prominently indicate any categories of persons excluded from coverage, or alternately, the rules governing eligibility, and shall further indicate with equal prominence any policy provisions which may cause a claim to be denied; and

(4) The certificate shall describe the disposition of the proceeds of the life insurance upon the debtor's death.

(e) A debtor under an open-end credit agreement may be enrolled only by his or her affirmative, written agreement, if a charge for the insurance is to be made to him or her. If benefits under the plan are to be reduced or if premiums are to be increased, notice of such action shall be given the debtor, and he or she shall be advised as to the manner in which he or she may discontinue the coverage.

(f) The amount of life insurance during any monthly period shall not be less than the amount for which a premium has been paid by the debtor for that period. Any proceeds of a life insurance policy in excess of the amount required to discharge the indebtedness completely shall be paid to the beneficiary named by the debtor, or if none, to his or her estate.

(g) A debtor's insurance may be terminated only as follows:

(1) On the date the debtor requests termination;

(2) On the date the debtor fails to pay the required premium;

(3) On any billing date coinciding with or following attainment of the maximum age;

(4) Upon default by the debtor, as defined in the creditor's rules, provided such rules do not discriminate against individual insured debtors;

(5) Upon termination of the open-end credit agreement; or

(6) Upon termination of the group policy after 30 days' notice to the debtor, unless there is immediate replacement of coverage by another insurer.

(h) The premium rates charged for credit insurance covering open-end credit transactions shall be consistent with the premium rates charged for other forms of credit insurance. The actual premium rates specified in Ins 1201.18 apply to credit insurance covering open-end credit transactions as well as all other forms of credit insurance.

(i) In the event of termination of a debtor's insurance, a pro rata refund of unearned premium, if any, shall be made to the debtor. No refund shall be required if it is less than $1.00.

(j) With respect to credit accident and health insurance, the insurer may include provisions indicating that the pre-existing condition limitations are to apply separately to each advance.

(k) The notice, certificate, or both, in (d)(1) above shall be furnished at least once while the account remains active.

(l) The effective date of the insurance required to be disclosed in the notice and/or certificate in (d)(2) above shall not be later than 30 days after the debtor makes written application for such insurance and agrees to pay the required premium.

History

#1900, eff 1-1-82; ss by #2441, eff 1-1-84; ss by #4287, eff 7-1-87; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.17 Statutory Requirements {#sec-ins-1201.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.17}

Failure to include any statutory provision in this part shall not be construed as a waiver of such provision by the commissioner.

History

#4287, eff 7-1-87; amd by #4369, eff 3-1-88; amd by #5116, eff 7-1-91; ss by #5650, eff 7-1-93, EXPIRED 7-1-99
#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.18 Actual Premium Rates {#sec-ins-1201.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.18}

(a) The actual premium rates, as defined in Ins 1201.03(b), established by this part for credit unions, commercial and savings banks, finance companies, motor vehicle dealers, and other sales finance shall be as set forth in the following table 1200-2:

Table 1200-2 Actual Premium Rates

Credit Unions

Commercial & Savings Banks

Finance Companies

Motor Vehicle Dealers

Other Sales Finance (including non-bank revolving charge accounts)

Actual Premium Rate Factor for All Plans of Credit Life Insurance

.694

1.034

.741

.526

.937

Single Premium Decreasing Credit Life – Single Life Coverage

$.327 per $100 for credit transactions of 12 months in duration

$.488 per $100 for credit transactions of 12 months in duration

$.349 per $100 for credit transactions of 12 months in duration

$.247 per $100 for credit transactions of 12 months in duration

$.441 per $100 for credit transactions of 12 months in duration

Outstanding Balance Decreasing Credit Life – Single Life Coverage

$.514 per $1000 per month

$.765 per $1000 per month

$.549 per $1000 per month

$.389 per $1000 per month

$.694 per $1000 per month

Actual Premium Rate Factor for All Plans of Credit Accident and Health Insurance

.618

.759

1.014

.509

.494

Credit Accident and Health – Single Premium – 14 DAY RETRO

$1.210 per $100 for credit transactions of 12 months in duration

$1.487 per $100 for credit transactions of 12 months in duration

$1.987 per $100 for credit transactions of 12 months in duration

$0.997 per $100 for credit transactions of 12 months in duration

$0.967 per $100 for credit transactions of 12 months in duration

(b) The nominal premium rates shown in Ins 1201.08 or Ins 1201.09 shall be used as the actual premium rates for any class of business not named in the above table.

History

#7146, eff 4-1-00, EXPIRED: 4-1-08
#9611, eff 1-4-10; ss by #12474, eff 2-2-18

N.H. Code Admin. R. Ann. Ins 1201.19 Waiver or Suspension of Rules {#sec-ins-1201.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 1201.19}

(1) Applying the rule provision would cause confusion, or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX A

Rule

Specific State Statute which the Rule Implements

Ins 1201.01

RSA 400-A:15, I; 408-A:1

Ins 1201.02

RSA 400-A:15, I; 408-A:2

Ins 1201.03

RSA 400-A:15, I; 408-A:2

Ins 1201.04

RSA 400-A:15, I; 408-A:4, 408-A:5, 408-A:6; 408-A:8; 408-A:10; 417:4, XVI

Ins 1201.05

RSA 400-A:15, I; 408-A:8; 417:4, XII

Ins 1201.06

RSA 400-A;15, I; 401.04; 408-A:3; 408-A:7

Ins 1201.07

RSA 400-A:15, I; 408-A:7; 408-A:8; 417:4, XII

Ins 1201.08

RSA 400-A:15, I; 408-A:8; 417:4, XII

Ins 1201.09

RSA 400-A:15, I; 408-A:8; 417:4, XII

Ins 1201.10

RSA 400-A;15, I; 408-A:8; 417:4, XII

Ins 1201.11

RSA 400-A;15, I; 408-A:12

Ins 1201.12

RSA 400-A:15, I; 408-A:12

Ins 1201.13

RSA 400-A:15, I; 408-A:8; 417:4, XII

Ins 1201.14

RSA 400-A:15, I; 408-A:6; 408-A:9; 408-A:11; 408-A:12; 417:4, XVI

Ins 1201.15

RSA 400-A:15, I; 408-A:3, 408-A:4; 408-A:5; 408-A:5-a; 408-A:6; 417:4

Ins 1201.16

RSA 400-A:15, I; 417:4, XII, XVI

Ins 1201.17

RSA 400-A:15, I; 408-A:12

Ins 1201.18

RSA 400-A:15, I; 408-A:8; 417:4, XII

Ins 1201.19

RSA 400-A:15, I; 408-A:12

Appendix I

RSA 400-A:15, I; 408-A:12

Appendix II

RSA 400-A:15, I; 408:A:12

APPENDIX I

Form A

CREDIT INSURANCE REPORT

TO THE

State of NEW HAMPSHIRE For the Year ____________ Reporting Company _________________

(to be filed on or before June 1)

Class of Business:

( ) Credit Unions

Plans of Benefits:

( ) Credit Life (Check one item in each of the next three boxes)

( ) Commercial or Savings Bank

( ) Single Premium

( ) Monthly Outstanding Balance

( ) Finance Companies

( ) Single Life

( ) Joint Life

( ) Motor Vehicle Dealers

( ) Decreasing

( ) Level

( ) Other Sales Finance

( ) Credit Accident and Health (Check one item in each of the next three boxes)

( ) Other: ___________

(please specify)

Elimination Period

( ) 14 Day( ) 30 Day

( ) Retroactive

( ) Nonretroactive

( ) Single Premium

( ) Monthly Outstanding Balance

( ) Single Life

( ) Joint Life

( ) Other: ___________

(please specify)

Credibility Data for the Three Year Experience Period:

Number of Life Years: _________________

Incurred Claim Count: _________________

COMPANY EXPERIENCE - STATE ONLY

Calendar Year:

TOTAL

Actual Earned Premiums at Rates in use.

a. Gross Premium Written

b. Refund on Termination

c. Net (a-b)

d. Premiums due but unpaid, beginning of period

e. Premiums due but unpaid, end of period

f. Premium reserve, beginning of period

g. Premium reserve, end of period

h. Earned Premiums (c-d+e+f-g)

Incurred Claims

a. Claims Paid

b. Unreported claims, beginning of period

c. Unreported claims, end of period

d. Claim reserve, beginning of period

e. Claim reserve, end of period

f. Incurred Claims (a-b+c+d-e)

Investment Income
Instructional Notes:

a. With respect to the insurer's credit insurance experience that is to be reported on Form A pursuant to Ins 1201.11, each company is to submit a separate Form A for each plan of benefits that is written for each separate class of business.

b. The Form A should not include any experience reported in the same year under Form B.

c. The calendar years to be shown above are the three calendar years preceding the year in which the report is due.

d. State only experience is to be shown.

e. Investment income for each year is to be calculated according to the formula appearing in Ins 1201.10. The beginning and ending premium reserves to be reported in items 1.f and 1.g. shall be the unearned premium reserves attributable to single premiums paid. Statutory reserves are not to be reported or used in calculating investment income.

f. A list of all accounts is to be attached.

g. Name of person the department can contact: _________________________________

Telephone Number:___________________________________________________

Report completed by: ____________________________________

Title: _________________________________________________

Date: _________________________________________________

h. Send to the attention of the Life, Accident and Health Division.

APPENDIX II

Form B

CREDIT INSURANCE REPORT

TO THE

State of NEW HAMPSHIRE For the Year ____________ Reporting Company _________________

(to be filed on or before June 1)

Class of Business:

( ) Credit Unions

Plans of Benefits:

( ) Credit Life (Check one item in each of the next three boxes)

( ) Commercial or Savings Bank

( ) Single Premium

( ) Monthly Outstanding Balance

( ) Finance Companies

( ) Single Life

( ) Joint Life

( ) Motor Vehicle Dealers

( ) Decreasing

( ) Level

( ) Other Sales Finance

( ) Credit Accident and Health (Check one item in each of the next three boxes)

( ) Other: ___________

(please specify)

Elimination Period

( ) 14 Day( ) 30 Day

( ) Retroactive

( ) Nonretroactive

( ) Single Premium[Life]

( ) Monthly Outstanding Balance

( ) Single Life

( ) Joint Life

( ) Other: ___________

(please specify)

Credibility Data for the Three Year Experience Period:

Number of Life Years: _________________

Incurred Claim Count: _________________

COMPANY EXPERIENCE - STATE ONLY

Calendar Year:

TOTAL

Actual Earned Premiums at Rates in use.

a. Gross Premium Written

b. Refund on Termination

c. Net (a-b)

d. Premiums due but unpaid, beginning of period

e. Premiums due but unpaid, end of period

f. Premium reserve, beginning of period

g. Premium reserve, end of period

h. Earned Premiums (c-d+e+f-g)

Incurred Claims

a. Claims Paid

b. Unreported claims, beginning of period

c. Unreported claims, end of period

d. Claim reserve, beginning of period

e. Claim reserve, end of period

f. Incurred Claims (a-b+c+d-e)

Investment Income
Was the above experience included in any of the experience reported by your company on Form A? (Circle One)

Yes No

Rate calculations (to be completed if a rate deviation is being requested or had been used at any time during the experience period)

a. Incurred Claims

b. Investment Income

c. Earned Premium

d. PLR

e. Credibility factor

f. Target Loss ratio (TLR)

g. CLR

h. Nominal Premium Rate (NPR)

i. Formula Deviated Rate

j. Rate deviation requested

k. Rate Deviation Proposed Effective Date

Instructional Notes:

a. With respect to the insurer's credit insurance experience that is to be reported on Form A pursuant to Ins 1201.11, each company is to submit a separate Form B for each plan of benefits that is written for each separate class of business.

b. The Form B should not include any experience reported in the same year under Form A.

c. The calendar years to be shown above are the three calendar years preceding the year in which the report is due.

d. State only experience is to be shown.

f. A list of all accounts is to be attached.

g. Name of person the department can contact: _________________________________

Telephone Number:___________________________________________________

Report completed by: ____________________________________

Title: _________________________________________________

Date: _________________________________________________

h. Send to the attention of the Life, Accident and Health Division.

History

#12474, eff 2-2-18

Chapter Ins 1300 Producers and Adjusters

Part Ins 1301 Continuing Education General Information

N.H. Code Admin. R. Ann. Ins 1301.01 Purpose {#sec-ins-1301.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1301.01}

and Applicability.

(a) The purpose of this rule is to provide criteria and requirements for continuing education.

(b) This rule shall apply to all:

(1) Resident producers;

(2) Resident adjusters; and

(3) Adjusters who chose New Hampshire as their designated home state as these adjusters shall be considered residents for continuing education purposes of property and casualty insurance, including workers' compensation.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1301.02 Definitions {#sec-ins-1301.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1301.02}

(a) “Adjuster” means:

(1) A public adjuster licensed by the department pursuant to RSA 402-D; and

(2) An insurance claims adjuster licensed by the department pursuant to RSA 402-B.

(b) “Commissioner” means the insurance commissioner of the state of New Hampshire.

(d) “Insurance producer” means an individual licensed by the New Hampshire insurance department pursuant to RSA 402-J.

(e) “Insurer” means an insurance company licensed or authorized to do business in the state of New Hampshire.

(f) “Producer” means insurance producer.

(g) “Self-study course” means a course that can be completed by self-study, independent reading, or online courses.

(h) “Sponsoring organization” means the organization that is preparing and presenting a continuing education program.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

Part Ins 1302 Continuing Educational Requirements for Producers and Adjusters

N.H. Code Admin. R. Ann. Ins 1302.01 Purpose {#sec-ins-1302.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1302.01}

The purpose of this part is to establish requirements and standards for continuing education programs for a person licensed as a:

(a) Resident producer;

(b) Public adjuster; and

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1302.02 Applicability {#sec-ins-1302.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1302.02}

(a) This part shall apply to producers licensed in the following line(s) of insurance:

(1) Life insurance, including annuities;

(2) Variable contracts, including annuities;

(3) Sickness, accident and health insurance; and

(4) All lines of property and casualty insurance.

(b) This part shall apply to persons licensed as:

(1) A public adjuster; and

(2) An insurance claims adjuster.

(c) This part shall not apply to a nonresident holding a producer license in this state and for which an examination is not required by law or rule in their state of domicile, if the nonresident producer’s home state recognizes the satisfaction of this state’s education requirements on the same basis. This part shall not apply to persons engaged in the sale of physical damage only, motor vehicle warranty, travel accident, home warranty, or title insurance.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1302.03 Educational Requirements For Producers {#sec-ins-1302.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1302.03}

(a) Every resident producer seeking renewal of a license shall have satisfactorily completed courses or programs of instruction or attended seminars during the preceding 24 months, no later than 60 days prior to the required renewal date, equivalent to 24 continuing education hours of instruction that have been previously approved by the commissioner pursuant to Ins 1303.

(b) Course certification shall be submitted to the department by the administrator of the department's continuing education programs on behalf of the applicant. However, each applicant shall be responsible for submitting the certification documentation required to be provided to them by Ins 1303.06 for inspection by the commissioner upon request.

(c) The courses or programs of instructions successfully completed with a passing grade deemed to meet the requirements for the biennial period shall be:

(1) Any part of the Life Underwriter Training Council Fellowship LUTCF Designation Program;

(2) Any part of the Chartered Life Underwriter (CLU), Chartered Financial Consultant (ChFC), or Certified Financial Planner (CFP) diploma curriculum;

(3) Completion of any part of the American Institute for Property and Liability Underwriters diploma curriculum;

(4) Any part of the Certified Insurance Counselor diploma program; or

(5) Any part of the Insurance Institute of America diploma curriculum.

(d) Programs or curricula for continuing education credit enumerated in Ins 1302.03(c) shall be subject to the course evaluation criteria and accreditation as required in Ins 1303.03 and Ins 1303.05.

(e) Continuing education credits shall not be given for any course that:

(1) Does not provide at least 50 minutes of classroom instruction for each continuing education credit assigned unless such course is a self-study course as determined by the continuing education council; and

(2) Is duplicated in the same license renewal period.

(f) Of the 24 continuing education hours required in (a) above, at least 3 hours, but no more than 10 hours, shall consist of courses approved for ethics credit.

(g) Successful passage of the state producer licensing exam shall satisfy the ensuing renewal.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1302.04 Educational {#sec-ins-1302.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1302.04}

Requirements for Insurance Claims Adjusters and Public Adjusters.

(a) Every insurance claims adjuster seeking renewal of a license shall, during the preceding 24 months, satisfactorily complete courses or programs of instruction or attend seminars equivalent to 24 continuing education hours of instruction, including a minimum of 3 hours of ethics, that have been approved by the commissioner.

(b) For insurance claims adjusters adjusting workers' compensation claims, of the 24 hours required in (a) above, 10 hours shall inform the licensee of the current workers’ compensation laws of this state, 3 hours of ethics, and the remaining hours shall be in any other preapproved multi-line claims adjusters course of instruction pursuant to Ins 1303.

(c) Every public adjuster seeking renewal of a license shall during the preceding 24 months satisfactorily complete courses or programs of instruction or attend seminars equivalent to 15 continuing education hours of instruction, including 3 hours of ethics, that have been approved by the commissioner pursuant to Ins 1303.

(d) Continuing education credits shall not be given for any course which does not provide at least 50 minutes of classroom instruction for each continuing education credit assigned unless such course is a self-study course.

(e) Successful passage of the state insurance claims adjuster licensing exam shall satisfy the ensuing renewal.

(f) Successful passage of the state public adjuster licensing exam shall satisfy the ensuing renewal.

(g) Continuing education credits shall not be given for duplicative course work in the same renewal period.

(h) Certifications shall be submitted to the department by the administrator of the department's continuing education programs on behalf of the applicant. However, each applicant shall be responsible for submitting the certification documentation required to be provided to them by Ins 1303.06 for inspection by the commissioner upon request.

(i) A nonresident insurance claims adjuster's or public adjuster's satisfaction of their home state's continuing education requirements for licensed insurance claims adjusters or public adjusters shall constitute satisfaction of this state's continuing education requirements if the nonresident insurance claims adjuster's or public adjuster's home state recognizes the satisfaction of its continuing education requirements imposed upon insurance claims adjusters or public adjusters from this state on the same basis.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; amd by #12973, eff 1-13-20; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1302.05 Penalty {#sec-ins-1302.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1302.05}

Any person failing to meet the requirements imposed by this rule and who has not been granted an extension of time within which to comply pursuant to Ins 1305 hereof shall be subject to the provisions of RSA 400-A:15 and Ins 200, as applicable, and no further license shall be issued to such person for any kind or kinds of insurance until such time as such person shall have demonstrated compliance with all the requirements of this part and all other laws applicable thereto.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

Part Ins 1303 Continuing Education Councils, Courses and Aprovals

N.H. Code Admin. R. Ann. Ins 1303.01 Purpose and Applicability {#sec-ins-1303.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1303.01}

(a) The purpose of this part is to establish criteria and membership for the continuing education advisory councils, continuing education courses, and course approvals.

(b) This part shall be applicable to the:

(1) Continuing education advisory councils;

(2) Course sponsoring organizations; and

(3) Students.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1303.02 Continuing Education Advisory Councils {#sec-ins-1303.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1303.02}

(a) There shall be established 2 continuing education advisory councils, as follows:

(1) One council shall be known as the “producers' council” and shall review and approve continuing education courses designated for producers; and

(2) One council shall be known as the “adjusters' council” and shall review and approve continuing education courses designated for adjusters.

(b) Each council shall consist of a total of 6 members engaged in the business of insurance.

(c) All council members shall be appointed by the commissioner and shall serve for a 2 year term. The terms of the current members shall continue until the expiration of their respective terms.

(d) The councils shall meet at least once a year, in-person or virtually, and additionally as required.

(e) The councils shall advise the commissioner on the plans and operation of the continuing education programs established by this part.

(f) For each council, 3 members shall constitute a quorum for the purposes of conducting meetings and making recommendations to the commissioner.

History

#8934, eff 8-1-07; ss by #10862, eff 8-1-15; amd by #12973, eff 1-13-20; ss by #13546, eff 1-31-23; ss by #14508, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 1303.03 Criteria {#sec-ins-1303.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1303.03}

(a) The continuing education advisory councils shall review and evaluate courses submitted for continuing education credit hours and recommend to the commissioner an appropriate number of continuing education hours for each course submitted. The commissioner shall then assign to each course the number of continuing education credit hours. In order to secure review and evaluation of the course by the continuing education advisory councils, submission shall be made at least 45 days prior to commencement of the program.

(b) The course review and evaluation by the continuing education advisory council(s) shall result in a recommendation for approval by the commissioner of an appropriate number of continuing education hours for each complete course submission made, provided the following criteria are met:

(1) A clear and concise statement of purpose, goals, and objectives;

(2) The level of knowledge the participant should obtain upon completion;

(3) Program relevancy;

(4) Contribution to the professional competence of the participant;

(5) Maintenance of records of attendance and successful completion of their program; and

(6) The program’s attempt to assess its effectiveness in accomplishing its purpose, goals, and objectives.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1303.04 Compliance {#sec-ins-1303.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1303.04}

(a) The sponsoring organization shall maintain records of all continuing education hours obtained through the sponsoring organization's programs for 6 years.

(b) Every sponsoring organization shall, on behalf of the successful student, furnish to the administrator of the department's continuing education program written certification as to the courses, programs, or seminars of instruction taken and successfully completed by such person. Such certification shall be executed by or on behalf of the sponsoring organization.

(c) The sponsor shall offer only those courses and curricula that have received properly pre-approved designation pursuant to this part.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1303.05 Course Approval {#sec-ins-1303.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1303.05}

(a) A sponsoring organization applying for continuing education course approval shall submit a course application containing the following:

(1) Name of sponsoring organization;

(2) Title of course;

(3) Course objective;

(4) Major course topic;

(5) Course length;

(6) States that have approved the course;

(7) Type of course;

(8) Teaching method;

(9) Method of evaluation;

(10) Method to verify attendance;

(11) Description of permanent records; and

(12) Name of contact person.

(b) No continuing education course or program for continuing education credit shall be conducted until the course or program has been approved by the commissioner.

(c) No course completion certificate shall be issued until the sponsor has complied with all provisions of Ins 1303.03 and Ins 1303.05.

(d) Any sponsor who fails to meet the requirements of this section or fails to comply with these rules shall not have their courses approved and no further accreditation shall be issued to such sponsor for any course or program until such time as such sponsor shall have demonstrated compliance with all the requirements of these rules and all other laws applicable thereto.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1303.06 Course Completion Certificate {#sec-ins-1303.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1303.06}

Each sponsoring organization shall provide to each student a course completion certificate for each course receiving continuing education credit containing the following:

(a) Sponsoring organization;

(b) Course number;

(d) Date of course;

(e) Total continuing education hours;

(f) Name of student; and

(g) Certification by sponsoring organization.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1303.07 Continuing Education Course List {#sec-ins-1303.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1303.07}

(a) It shall be the responsibility of the student to ascertain the approved status of a course or program being offered.

(b) Credit shall not be given to any student who completes an unapproved course or program.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

Part Ins 1304 One Time Flood Insurance Training Requirement

N.H. Code Admin. R. Ann. Ins 1304.01 Purpose {#sec-ins-1304.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1304.01}

The purpose of this part is to establish requirements for flood insurance education training for a resident individual person licensed as a producer with property and casualty line of authority with an effective date on or after January 1, 2008.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1304.02 Applicability {#sec-ins-1304.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1304.02}

This part shall apply to all licensed resident individual producers with property and casualty line of authority whether or not they have attempted to place, have placed, or intend to place flood insurance through the National Flood Insurance Program (NFIP).

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1304.03 Educational Requirements {#sec-ins-1304.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1304.03}

(a) Notwithstanding any other requirement in this chapter, each individual producer who is issued a property and casualty line of authority on or after January 1, 2008, and in accordance with RSA 402-J shall complete a basic flood insurance course approved by the department pursuant to Part Ins 1303.

(b) Courses satisfying this part shall be:

(1) Listed on the department's list of approved continuing education courses; and

(2) Identified with the prefix “FEMA”.

(c) This educational requirement shall be completed within one calendar year of the effective date of the property and casualty line of authority.

(d) The producer, upon course completion, shall:

(1) Retain the completion certificate indefinitely; and

(2) Produce the certificate for inspection at the commissioner's request.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

N.H. Code Admin. R. Ann. Ins 1304.04 Penalty {#sec-ins-1304.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1304.04}

A resident individual producer failing to meet the requirements of this part shall be subject to the penalty provisions of Ins 1302.05.

History

(See Revision Note at chapter heading for Ins 1300) #8934, eff 8-1-07; ss by #10862, eff 8-1-15; ss by #13546, eff 1-31-23

Part Ins 1305 Waiver of Rules

N.H. Code Admin. R. Ann. Ins 1305.01 Waiver of Rules {#sec-ins-1305.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1305.01}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) Waivers that are granted shall be in effect for the period of time requested and approved by the

commissioner.

APPENDIX

Rule

Statute

Ins 1301.01

RSA 400-A:15, I; 402-B; 402-D; 402-J

Ins 1301.02

RSA 400-A:15, I; 402-D:2; 402-J:2

Ins 1302.01

RSA 400-A:15, I; 402-B:5-a; 402-D:4-a

Ins 1302.02

RSA 400-A:15, I; 402-J:16, II

Ins 1302.03

RSA 400-A:15, I; 402-J:7, II

Ins 1302.04

RSA 400-A:15, I; 402-B:5-a; 402-D:4; 402-D:12

Ins 1302.04(a) – (c)

RSA 400-A:15, I; RSA 402-B:5-a; 402-D:12

Ins 1302.05

RSA 400-A:15, I; 402-B:6

Ins 1303.01

RSA 400-A:15, I; 402-B; 402-D; 402-J

Ins 1303.02

RSA 400-A:11; RSA 400-A:15, I; RSA 402-B:6; RSA 402-D:20; RSA 402-J:18

Ins 1303.03

RSA 400-A:11; 400-A:15, I; 402-B:6; 402-D:20; 402-J:18

Ins 1303.04

RSA 400-A:11; 400-A;15, I; 402-B:6; 402-D:20; 402-J:18

Ins 1303.05

RSA 400-A:11, 400-A;15, I; 402-B:6; 402-D:20; 402-J:18

Ins 1303.06

RSA 400-A;11; 400-A;15, I; 402-B:6; 402-D:20; 402-J:18

Ins 1303.07

RSA 400-A:11; 400-A:15, I; 402-B:6; 402-D:20; 402-J:18

Ins 1304.01

RSA 400-A:15, I; 402-J:16; 402-J:18

Ins 1304.02

RSA 400-A;15, I; 402-J:16; 402-J:18

Ins 1304.03

RSA 400-A;15, I; 402-J:16; 402-J:18; 70 FR 52117

Ins 1304.04

RSA 400-A:15, I; 402-J:7; 402-J:12

Ins 1305.01

RSA 400-A;15, I; RSA 541-A:22, IV

History

#12973, eff 1-13-20; ss by #13546, eff 1-31-23

Chapter Ins 1400 Private Passenger Automobile Insurance

Part Ins 1401 Purpose and Scope and Service Requirements for the Voluntary Market and the New Hampshire Automobile Reinsurance Facility

N.H. Code Admin. R. Ann. Ins 1401.01 Purpose {#sec-ins-1401.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1401.01}

The purpose of this chapter is to:

(a) Establish rules and guidelines in order to ensure that primary automobile insurance is readily available to citizens of the state of New Hampshire at rates and premiums which are adequate, reasonable, and not unfairly discriminatory;

(b) Provide rules and structure for the New Hampshire automobile reinsurance facility; and

(c) Ensure all insurers authorized to write automobile insurance in this state issue to any eligible risk a policy of automobile insurance covering private passenger automobiles.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21

N.H. Code Admin. R. Ann. Ins 1401.02 Scope {#sec-ins-1401.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1401.02}

This chapter shall apply to all insurers authorized to write automobile insurance in this state.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21

Part Ins 1402 Service Requirements for the Voluntary Market and the New

N.H. Code Admin. R. Ann. Ins 1402.01 Service {#sec-ins-1402.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1402.01}

(a) All insurers authorized to write automobile insurance in this state shall issue to any eligible risk a policy of automobile insurance covering private passenger automobiles.

(b) Every participating insurer and producer shall provide to any eligible risk seeking automobile insurance covering private passenger automobiles the same level of service regardless of whether the person is or becomes a risk which is ceded to the facility.

(c) The policy shall be of the type afforded by such insurer to the public, and utilizing the premium payment plans, rules, and classification systems then in effect for such insurer, and shall provide the coverages and coverage limits as requested by the insured and as required under the provisions of Ins 1403.03(a).

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21

Part Ins 1403 The Writing of Automobile Insurance in the Voluntary Market

N.H. Code Admin. R. Ann. Ins 1403.01 Purpose {#sec-ins-1403.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1403.01}

This part establishes the rules and guidelines that foster a competitive and dynamic private passenger automobile insurance market with products readily available to residents of the state of New Hampshire at rates and premiums which are adequate, reasonable, and not unfairly discriminatory.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13533, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1403.02 Definitions Applicable to the Voluntary Market {#sec-ins-1403.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1403.02}

(a) “Automobile insurance” means primary insurance, including non-owned vehicle only policies, against bodily injury or property damage, including legal liability, arising out of the ownership, operation, maintenance, or use of motor vehicle(s). The term includes medical payments insurance, physical damage insurance, uninsured motorists insurance, and other related insurance coverage arising out of the ownership, operation, maintenance, or use of motor vehicle(s), but does not include umbrella or excess coverage.

(b) “Commissioner” means the commissioner of insurance.

(c) “Eligible risk” means a person who is a resident of New Hampshire when the policy is issued or renewed or the vehicle to be insured is exclusively garaged in New Hampshire when the policy is issued or renewed.

(d) “Experience period” means the time period of 3 years immediately preceding the effective date of the policy.

(e) “Exposure” means the rating units on which insurance premium is based. For automobile insurance, exposure unit means one car insured for one 12-month period.

(f) “Insurer” means a licensed company, or group of affiliated companies, that are authorized to transact automobile insurance in the state of New Hampshire and, if a group of companies, are affiliated by ownership or contractual relationship encompassing joint operations or processes filed and approved by the commissioner.

(g) “Licensed driver” means any person with an authorized driver’s license or any other license or permit to drive a vehicle issued under the laws of this state, including any temporary or learner’s permit.

(h) “Motor vehicle” means any of the following vehicles:

(1) An automobile;

(2) A pick-up truck, panel truck, or similar type vehicle;

(3) Motorcycle, motorbike, motorscooter, or similar 2-wheel or 3-wheel vehicle;

(4) Off highway recreational vehicles which are registerable under RSA 215-A; or

(5) Motorhomes, meaning a self-propelled motor vehicle with a living area that is an integral part of the vehicle chassis or a pickup with a permanently attached camper body in which the living area or camper body consists of facilities for cooking and sleeping.

(i) “Person” means any natural person, spouse, family member, or any individual with express or implied consent to use a motor vehicle.

(j) “Policy of automobile insurance” means a policy issued with respect to any motor vehicle registered or exclusively garaged in this state, insuring a person as named insured, or one or more related individuals resident of the same household, and under which the insured vehicles therein designated includes a private passenger automobile.

(k) “Policy period” means:

(1) The period of time set forth in the policy itself during which the policy is to remain in effect; or

(2) Twelve months if the policy contains no fixed expiration date.

(l) “Private passenger automobile” means any motor vehicle as defined in (h) above written for personal, family, or household use that is intended for non-commercial coverage.

(m) “Prospective loss cost” means the expected average loss per unit of exposure.

(n) “Rate” means that cost of insurance per exposure unit whether expressed as a single number or as a prospective loss cost with an adjustment to account for the treatment of expenses, profit, and individual insurer variation in loss experience, prior to any application of individual risk variations based on loss or expense considerations. The term does not include minimum premiums.

(o) “Rating plan” means a system by which insurers establish a premium or rate to be charged for insurance coverage.

(p) “Renewal” means the issuance and delivery by an insurer of a policy superseding at the end of the policy period a policy previously issued and delivered by the same insurer and having the types and limits of coverage at least equal to those contained in the policy being superseded.

(q) “Replacement policy” means a policy that a company issues to replace a voluntary policy for the purpose of ceding the insured to the facility or moving the insured to a higher rated company or tier.

(r) “Resident” means a person who is domiciled in the state of New Hampshire and who, through all of his or her actions, has demonstrated a current intent to designate this state as his or her true, fixed, and permanent residence to the exclusion of all others. Resident status shall not be lost by a temporary absence from this state, including but not limited to travel, military service, or being retired, if there is an intent to return to this state as the person’s true, fixed, and permanent residence to the exclusion of all others. Resident includes a person who meets the definition of resident but is without a permanent street address due to homelessness.

(s) “Supplementary rate information” means any manual or plan of rates, classification, rating schedule, minimum premium, policy fee, rating rule, and any other similar information needed to determine an applicable rate in effect or to be in effect.

(t) “Supporting information” means:

(1) The experience and judgment of the filer and the experience or data of other insurers or organizations relied upon by the filer;

(2) The interpretation of any statistical data relied upon by the filer;

(3) A description of methods used in making the rates; and

(4) Other similar information relied upon by the filer.

(u) “Tier” means a level or division of a company's or group’s rating system that will yield a separate and distinct rate for automobile insurance.

(v) “Underwriting guidelines” mean:

(1) Any written mechanism developed as an aid in the selection, placement, or tiering of private passenger automobile risks; and

(2) The portion of the rate classification system submitted to the commissioner pursuant to RSA 412:16.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13533, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1403.03 Voluntary Market Refusal to Write; Refusal to Renew; Cancellation {#sec-ins-1403.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1403.03}

(a) Insurers shall make the same coverage and limits available to each applicant or insured, regardless of tier or company placement, up to the maximum coverage options available in the facility shown under Ins 1406.10(b), unless the insurer's maximum available underlying limits, or reinsurance contracts, preclude it from offering such coverage and limit options. The limits of liability shall not be provided at different amounts within the same policy of automobile insurance unless permitted by RSA 259 or RSA 264.

(b) Insurers shall not claim that suspension or revocation of an insured’s driving privileges are grounds for asserting that coverage has been forfeited under the provisions of RSA 264:3 or cancelled under RSA 417-A:4, when the suspension or revocation can be directly attributed to the insurer’s failure to file the necessary certification in compliance with RSA 264.

(c) Insurers shall establish and maintain a system by which each automobile policy cancellation, other than for nonpayment of premium, and each nonrenewal, other than at the insured’s request, is recorded together with the specific reason for the cancellation or nonrenewal. Cancellation reasons such as “for underwriting reasons” or “does not meet underwriting requirements” are lacking in specificity and shall not be sufficient reasons for compliance with the provisions of RSA 417-A:5.

(d) For the purposes of this section, and to comply with the provisions of RSA 417-A:1, II, if the policy of automobile insurance provides for a policy period of less than 12 months in duration, the policy period means 12 months.

(e) Insurers shall not penalize producers in any way for submitting applications for a policy of automobile insurance to such insurer. A pattern of agency terminations by an insurer shall be deemed evidence of an intent by an insurer to circumvent RSA 417-A:3.

(f) Insurers shall not void or cancel a policy back to its inception date, unless permitted by law.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13533, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1403.04 Movement or Placement of a Policy in the Voluntary Market {#sec-ins-1403.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1403.04}

(a) A new business applicant shall not be placed into a program or tier solely because of any of the factors cited in RSA 417-A:3 and RSA 417:4, VIII(e).

(b) No insurer shall move a policy to a different tier within one company, or from one company to another within a group, which results in a different rate for the insured unless it does so in accordance with its underwriting guidelines filed with the commissioner in accordance with the provisions of RSA 412.

(c) A member of affiliated companies may refuse to write, cancel, or refuse to renew a policy consistent with RSA 417-A and with its filed underwriting guidelines so long as the member provides the applicant or insured with the ability to immediately obtain a policy from another member of the affiliated companies. If the member cancels or refuses to renew, the replacement offer and terms shall be delivered or mailed together with the notice of cancellation or nonrenewal.

(d) The movement of a policy from one company to another within an insurance group or the movement of a policy to a different tier within one company shall be permitted within the first 60 days of the initial policy period if the movement is consistent and in compliance with the company's filed underwriting guidelines. Otherwise such movement shall only occur on the renewal date of the policy and shall require a 45-day written notice of such action to the policyholder. The replacement offer and terms shall be delivered or mailed together with the notice of cancellation or nonrenewal.

(e) The following shall not be used or considered in any rating plan or set of underwriting criteria:

(1) The following occurrences or instances:

a. Where the automobile was lawfully parked. An automobile rolling from a parked position shall be considered unlawfully parked under the operation of the last operator;

b. Where the applicant, other operator residing in the same household, or owner was reimbursed by, or on behalf of, a person responsible for the accident or has a judgment against such person;

c. Where the automobile of an applicant or other operator residing in the same household was struck in its rear by another vehicle, and the applicant or other resident operator has not been convicted of a moving traffic violation connected therewith;

d. Where the operator of the other automobile involved in such accident was convicted of a moving traffic violation, and the applicant or other resident in the same household was not convicted of a moving traffic violation in connection therewith;

e. Where the automobile operated by the applicant or other operator residing in the same household is damaged as a result of contact with a "hit and run" driver, and the applicant or other operator so reports the accident to the proper authority within 24 hours;

f. Accidents involving damage by contact with animals;

g. Accidents involving physical damage limited to and caused by flying gravel, missiles, or falling objects;

h. Accidents occurring as a result of the operation of an automobile in response to an emergency if the operator, at the time of the accident, was responding to a call to duty as a paid or volunteer member of any police or fire department, first aid squad, or of any law enforcement agency but not an accident occurring after the emergency situation ceases or after the private passenger automobile ceases to be used in response to such emergency; or

i. Accidents occurring as a result of the operation of a vehicle by a municipal public works or highway department employee while on official duty but not an accident occurring once the municipal public works or highway department employee is no longer on official duty;

(2) Lack of prior insurance in the following instances:

a. Applicants who were previously listed on a family member’s policy;

b. Applicants who are newly licensed operators;

c. Applicants who have had, within the past 30 days, use of an insured company vehicle; or

d. Applicants who are returning military personnel; or

(3) A requirement of continuous employment.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13533, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1403.05 Evidence of Financial Responsibility {#sec-ins-1403.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1403.05}

The insurer shall protect the driving privileges of its insureds licensed to operate a motor vehicle in the state of New Hampshire. Therefore, upon notice to the insurer that it has become necessary for an insured to file evidence of financial responsibility with the state of New Hampshire, the insurer or producer covering the risk shall provide the insured with evidence of financial responsibility as soon as the insurer or producer becomes aware of the requirement or upon request of the insured.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13533, eff 1-24-23

Part Ins 1404 Voluntary Market Regulation Pertaining to Rates, Rating Plans and Practices

N.H. Code Admin. R. Ann. Ins 1404.01 Rating and Rating Plans {#sec-ins-1404.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1404.01}

(a) Insurers shall establish a system of base rates, risk classifications and accompanying factors, other modifications and factors which can reflect individual characteristics of the insured and coverage choices, and underwriting or tiering rules by which individuals are placed in affiliated companies, marketing tiers, or programs.

(b) The entire rating plan and accompanying rates and factors shall be justified actuarially and filed with the commissioner. If the insurer is relying upon a credit report or insurance scoring system or model as defined in Ins 3300 to underwrite or rate any applicant or person inquiring about insurance, or re-underwrite or re-rate any existing class or subclass of insureds, the insurer shall, before its use on any consumer risk, file the credit scoring system with the commissioner pursuant to all rules stated in Ins 3300.

(1) Schedules of base rates and rates or factors for optional coverage choices;

(2) Risk classification system and accompanying factors, relativities, or charges;

(3) Modification factors, discounts, or surcharges reflective of individual risk experience or behavior;

(4) Pricing algorithms or rating steps used to establish final premium;

(5) Underwriting guidelines to the extent that they differentiate risks, with the result being different rates or premiums charged to one insured compared to another;

(6) Credit scoring mechanisms and scoring models relied upon in underwriting, risk classification, or rating; and

(7) Standards applied to insureds governing placement in affiliated companies within a group, or tiers within a single company, resulting in different rates or premiums being charged for one insured versus another.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21

N.H. Code Admin. R. Ann. Ins 1404.02 Rating Practices {#sec-ins-1404.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1404.02}

(a) Insurance companies shall not make premium changes to an automobile policy during the policy period in the voluntary market other than for the following reasons:

(1) Addition of a new or replacement vehicle;

(2) Addition or deletion of a driver;

(3) Change in garaged location;

(4) Change in coverage;

(5) Change in limits;

(6) Change in use of vehicle;

(7) The insured has attained a new age;

(8) Change in marital status of any listed driver;

(9) The addition of new coverage to a vehicle on the policy or for a replacement vehicle;

(10) Deletion of a vehicle; or

(11) Discovery of convictions or occurrences, which occurred during the current or first prior policy period, resulting in losses incurred or paid.

(b) Changes which occur during the policy period shall be calculated using the rates in effect at the beginning of the policy period.

(c) If premium changes are made during the policy period to reflect changes pursuant to (a)(11) above, they shall be appropriately removed on the same basis during a subsequent policy period.

(d) For the purposes of this section, if the policy of automobile insurance provides for a policy period of less than 12 months, then “policy period” means the period of time set forth in the policy itself.

(e) Insurers shall not rate a person as an operator resident in the same household if the named insured swears in an affidavit that the alleged operator is, in fact, not a resident in the same household. It shall be the responsibility of the named insured to inform their insurance company at renewal if the residency information contained in the affidavit ceases to be correct.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21

N.H. Code Admin. R. Ann. Ins 1404.03 Reflecting Driver Performance {#sec-ins-1404.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1404.03}

(a) Rating systems or rating plans used by insurers shall include means by which insureds are credited with good driving experience or surcharged to reflect certain loss and violation history.

(b) Every insurer shall clearly provide on, or attached to, the renewal notice or declaration page of each policy delivered to the insured an indication that discounts, credits, or surcharges are included in the premium charge. Any insurer unable to provide a listing with sufficient detail showing occurrences and violations which have impacted the premium shall, at a minimum, indicate that the insured may contact the producer or insurer for more specific information.

(c) Insurers shall clearly identify within their filed rating plans and guidelines specifics with respect to the types of violations and occurrences which impact an insured’s premium and the means by which this is accomplished.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21

Part Ins 1405 Record Retention Procedures in the Voluntary Market and the New Hampshire Automobile Reinsurance Facility

N.H. Code Admin. R. Ann. Ins 1405.01 Record Retention Procedures {#sec-ins-1405.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1405.01}

(a) Insurers shall establish a system or procedure that shows the re-tiering of an automobile policy between rating tiers. A cancellation or nonrenewal with concurrent writing of another policy shall be deemed re-tiering for purposes of this rule. Each insurer shall track the re-tiering of an automobile policy for a minimum of the current policy year plus 5 years from the effective date of the current in force policy.

(b) Insurers shall maintain for a period of the current policy year plus 5 years a record retrieval system of all company refusals to write insurance coverage and all company-initiated cancellations and non-renewals of insurance policies and the factual reasons for the refusal to write, cancellation, or non-renewal.

(c) Companies writing insurance in this state shall maintain all underwriting and rating documentation from which any premium charge is developed. Such documentation shall in all cases include the underlying factual basis which supports the premium charge developed, not merely the underwriting or rating conclusion drawn from such facts, and be retained in a manner so that the commissioner can readily ascertain during an examination the insurer's compliance with its filed and approved rates, rating plans, underwriting models, and state insurance laws and rules. These records shall be retained for the current year plus 5 years.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21

Part Ins 1406 Plan of Operation for the New Hampshire Automobile Reinsurance Facility

N.H. Code Admin. R. Ann. Ins 1406.01 Purpose {#sec-ins-1406.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.01}

The purpose of this part is:

(a) To make automobile insurance readily available to citizens of the state of New Hampshire at rates and premiums which are adequate, reasonable, and non-discriminatory by approving and promulgating the plan of operation for the New Hampshire automobile reinsurance facility plan, hereinafter “facility”;

(b) To specify the basis of participation of insurers and producers therein and the conditions under which eligible risks which are equitably entitled but otherwise unable to obtain automobile insurance covering private passenger automobiles shall be accepted by such insurers and producers; and

(c) To provide a comprehensive set of definitions and requirements applicable solely to personal automobile insurance risks eligible for and ceded to the facility.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.02 Definitions {#sec-ins-1406.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.02}

(b) “Car year” means one vehicle insured for one 12-month period.

(c) “Chargeable accident” means, for purposes of placement to the facility and as defined in a facility rate manual, an at-fault occurrence that results in bodily injury in excess of $750.00, death or property damage in excess of $1,500.00, but does not include an occurrence involving only bodily injury or property damage to the applicant or any operator of the automobile currently a resident in the same household, unless the said applicant or operator is convicted of a moving motor vehicle violation in connection with the occurrence.

(d) “Commission allowance” means actual commissions paid to producers or other expenses incurred in lieu of producers' commission.

(e) “Commissioner” means the commissioner of insurance.

(f) “Continuation premium” means the premium that is periodically paid to maintain in-force a policy that is written on a continuous basis.

(g) “Continuous basis” means a policy written on a condition indicating that such policy will be continued, renewed, or considered in-force if the required premium is paid to or received by the insurer on or before a specified date or a policy written on a continuous-until-cancelled basis.

(h) “Continuous-until-cancelled” means a policy issued with no fixed expiration date that remains in-force until cancelled.

(i) “Eligible risk” means a person who is a resident of New Hampshire when the policy is issued or renewed or the person’s vehicle that is to be insured is exclusively garaged in New Hampshire when the policy is issued or renewed and, in either case, the person has at least one safe driver incentive plan (SDIP) point.

(j) “Experience period” means the 3 years immediately preceding the effective date of the policy.

(k) “Facility gross premium” means gross base premium.

(l) “Fleet” means 5 or more motor vehicles of any type.

(m) “Gross base premium” means premium charged to the insured before the application of any SDIP surcharge.

(n) “Licensed driver” means any person with an authorized driver’s license or any other license or permit to drive a vehicle issued under the laws of this state, including any temporary or learner’s permit.

(o) “Member” means an insurer authorized to write automobile insurance in the state of New Hampshire.

(p) “Motor vehicle” means any of the following vehicles:

(1) An automobile;

(2) A pick-up truck, panel truck, or similar type vehicle;

(3) Motorcycle, motorbike, motorscooter, or similar 2-wheel or 3-wheel vehicle;

(4) Off highway recreational vehicles which are registerable under RSA 215-A; or

(q) “New Hampshire automobile reinsurance facility (facility)” means the mandatory risk sharing plan, established pursuant to RSA 404-C:1, to provide a market mechanism for personal automobile insurance for eligible risks.

(r) “Person” means any natural person, spouse, family member, or any individual with express or implied consent to use a motor vehicle.

(s) “Policy of automobile insurance” means a policy issued with respect to any motor vehicle registered or exclusively garaged in this state, insuring a person as named insured, or one or more related individuals resident of the same household, and under which the insured vehicles therein designated includes a private passenger automobile.

(t) “Policy period” means:

(1) That period of time set forth in the policy itself during which the policy is to remain in effect; or

(2) Twelve months if the policy contains no fixed expiration date or if the policy provides for a policy period of less than 12 months in duration.

(u) “Private passenger automobile” means any motor vehicle as defined in (p) above written for personal, family, or household use that is intended for non-commercial coverage.

(v) “Renewal" means the issuance and delivery by an insurer of a policy superseding at the end of the policy period a policy previously issued and delivered by the same insurer and having the types and limits of coverage at least equal to those contained in the policy being superseded.

(w) “Replacement policy” means a policy that a company issues to replace a voluntary policy for the purpose of ceding the insured to the facility.

(x) “Resident” means a person who is domiciled in the state of New Hampshire and who, through all of his or her actions, has demonstrated a current intent to designate this state as his or her true, fixed, and permanent residence to the exclusion of all others. Resident status shall not be lost by a temporary absence from this state, including but not limited to travel, military service, or being retired, if there is an intent to return to this state as the person’s true, fixed, and permanent residence to the exclusion of all others. Resident includes a person who meets the definition of resident but is without a permanent street address due to homelessness.

(y) “Safe Driver Incentive Plan (SDIP)” means the surcharge rating plan used with all policies to develop the surcharge portion of the total policy premium.

(z) “Total policy premium” means the sum of all premiums for all liability and physical damage coverages.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.03 Insurers Required to Participate {#sec-ins-1406.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.03}

All insurers authorized to write automobile insurance in this state and all producers licensed to represent such insurers for automobile insurance in this state shall participate in the facility.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.04 Basis of Participation {#sec-ins-1406.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.04}

(a) All insurers authorized to write automobile insurance in this state shall issue to any eligible risk a policy of automobile insurance covering private passenger automobiles. The policy shall be of the type afforded by such insurer to the public, and utilizing the premium payment plans, rules, and classification systems then in effect for such insurer, and shall provide the coverages and coverage limits as requested by the applicant or insured. However, any policy ceded to the facility shall be charged the approved facility rate and no insurer shall be required to afford coverages or coverage limits in excess of those coverages and coverage limits offered by the facility. Each member of a group of affiliated insurers shall not be considered a separate insurer for purposes of this section.

(b) No producer appointed to represent an insurer shall refuse to furnish to any eligible risk a quotation of premium for automobile insurance covering private passenger automobiles.

(c) If the eligible risk accepts the quotation, the producer shall promptly submit the application to the insurer and shall exercise whatever binding authority is normally available from that insurer.

(d) If the eligible risk accepts the quotation but it is not within the producer’s binding authority, the producer shall promptly submit the application to the insurer and, unless a later effective date is requested by the insured, the coverage shall be bound and effective at 12:01 A.M. on the date following the date of mailing of the application to the insurer as shown by the postmark on the transmittal envelope. If the postmark is not legible, the coverage shall be effective at 12:01 A.M. on the day following receipt of the application by the insurer.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.05 Evidence of Financial Responsibility {#sec-ins-1406.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.05}

The insurer shall protect the driving privileges of its insureds to be licensed to operate a motor vehicle in the state of New Hampshire. Therefore, upon notice to the insurer that it has become necessary for an insured to file evidence of financial responsibility with the state of New Hampshire, the insurer or producer covering the eligible risk shall provide the insured with evidence of financial responsibility as soon as the insurer or producer becomes aware of the requirement or upon request of the insured.

History

(See Revision Note at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.06 Obligation of Members {#sec-ins-1406.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.06}

(a) Every member shall be bound by the plan of operation of the facility.

(b) Any member whose membership in the facility terminates, nevertheless shall continue to be bound by the plan of operation of the facility with respect to its obligations incurred during its membership.

(c) Any unsatisfied net liability to the facility of any insolvent member shall be assumed by and apportioned among the remaining members in the facility in the manner provided in Ins 1406.13. The facility shall have all rights allowed by law on behalf of the remaining members against the estate or funds of such insolvent member for sums due the facility.

(d) When a member has been merged or consolidated into another insurer, or another insurer has reinsured a member's entire New Hampshire automobile insurance business, such member and its successors in interest and such other insurer shall be liable for such member's obligations hereunder.

(e) To ensure the efficient and equitable operation of the facility, the individual members shall not be held liable for any judgment against the facility pursuant to the provisions of RSA 404-C:2, III.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.07 Board of Governors {#sec-ins-1406.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.07}

(a) The commissioner shall appoint a board of governors (board) composed of 12 representatives and nominated as follows:

(1) The merger of the American Insurance Association (AIA) and the Property Casualty Insurers Association of America (PCI) resulted in the formation of the American Property Casualty Insurance Association (APCIA) which shall nominate 4 members;

(2) Insurers which are not members of the organizations enumerated in (1) above shall nominate 2 members;

(3) The 6 members nominated according to (1) and (2) above shall nominate 2 at-large members;

(4) The commissioner shall select one consumer not a member of any of the organizations enumerated in subparagraphs (1) through (3) above;

(5) The commissioner shall select one member who is an employee of the insurance department; and

(6) The commissioner shall select 2 licensed New Hampshire insurance producers.

(b) Not more than one member in a group of companies under common management or control shall be represented on the board at the same time.

(c) The names of the nominees as selected in accordance with (a) above shall be placed in nomination before the commissioner prior to the completion of the terms of the appointees that the nominees are replacing.

(d) Each board representative shall serve for a term of 2 years but may serve succeeding terms if subsequently designated to serve the additional term in the manner provided herein for the initial designation.

(e) All board representatives shall serve until their successors are designated. Any vacancy on the board, by resignation of a representative or otherwise, shall be filled in the manner provided herein for initial designation, but the designee shall serve only for the unexpired portion of the term for which the representative is designated, unless such representative is subsequently appropriately designated to serve an additional term or terms.

(f) Actions of the board shall be binding when voted by a majority of those eligible to vote who are present and voting, and no vote may be taken unless 7 representatives on the board who are eligible to vote on the matter are present. The consumer and insurance department representative on the board shall be eligible to vote on all matters not directly involving the facility's budget or personnel administration.

(g) All board meetings shall be open to members, producers, the commissioner or a person designated by the commissioner, and to the public except upon majority vote of the board when permitted or required by law.

(h) The board shall recommend to the commissioner:

(1) A day-to-day plan of operation to carry out the intent and purpose of the facility;

(2) Appointment or employment of such staff as is necessary to carry out the business of the facility;

(3) Contracts as necessary to provide space, equipment, and services for the facility's purposes;

(4) Appointment of standing or temporary committees from among members and producers;

(5) Assessments as necessary for the operating expenses of the facility;

(6) Apportionment of the underwriting results among the members and the need to levy assessments or make such distributions as are appropriate for such apportionment;

(7) Distribution of an annual report and minutes of board meetings to members and to the commissioner;

(8) Selection at the biennial meeting of a chair, who shall not serve for more than 2 consecutive terms;

(9) Selection at the biennial meeting of a vice chair, who shall:

a. In the absence of the chair, act as the chair; and

b. Not serve for more than 2 consecutive terms; and

(10) Any other action it deems necessary or appropriate for efficient and effective operation of the facility.

(i) The board or its designees shall periodically review the market for automobile insurance throughout the state of New Hampshire to make certain that eligible risks can readily obtain such insurance. Such review shall include a review of any complaints received from the public and from duly licensed producers and addressed to the facility or to the commissioner.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.08 Meetings {#sec-ins-1406.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.08}

(a) There shall be a biennial meeting of the facility in New Hampshire at a date and time designated by the board.

(b) Special meetings of the facility may be called at any time by the chair of the board, and special meetings shall be called by the chair upon the written request of:

(1) The commissioner;

(2) At least 6 board representatives; or

(3) At least 15 members not under the same management and which write at least 25% of the state private passenger automobile insurance premium.

(c) Notice of all biennial and special meetings of the facility shall be given, or caused to be given, by the chair in writing, mailed to or by facsimile, e-mail, electronic transmission, or similar electronic mediums directed to each member at its latest address appearing upon the records of the facility and to the commissioner. Except where otherwise provided in this rule, if notice is mailed, it shall be placed in the mail not less than 10 days prior to the date of the meeting. If notice is given by a generally accepted electronic medium, it shall be given not less than 5 days prior to the meeting.

(d) A quorum at any biennial or special meeting of the facility shall be constituted by those represented by a proxy and those in attendance. A member company shall not appoint more than one company in its class of companies to execute a proxy.

(e) The matters to be considered at any special meeting of the facility shall be only those matters set forth in the notice of such meeting. At biennial meetings, members may consider and act upon all matters properly brought before them, whether or not contained in the notice thereof.

(f) Each member of the facility shall be entitled to one vote at all biennial or special meetings of the facility.

(g) Members may vote by mail on written propositions and such votes shall have the same standing as if cast by such member in person. Such votes shall be kept on file by the facility and shall be made available to the commissioner upon request.

(h) Minutes of all meetings of the facility and of the board shall be sent to all members and to the commissioner. The commissioner shall make copies of the minutes available to the public upon request, pursuant to the provisions of RSA 91-A.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.09 Statistical Data {#sec-ins-1406.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.09}

Each member shall furnish or cause to be furnished such statistics in connection with insurance subject to the facility as required by the board, or commissioner, and each member shall authorize its statistical agent to release any such data as requested by the board. Such statistics shall be furnished when requested by the commissioner.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.10 Cessions {#sec-ins-1406.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.10}

(a) When a policy of insurance is ceded to the facility, a member shall cede all terms and provisions of the policy covering private passenger automobile(s).

(b) Coverages up to the following limits shall be eligible for cession to the facility:

(1) Bodily injury liability $250,000 each person, $500,000 each accident;

(2) Property damage liability $100,000 each accident;

(3) Single limit bodily injury and property damage liability $500,000 each accident;

(4) Medical payments $10,000 each person;

(5) Uninsured motorists at least equal to bodily injury liability limits;

(6) Physical damage, loss of use, or damage to automobiles on an actual cash value basis subject to the policy deductible provisions;

(7) Towing and labor $25 per disablement; and

(8) Any other automobile insurance or limits required by law.

(c) Cessions to the facility with respect to a policy written on business which is new to a member and which is new to the group of insurers under common management or control to which the member belongs shall be as follows:

(1) A policy may be ceded by a member as of the policy effective date, provided the policy meets the cession eligibility requirements and the following criteria:

a. The notice of cession is received by the facility within 20 days after the policy effective date; or

b. The notice of cession is received by the facility from 21 to 60 days after the policy effective date and either:

The company provides documentation to the facility that the policy was ceded as a result of misinformation provided by the insured; or
The company provides documentation to the facility that the policy was originally written as a facility policy, at the facility rate, indicating that the company or producer initially intended to cede the policy. Otherwise, the cession shall be effective on the date the notice of cession is received by the facility;

(2) No loss incurred within the 60-day retroactive period shall be covered by the facility unless the member provides reliable information to the board that the policy was ceded as a result of misinformation provided by the insured not merely because of the loss;

(3) With respect to a policy written on business which is new to a member and which is new to the group of insurers under common management or control to which the member belongs, if any, the premium for such a policy ceded subsequent to the policy effective date shall be the facility premium retroactive to the policy effective date;

(4) Notwithstanding (2) above, if the insured elects not to accept the offer made in the notification of change as required by Ins 1406.10(i), any earned premium charged to the insured shall be at the originally quoted rate, unless the cession or movement to a new company or tier is based upon misinformation provided by the insured;

(5) Any return premium from this cancellation request pursuant to (4) above shall be calculated pro rata and returned within 30 days pursuant to RSA 402:81;

(6) With respect to a replacement policy as defined in Ins 1406.02(w), the cession shall be effective as of the effective date of the replacement policy, provided the notice of cession is received by the facility within 20 days of the replacement policy effective date. Otherwise, the cession shall be effective on the date the notice of cession is received by the facility;

(7) With respect to a renewal policy as defined in Ins 1406.02(v), on the renewal date of an expiring policy, provided written notice is received by the facility before the effective date of the renewal policy. Otherwise, the cession shall be effective on the date written notice is received by the facility;

(8) With respect to a policy ceded at other times, on receipt by the facility of the required notice, but such acceptance shall not be retroactive; and

(9) No renewal policy shall be ceded to the facility unless a 45-day written notice of such action is delivered to the policyholder.

(d) The facility charge for members on ceded policies shall be the facility gross premium less 15 percent facility gross premium and less commission allowance for the cedable limits, regardless of the date of cession, except that a pro rata credit against the charge shall be allowed in the event of cancellation of the policy.

(e) Policies ceded shall remain in the facility until the expiration date or cancellation date of the policy.

(f) No policy shall be ceded to the facility unless such policy has at least one SDIP point. In addition, a motor vehicle report shall be ordered on all licensed members of the household on all policies ceded to the facility as new business and at least every 3 years thereafter on renewal business for the purpose of determining SDIP points.

(g) No policy shall be ceded to the facility solely because of age, place, or area or residence, race, color, creed, national origin, marital status, lawful occupation including military service, or credit information pursuant to RSA 417:4, VIII(e).

(h) Each member shall have the following limitations on its cessions to the facility:

(1) Each member shall cede no more than 10 percent of its business;

(2) Each member shall pay to the facility 2 dollars for each dollar of premium over the limitation that it has ceded to the facility;

(3) Each member's cessions shall be calculated based on a fiscal year of January 1 to December 31; and

(4) The cession date shall be determined by the effective date of the policy ceded.

(i) No cession of a new policy to the facility shall be initiated after the 60th day following the effective date of the new policy and shall not be effective unless written notice is mailed to the insured. Such notice shall include the terms and premiums for coverage.

(j) Once no SDIP point(s) is included in the experience period for a renewal policy, the insurer shall offer the renewal policy in the voluntary market.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.11 Facility Charges, Premium, and Allowance {#sec-ins-1406.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.11}

(a) Each member ceding a policy of automobile insurance covering a private passenger automobile eligible risk to the facility shall give notice of cession to the facility for that eligible risk. The facility shall debit the member's account in the amount of the member premiums ceded. Premium ceded shall be 85 percent of the facility gross premium less commission allowance.

(b) Each member ceding eligible risks shall, with respect to losses incurred in connection therewith, subject to the limits of coverage provided in this rule, receive a credit against the sum of such debits and facility gross premiums on ceded business for losses paid less recoveries received each month.

(c) The facility shall, quarterly or less frequently as determined by the board, issue summaries to all members reflecting each member's cumulative balances on business it ceded to the facility, providing reimbursement for those members with allowable credits in excess of debits, and shall submit a statement to those members with debits which are in excess of allowable credits. A member so billed for debits shall remit such excess within the period provided in the plan of operation, subject to interest charges at a legal interest rate per month, or fractional part thereof, for late payment as provided therein.

(d) A member which in any month reports allowable credits in excess of debits for ceded eligible risks may request reimbursement for such excess. The facility shall reimburse the member for such excess after the board acts upon such request. The board shall act on an insurers request for reimbursement pursuant to this section.

(e) The maximum commission allowance which may be credited against the premium ceded to the facility shall be 10 percent of the facility gross premium for those companies paying an actual commission. For all other companies, the maximum commission allowance which may be credited against the premium ceded to the facility shall be 5 percent of the facility gross premium. The charges in lieu of paid commissions shall be allowable only to the extent that such have been filed with the insurance department.

(f) SDIP point surcharges shall be applied to the gross base premium as follows:

(1) Each member shall cede to the facility 85 percent of the surcharge amounts less commission allowance, according to the SDIP points chargeable in accordance with the provisions of Ins 1406.12 below, to the ceded policy in accordance with the following schedule:

a. For a policy subject to 1 SDIP point - 90;

b. For a policy subject to 2 SDIP points - 200;

c. For a policy subject to 3 SDIP points - 330;

d. For a policy subject to 4 SDIP points - 480;

e. For a policy subject to 5 SDIP points - 650;

f. For a policy subject to 6 SDIP points - 840;

g. For a policy subject to 7 SDIP points - 1,040;

h. For a policy subject to 8 SDIP points - 1,240; and

i. For each additional point - 200; and

(2) The surcharge commission shall be $5 for each point to a maximum of $25 per policy or the actual commission allowance, whichever is less.

(g) The premium amount to be ceded shall be 85 percent of gross base premium other than SDIP surcharges less 10 percent if commissions are paid or less 5 percent if commissions are not paid plus 85 percent of the SDIP surcharge less the SDIP commission allowance or the actual SDIP commission, whichever is less.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.12 Safe Driver Incentive Plan and SDIP Points for the New Hampshire Automobile Reinsurance Facility {#sec-ins-1406.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.12}

(a) SDIP points for motor vehicle convictions shall be assigned per licensed operator in accordance with motor vehicle records during the experience period as follows:

(1) Convictions shall be assigned 4 points for the following offenses:

a. Homicide or assault arising out of the operation of a motor vehicle;

b. Failure to stop and report when involved in an accident; or

c. Driving a motor vehicle while under the influence of intoxicating liquor or narcotic drugs;

(2) Convictions shall be assigned 3 points for the following offenses:

a. Driving a motor vehicle in a careless or reckless manner;

b. Driving while a license is suspended or revoked;

c. Operating a motor vehicle without the owner's permission or consent;

d. Highway racing;

e. Driving to endanger; or

f. Text messaging and device usage while operating a motor vehicle; and

(3) Convictions for improper passing of a school bus shall be assigned 2 points.

(b) Conviction of any moving traffic violation other than those listed above shall result in the assignment of one point after the second conviction of such moving traffic violation and one point for each additional conviction.

(c) Convictions for the following shall be subject to assignment of one point but only upon the second conviction for the same offense within the 2 years immediately preceding the effective date of the policy period:

(1) Any violation of motor vehicle equipment requirements under RSA 266;

(2) Failure to display current license plates or registration stickers or diesel fuel permits;

(3) Failure to have a valid operator’s license or registration certificate; or

(4) Non-inspection of a motor vehicle.

(d) SDIP points for chargeable accidents shall be assigned for chargeable accidents that occurred during the experience period involving the applicant or any other operator of the vehicle currently a resident of the same household as follows:

(1) For each automobile accident resulting in the following, one point shall be assigned:

a. Excess of $750 in bodily injury but less than $7,500 in bodily injury; or

b. Excess of $1,500 damage but less than $15,000 in damage to any property, including their own;

(2) For each automobile accident resulting in the following, 2 points shall be assigned:

a. Death of any person;

b. $7,500 or more bodily injury to any person; or

c. $15,000 or more in damage to any property including one’s own;

(3) For each SDIP chargeable automobile accident in excess of 2 chargeable accidents occurring within the experience period, 3 points shall be assigned;

(4) No point(s) shall be assigned for an accident if the insured demonstrates that the accident occurred under the following circumstances:

a. The automobile was lawfully parked. An automobile rolling from a parked position shall be considered unlawfully parked under the operation of the last operator;

b. The applicant, other operator residing in the same household, or owner was reimbursed by, or on behalf of, a person responsible for the accident or has a judgment against such person;

c. The automobile of an applicant or other operator resident in the same household was struck in its rear by another vehicle, and the applicant or other resident operator has not been convicted of a moving traffic violation in connection with the accident;

d. The operator of the other automobile involved in such accident was convicted of a moving traffic violation, and the applicant or other resident in the same household was not convicted of a moving traffic violation in connection therewith;

e. The automobile operated by the applicant or other operator resident in the same household is damaged as a result of contact with a “hit and run” driver, and the applicant or other operator so reports the accident to the proper authority within 24 hours;

f. Accidents involving damage by contact with animals;

g. Accidents involving physical damage limited to and caused by flying gravel, missiles, or falling objects;

h. Accidents occurring as a result of the operation of an automobile in response to an emergency if the operator at the time of the accident was responding to a call to duty as a paid or volunteer member of any police or fire department, first aid squad, or of any law enforcement agency but not an accident occurring after the emergency situation ceases or after the private passenger automobile ceases to be used in response to such emergency;

i. An automobile accident involving only bodily injury or property damage to the applicant or any other operator of the automobile currently a resident in the same household, unless the said applicant or operator is convicted of a moving traffic violation in connection with the occurrence; or

j. Accidents occurring as a result of the operation of a vehicle by a municipal public works or highway department employee while on official duty but not an accident occurring once the municipal public works or highway department employee is no longer on official duty.

(5) If the principal operator of the automobile has no surcharge for an accident, but has been licensed less than 2 years, one point shall be assigned;

(6) Conviction points shall be assigned in addition to any points for accidents; and

(7) Accident surcharge points shall only be based on paid losses.

(e) Changes requiring adjustments of premium shall be computed pro-rata.

(f) Changes which occur during the term of the policy shall be calculated using the rates on the inception date of the policy period.

(g) Insurance companies shall not make premium changes to an automobile policy during the policy period in the reinsurance facility other than for the following reasons:

(1) Addition of a new or replacement vehicle;

(2) Addition or deletion of a driver;

(3) Change in garaged location;

(4) Change in coverage;

(5) Change in limits;

(6) Change in use of vehicle;

(7) The insured has attained a new age;

(8) Change in marital status of any listed driver;

(9) The addition of new coverage to a vehicle on the policy or for a replacement vehicle;

(10) Deletion of a vehicle; or

(11) Discovery of convictions or occurrences, which occurred during the current or first prior policy period, resulting in losses incurred or paid.

(h) If premium changes are made during the policy period to reflect changes pursuant to (g)(11) above, they shall be appropriately removed on the same basis during a subsequent policy period.

(i) Policies ceded to the facility shall not be eligible for safe driver discounts.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.13 Assessments and Participation {#sec-ins-1406.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.13}

(a) Facility earned premiums, incurred losses, income, and expenses shall be determined on the basis of generally accepted insurance accounting principles. The plan of operation shall provide that all investment income earned on business reinsured by the facility shall enter into the determination of the facility’s net operating results. The facility shall provide periodic settlement to the members based on the facility’s net operating results. The members shall retain for their individual credit all investment income earned prior to the time facility gross premium is forwarded to the facility.

(b) Assessments to pay for facility losses and expenses shall be levied, and any profits shall be distributed, pursuant to the plan of operation.

(c) Such assessments or distributions shall be allocated among the members based on New Hampshire written or earned premium in accordance with the following:

(1) Assessments for private passenger automobile insurance, other than physical damage, shall be shared amongst the members as follows:

a. The ratio of a member's total private passenger automobile net direct written car years to the total of such car years of all members shall be used for allocation of 20 percent of the facility's profits or losses to the individual members; and

b. The ratio of a member's ceded private passenger automobile insurance car years to the total of all such ceded car years shall be used for the allocation of 80 percent of all the facility's profits or losses to the individual members;

(2) Assessments for private passenger automobile physical damage insurance shall be shared amongst the members as follows:

a. The ratio of a member's total private passenger automobile physical damage net direct written car years to the total of such car years of all members shall be used for the allocation of 20 percent of the facility's profits or losses to the individual members; and

b. The ratio of a member's ceded private passenger automobile physical damage years to the total of all such ceded car years shall be used for the allocation of 80 percent of all the facility's profits or losses to the individual members; and

(3) Assessments of facility net operation expense shall be shared amongst the members as follows:

a. The ratio of a member's total private passenger automobile net direct written car years for the most recent available calendar year to the total of such car years of all members shall be used for the allocation of 20 percent of all assets, liabilities, income, and expenses not properly chargeable to the profit or loss of ceded risks; and

b. The ratio of a member's ceded car years for the most recent available calendar year to the total of all such ceded car years shall be used for allocation of 80 percent of all assets, liabilities, income, and expenses not properly chargeable to the profit or loss of ceded risks.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.14 Audits {#sec-ins-1406.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.14}

(a) Facility business written by members shall be subject to review and audit in a manner and time prescribed by the board, and each member of the facility specifically authorizes the board or its designee to audit that part of the member's business which is ceded to the facility or which is relevant to the operation of the facility.

(b) The facility shall be subject to examination at the facility's expense by the commissioner.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.15 Indemnification {#sec-ins-1406.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.15}

(a) Any person or member made or threatened to be made a party to any action, suit, or proceeding, because such person or member served on the board or on a committee of the facility or was an officer or employee of the facility, shall be indemnified by the facility.

(b) The indemnification shall consist of all judgments, fines, amounts paid in settlement, reasonable costs and expenses, including attorney's fees, and any other liabilities that might be incurred as a result of such action, suit, or proceeding, or threatened action, suit, or proceeding.

(c) A member or person shall not be indemnified by the facility in relation to matters to which the person or member is adjudged in such action, suit, or proceeding to be liable by reason of breach of duty involving gross negligence, bad faith, dishonesty, willful misfeasance, or reckless disregard of the responsibilities in performance of the member’s or person’s duties or obligations to the facility and with respect to any criminal actions or proceedings.

(d) If a person or member had reasonable cause to believe that their conduct was lawful, such indemnification shall be provided whether or not such person or member is a member or is holding office or is employed at the time of such action, suit, or proceeding.

(e) Indemnification shall not be exclusive of other rights such person or member may have and shall extend to the successors, heirs, executors, or administrators of such person or member.

(f) In the event of settlement or other termination of a matter before final adjudication, indemnification shall be provided only if the board is advised by independent counsel that the person or member to be indemnified did not, in counsel's opinion, commit such a breach of duty.

(g) In each instance in which a question of indemnification arises, entitlement thereto, pursuant to the conditions set forth above, shall be determined by the board which shall also determine the time and manner of payment of such indemnification.

(h) A person or member who or which has been wholly successful, on the merits or otherwise, in the defense of a civil or criminal action, suit, or proceeding of the character described above shall be entitled to indemnification as authorized in this section.

(i) Nothing herein shall be deemed to bind a person or member who or which the board has determined not entitled to indemnification or to preclude such person or member from asserting the right to such indemnification by legal proceedings.

(j) Indemnification as is herein provided shall be apportioned among all members, including any named in any such action, suit, or proceeding, pursuant to this rule.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.16 Hearings and Review {#sec-ins-1406.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.16}

(a) Any person aggrieved with respect to the operation of the facility may petition the board for review on any alleged failure to comply with the plan of operation or any alleged improper act or ruling in the administration of the facility pursuant to Ins 1406.07(i). The request for review shall be made within 30 days after the date of the alleged violation or improper act or ruling. The review shall be held within 30 days after receipt of the request. The review shall be held by a panel, appointed by the chair, consisting of 3 board members entitled to vote. The decision of a majority of the panel shall be deemed to be the decision of the board unless the full board on its own motion shall modify or rescind the panel's action.

(b) Any board decision may be appealed to the commissioner by filing notice of appeal with the facility and commissioner within 30 days after the date of the decision's issuance. The commissioner shall conduct a hearing under RSA 400-A:17-23.

(c) Any aggrieved member may request a public hearing and ruling by the commissioner on the provisions of the plan of operation. The request for a hearing shall specify the matters to be considered. The hearing shall be held within 30 days after receipt of the request. The commissioner shall give public notice of the hearing and the matters to be considered not less than 10 days in advance of the hearing date.

(d) In the case of any review held by the board pursuant to this section, the board shall issue a decision within 30 days after the review. In the case of any hearing held by the commissioner pursuant to this section, the commissioner shall issue a ruling or order within 90 days after the close of the hearing.

(e) Orders of the commissioner on hearings under this rule shall be subject to judicial review as provided in RSA 400-A:24.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.17 Amendments {#sec-ins-1406.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.17}

(a) The plan of operation for the New Hampshire automobile reinsurance facility shall be amended by the commissioner at any time pursuant to the provisions of RSA 541-A.

(b) Amendments to the plan of operation shall be proposed at any biennial, special, or board meeting of the facility and recommended to the commissioner for approval. Not less than 15 days written notice of any such meeting shall be given or caused to be given by the chair of the board, in which notice the action proposed to be taken shall be fully set forth. Such amendments proposed by the members shall not become effective unless approved by the commissioner pursuant to the provisions of RSA 404-C:1.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.18 Claim Reserves {#sec-ins-1406.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.18}

Each member shall maintain claim reserving procedures for claims arising out of facility business commensurate with the procedures utilized by the members for claims arising out of non-facility business.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.19 Reinsurance Facility Rates {#sec-ins-1406.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.19}

The facility rates shall be developed utilizing data generated by the facility and filed for approval pursuant to the provisions of RSA 412:15 and RSA 412:16.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

N.H. Code Admin. R. Ann. Ins 1406.20 Nonrenewal and Cancellation Protection {#sec-ins-1406.20 omnilex-key=us-nh-regs-official--agency-ins--Ins 1406.20}

Insureds ceded to the facility shall be entitled to the same statutory and regulatory protections governing nonrenewal and cancellation as in the voluntary market.

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; ss by #13534, eff 1-24-23

Part Ins 1407 Waiver of Rules Provision

N.H. Code Admin. R. Ann. Ins 1407.01 Waiver of Rules {#sec-ins-1407.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1407.01}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX

Rule

State Statute the Rule Implements

Ins 1401.01

RSA 400-A:15, I; RSA 404-C; RSA 412; RSA 417-A

Ins 1401.02

RSA 400-A:15, I; RSA 404-C; RSA 412; RSA 417-A

Ins 1402.01

RSA 259; RSA 264; RSA 400-A:15, I; RSA 404-C;

RSA 412:43

Ins 1403.01

RSA 400-A:15, I; RSA 412:1; RSA 412:9; RSA 412:43; RSA 417-A; RSA 404-C:1

Ins 1403.02

RSA 259:61, I; RSA 264:18, VI; RSA 404-C; RSA 400-A:15, I; RSA 412:3; RSA 412:43

Ins 1403.03

RSA 259; RSA 264:3; RSA 400-A:15, I; RSA 412:43;

RSA 417-A:1; RSA 417-A:3; RSA 417-A:4; RSA 417-A:5

Ins 1403.04

RSA 400-A:15, I; RSA 412; RSA 412:43; RSA 417-A:3; RSA 417:4, VIII(e)

Ins 1403.05

RSA 264; RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1404.01

RSA 400-A:15, I; RSA 412:3, RSA 412:15; RSA 412:16; RSA 412:43

Ins 1404.02

RSA 400-A:15, I; RSA 412:15; RSA 412:16; RSA 412:43

Ins 1404.03

RSA 400-A:15, I; RSA 412; RSA 412:43

Ins 1405.01

RSA 400-A:15, I; RSA 400-B:4; RSA 412:38, II;

RSA 412:43

Ins 1406.01

RSA 400-A:15, I; RSA 404-C:1; RSA 412:1; RSA 412:9; RSA 412:43; RSA 417-A

Ins 1406.02

RSA 215-A; RSA 259:48; RSA 259:61, I; RSA 264:18;

RSA 400-A:15, I; RSA 404-C; RSA 412:3; 412:43; RSA 417-A

Ins 1406.03

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.04

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.05

RSA 264; RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.06

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.07

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.08

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.09

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.10

RSA 400-A:15, I; RSA 404-C; RSA 412:43; RSA 417:4, VIII(e)

Ins 1406.11

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.12

RSA 264:33; RSA 265:79-c; RSA 400-A:15, I; RSA 404-C; RSA 412:6; RSA 412:43

Ins 1406.13

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.14

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.15

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.16

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.17

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.18

RSA 400-A:15, I; RSA 404-C; RSA 412:43

Ins 1406.19

RSA 400-A:15, I; RSA 404-C; RSA 412:15; RSA 412:16; RSA 412:43

Ins 1406.20

RSA 400-A:15, I; RSA 404-C; RSA 412:43; RSA 417-A

Ins 1407.01

RSA 400-A:15, I; RSA 541-A:22, IV

History

(See Revision Note #1 at chapter heading for Ins 1400) #13162, eff 1-25-21; renumbered by #13115 (formerly Ins 1408.01) (see Revision Note #2 at chapter heading for Ins 1400)

Chapter Ins 1500 Insurance Holding Companies

Part Ins 1501 Filings

N.H. Code Admin. R. Ann. Ins 1501.01 Purpose {#sec-ins-1501.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.01}

The purpose of this chapter is to set forth rules and procedural requirements which the commissioner deems necessary to carry out the provisions of the NAIC Insurance Holding Company System Regulatory Act, RSA 401-B, hereinafter referred to as "the Act". The information called for by this chapter is hereby declared to be necessary and appropriate in the public interest and for the protection of the policyholders in this state.

History

#5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.02 Definitions {#sec-ins-1501.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.02}

(a) "Executive officer" means chief executive officer, chief operating officer, chief financial officer, treasurer, secretary, controller, and any other individual performing functions corresponding to those performed by the foregoing officers under whatever title.

(b) "Ultimate controlling person" means that person which is not controlled by any other person.

(c) Unless the context otherwise requires, other terms found in these parts are used as defined in RSA 401‑B:1. Other nomenclature or terminology is according to New Hampshire insurance law, or industry usage if not defined by New Hampshire insurance laws.

History

#5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.03 Forms ‑ General Requirements {#sec-ins-1501.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.03}

(a) Forms A, B, C, D, E and F are intended to be guides in the preparation of the statements required by RSA 401‑B:3, RSA 401‑B:3-a, RSA 401‑B:4 and RSA 401‑B:5. They are not intended to be blank forms which are to be filled in. The statements filed shall contain the numbers and captions of all items, but the text of the items may be omitted provided the answers thereto are prepared in such a manner as to indicate clearly the scope and coverage of the items. All instructions, whether appearing under the items of the form or elsewhere therein, are to be omitted. Unless expressly provided otherwise, if any item is inapplicable or the answer thereto is in the negative, an appropriate statement to that effect shall be made.

(b) Three complete copies of the Form A, and one complete copy of each other statement including exhibits and all other papers and documents filed as a part thereof, shall be filed with the commissioner by personal delivery or mail addressed to: Insurance Commissioner, State of New Hampshire, 21 South Fruit Street, Suite 14, Concord, NH 03301, Attention: Chief Analyst. At least one of the copies shall be signed in the manner prescribed on the form. Unsigned copies shall be conformed. If the signature of any person is affixed pursuant to a power of attorney or other similar authority, a copy of the power of attorney or other authority shall also be filed with the statement.

(c) If an applicant requests a hearing on a consolidated basis under RSA 401-B:3, VI(b), in addition to filing the Form A with the commissioner, the applicant shall file a copy of Form A with the National Association of Insurance Commissioners (NAIC) in electronic form.

(d) Statements should be prepared electronically. Debits in credit categories and credits in debit categories shall be designated so as to be clearly distinguishable as such on photocopies. Statements shall be in the English language and monetary values shall be stated in United States currency. If any exhibit or other paper or document filed with the statement is in a foreign language, it shall be accompanied by a translation into the English language and any monetary value shown in a foreign currency normally shall be converted into United States currency.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.04 Forms ‑ Incorporation by Reference, Summaries and Omissions {#sec-ins-1501.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.04}

(a) Information required by any item of Form A, Form B, Form D, Form E or Form F may be incorporated by reference in answer or partial answer to any other item. Information contained in any financial statement, annual report, proxy statement, statement filed with a governmental authority, or any other document may be incorporated by reference in answer or partial answer to any item of Form A, Form B, Form D, Form E, or Form F provided the document is filed as an exhibit to the statement. Excerpts of documents may be filed as exhibits if the documents are extensive. Documents currently on file with the commissioner which were filed within 3 years need not be attached as exhibits. References to information contained in exhibits or in documents already on file shall clearly identify the material and shall specifically indicate that such material is to be incorporated by reference in answer to the item. Matter shall not be incorporated by reference in any case where the incorporation would render the statement incomplete, unclear or confusing.

(b) Where an item requires a summary or outline of the provisions of any document, only a brief statement shall be made as to the pertinent provisions of the document. In addition to the statement, the summary or outline may incorporate by reference particular parts of any exhibit or document currently on file with the commissioner which was filed within 3 years and may be qualified in its entirety by such reference. In any case where 2 or more documents required to be filed as exhibits are substantially identical in all material respects except as to the parties thereto, the dates of execution, or other details, a copy of only one of the documents shall be filed with a schedule identifying the omitted documents and setting forth the material details in which the documents differ from the documents, a copy of which is filed.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.05 Forms ‑ Information Unknown or Unavailable and Extension of Time to Furnish {#sec-ins-1501.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.05}

If it is impractical to furnish any required information, document or report at the time it is required to be filed, there may be filed with the commissioner a separate document:

(a) Identifying the information, document or report in question;

(b) Stating why the filing thereof at the time required is impractical; and

(c) Requesting an extension of time for filing the information, document or report to a specified date. The request for extension shall be deemed granted unless the commissioner within 60 days after receipt thereof enters an order denying the request.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.06 Forms ‑ Additional Information and Exhibits {#sec-ins-1501.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.06}

In addition to the information expressly required to be included in Form A, Form B, Form C, Form D, Form E and Form F, the commissioner may request such further material information, if any, as may be necessary to make the information contained therein not misleading. The person filing may also file such exhibits as he or she may desire in addition to those expressly required by the statement. The exhibits shall be so marked as to indicate clearly the subject matters to which they refer. Changes to Forms A, B, C, D, E or F shall include on the top of the cover page the phrase: "Change No. (insert number) to" and shall indicate the date of the change and not the date of the original filing.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.07 Subsidiaries of Domestic Insurers {#sec-ins-1501.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.07}

The authority to invest in subsidiaries under RSA 401-B:2, II is in addition to any authority to invest in subsidiaries which may be contained in any other provision of Title XXXVII.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.08 Acquisition of Control ‑ Statement Filing {#sec-ins-1501.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.08}

A person required to file a statement pursuant to RSA 401‑B:3 shall furnish the required information on Form A, hereby made a part of this rule. Such person shall also furnish the required information on Form E, hereby made a part of this rule and described in Ins 1501.11.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.09 Amendments to Form A {#sec-ins-1501.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.09}

The applicant shall promptly advise the commissioner of any changes in the information furnished on Form A arising subsequent to the date upon which the information was furnished but prior to the commissioner's disposition of the application.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.10 Acquisition of Persons Controlling a Domestic Insurer {#sec-ins-1501.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.10}

(a) If the person being acquired is deemed to be a "domestic insurer" solely because of the provisions of RSA 401-B:3, I(d), the name of the domestic insurer on the cover page should be indicated as follows:

“ ”, a subsidiary of

(Insert name of insurance company)

“ ”

(Insert name of corporation)

(b) Where a RSA 401-B:3, I(d) insurer is being acquired, references to "the insurer" contained in Form A shall refer to both the domestic subsidiary insurer and the person being acquired.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.11 Pre-Acquisition Notification {#sec-ins-1501.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.11}

(a) If a domestic insurer, including any person controlling a domestic insurer, is proposing a merger or acquisition pursuant to RSA 401-B:3, I, that person shall file a pre-acquisition notification form, Form E, which was developed pursuant to RSA 401-B:3-a, III(a).

(b) Additionally, if a non-domiciliary insurer licensed to do business in this state is proposing a merger or acquisition pursuant to RSA 401-B:3-a, that person shall file a pre-acquisition notification form, Form E. No pre-acquisition notification form need be filed if the acquisition is beyond the scope of RSA 401-B:3-a as set forth in RSA 401-B:3-a, II(b).

(c) In addition to the information required by Form E, the commissioner may wish to require an expert opinion as to the competitive impact of the proposed acquisition.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.12 Annual Registration of Insurers ‑ Statement Filing {#sec-ins-1501.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.12}

An insurer required to file an annual registration statement pursuant to RSA 401‑B:4, shall furnish the required information on Form B, hereby made a part of these rules.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.13 Summary of Registration ‑ Statement Filing {#sec-ins-1501.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.13}

An insurer required to file an annual registration statement pursuant to RSA 401-B:4 is also required to furnish information required on Form C, hereby made a part of these rules.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.14 Amendments to Form B {#sec-ins-1501.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.14}

(a) An amendment to Form B shall be filed within 15 days after the end of any month in which there is a material change to the information provided in the annual registration statement.

(b) Amendments shall be filed in the Form B format with only those items which are being amended reported. Each amendment shall include at the top of the cover page "Amendment No. (insert number) to Form B for (insert year)" and shall indicate the date of the change and not the date of the original filings.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.15 Alternative and Consolidated Registrations {#sec-ins-1501.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.15}

(a) Any authorized insurer may file a registration statement on behalf of any affiliated insurer or insurers which are required to register under RSA 401-B:4. A registration statement may include information not required by the Act regarding any insurer in the insurance holding company system even if the insurer is not authorized to do business in this state. In lieu of filing a registration statement on Form B, the authorized insurer may file a copy of the registration statement or similar report which it is required to file in its state of domicile, provided:

(1) The statement or report contains substantially similar information required to be furnished on Form B; and

(2) The filing insurer is the principal insurance company in the insurance holding company system.

(b) The question of whether the filing insurer is the principal insurance company in the insurance holding company system is a question of fact and an insurer filing a registration statement or report in lieu of Form B on behalf of an affiliated insurer, shall set forth a brief statement of facts which will substantiate the filing insurer's claim that it, in fact, is the principal insurer in the insurance holding company system.

(c) With the prior approval of the commissioner, an authorized insurer may follow any of the procedures which could be done by an authorized insurer under Ins 1501.15(a).

(d) Any insurer may take advantage of the provisions of RSA 401‑B:4, VIII and IX without obtaining the prior approval of the commissioner. The commissioner, however, reserves the right to require individual filings if he or she deems such filings necessary in the interest of clarity, ease of administration or the public good.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.16 Disclaimers and Termination of Registration {#sec-ins-1501.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.16}

(a) A disclaimer of affiliation or a request for termination of registration claiming that a person does not, or will not upon the taking of some proposed action, control another person, hereinafter referred to as the "subject", shall contain the following information:

(1) The number of authorized, issued and outstanding voting securities of the subject;

(2) With respect to the person whose control is denied and all affiliates of such person, the number and percentage of shares of the subject's voting securities which are held of record or known to be beneficially owned, and the number of such shares concerning which there is a right to acquire, directly or indirectly;

(3) All material relationships and bases for affiliation between the subject and the person whose control is denied and all affiliates of such person; and

(4) A statement explaining why the person should not be considered to control the subject.

(b) A request for termination of registration shall be deemed to have been granted unless the commissioner, within 30 days after receipt of the request, notifies the registrant otherwise.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by #10450, eff 1-1-14; ss by#10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.17 Transactions Subject to Prior Notice ‑ Notice Filing {#sec-ins-1501.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.17}

(a) An insurer required to give notice of a proposed transaction pursuant to RSA 401‑B:5 shall furnish the required information on Form D, hereby made a part of these rules.

(b) Agreements for cost sharing services and management services shall at a minimum and as applicable:

(1) Identify the person providing services and the nature of such services;

(2) Set forth the methods to allocate costs;

(3) Require timely settlement, not less frequently than on a quarterly basis, and compliance with the requirements in the NAIC Accounting Practices and Procedures Manual;

(4) Prohibit advancement of funds by the insurer to the affiliate except to pay for services defined in the agreement;

(5) State that the insurer will maintain oversight for functions provided to the insurer by the affiliate and that the insurer will monitor services annually for quality assurance;

(6) Define records and data of the insurer to include all records and data developed or maintained under or related to the agreement that are otherwise the property of the insurer, in whatever form maintained, including, but not limited to, claims and claim files, policyholder lists, application files, litigation files, premium records, rate books, underwriting manuals, personnel records, financial records or similar records within the possession, custody or control of the affiliate;

(7) Specify that all books and records of the insurer are and remain the property of the insurer and:

a. Are subject to control of the insurer;

b. Are identifiable; and

c. Are segregated from all other persons’ records and data or are readily capable of segregation at no additional cost to the insurer;

(8) State that all funds and invested assets of the insurer are the exclusive property of the insurer, held for the benefit of the insurer and are subject to the control of the insurer;

(9) Include standards for termination of the agreement with and without cause;

(10) Include provisions for indemnification of the insurer in the event of gross negligence or willful misconduct on the part of the affiliate providing the services and for any actions by the affiliate that violate provisions of the agreement required in Subsections Ins 1501.17(b)(11), Ins 1501.17(b)(12), Ins 1501.17(b)(13), Ins 1501.17(b)(14) and Ins 1501.17(b)(15) of this rule;

(11) Specify that, if the insurer is placed in supervision, seizure, conservatorship or receivership pursuant to RSA 402-C:

a. All of the rights of the insurer under the agreement extend to the receiver or commissioner to the extent permitted by RSA 402-C;

b. All records and data of the insurer shall be identifiable and segregated from all other persons’ records and data or readily capable of segregation at no additional cost to the receiver or the commissioner;

c. A complete set of records and data of the insurer will immediately be made available to the receiver or the commissioner, shall be made available in a usable format and shall be turned over to the receiver or commissioner immediately upon the receiver or the commissioner’s request, and the cost to transfer data to the receiver or the commissioner shall be fair and reasonable; and

d. The affiliated person(s) will make available all employees essential to the operations of the insurer and the services associated therewith for the immediate continued performance of the essential services ordered or directed by the receiver or commissioner;

(12) Specify that the affiliate has no automatic right to terminate the agreement if the insurer is placed in receivership pursuant to RSA 402-C; and

(13) Specify that the affiliate will provide the essential services for a minimum period of time [specified in the agreement] after termination of the agreement, if the insurer is placed into supervision, seizure, conservatorship or receivership pursuant to RSA 402-C, as ordered or directed by the receiver or commissioner. Performance of the essential services will continue to be provided without regard to pre-receivership unpaid fees, so long as the affiliate continues to receive timely payment for post-receivership services rendered, and unless released by the receiver, commissioner or supervising court;

(14) Specify that the affiliate will continue to maintain any systems, programs or other infrastructure, notwithstanding supervision, seizure, conservatorship or receivership pursuant to RSA 402-C, and will make them available to the receiver or commissioner as ordered or directed by the receiver or commissioner for so long as the affiliate continues to receive timely payment for post-receivership services rendered, and unless released by the receiver, commissioner or supervising court; and

(15) Specify that, in furtherance of the cooperation between the receiver and the affected guaranty association(s) and subject to the receiver’s authority over the insurer, if the insurer is placed into supervision, seizure, conservatorship or receivership pursuant to RSA 402-C, and portions of the insurer’s policies or contracts are eligible for coverage by one or more guaranty associations, the affiliate's commitments under Subsections Ins 1501.17(b)(11), Ins 1501.17(b)(12), Ins 1501.17(b)(13) and Ins 1501.17(b)(14) of this rule will extend to such guaranty association(s).

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by#10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.18 Enterprise Risk Report {#sec-ins-1501.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.18}

The ultimate controlling person of an insurer required to file an enterprise risk report pursuant to RSA 401-B:4, XII shall furnish the required information on Form F, hereby made a part of these rules.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5652, eff 7-1-93; ss by #6985, eff 5-1-99, EXPIRED: 5-1-07
#8910, eff 7-1-07; ss by#10450, eff 1-1-14; ss by #13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.19 Group Capital Calculation {#sec-ins-1501.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.19}

(a) Where an insurance holding company system has previously filed the annual group capital calculation at least once, the lead state commissioner has the discretion to exempt the ultimate controlling person from filing the annual group capital calculation if the lead state commissioner makes a determination based upon that filing that the insurance holding company system meets all of the following criteria:

(1) Has annual direct written and unaffiliated assumed premium (including international direct and assumed premium), but excluding premiums reinsured with the Federal Crop Insurance Corporation and Federal Flood Program, of less than $1,000,000,000;

(2) Has no insurers within its holding company structure that are domiciled outside of the United States or one of its territories;

(3) Has no banking, depository or other financial entity that is subject to an identified regulatory capital framework within its holding company structure;

(4) The holding company system attests that there are no material changes in the transactions between insurers and non-insurers in the group that have occurred since the last filing of the annual group capital; and

(5) The non-insurers within the holding company system do not pose a material financial risk to the insurer’s ability to honor policyholder obligations.

(b) Where an insurance holding company system has previously filed the annual group capital calculation at least once, the lead state commissioner has the discretion to accept in lieu of the group capital calculation a limited group capital filing if:

(1) The insurance holding company system has annual direct written and unaffiliated assumed premium (including international direct and assumed premium), but excluding premiums reinsured with the Federal Crop Insurance Corporation and Federal Flood Program, of less than $1,000,000,000, and all of the following additional criteria are met:

a. Has no insurers within its holding company structure that are domiciled outside of the United States or one of its territories;

b. Does not include a banking, depository or other financial entity that is subject to an identified regulatory capital framework; and

c. The holding company system attests that there are no material changes in transactions between insurers and non-insurers in the group that have occurred since the last filing of the report to the lead state commissioner and the non-insurers within the holding company system do not pose a material financial risk to the insurers ability to honor policyholder obligations.

(c) For an insurance holding company that has previously met an exemption with respect to the group capital calculation pursuant to Section Ins 1501.19(a) or Ins 1501.19(b) of this rule, the lead state commissioner may require at any time the ultimate controlling person to file an annual group capital calculation, completed in accordance with the NAIC Group Capital Calculation Instructions, if any of the following criteria are met:

(1) Any insurer within the insurance holding company system is in a Risk-Based Capital action level event as set forth in RSA 404-F:3 or a similar standard for a non-U.S. insurer; or

(2) Any insurer within the insurance holding company system meets one or more of the standards of an insurer deemed to be in hazardous financial condition as defined in Ins 2900; or

(3) Any insurer within the insurance holding company system otherwise exhibits qualities of a troubled insurer as determined by the lead state commissioner based on unique circumstances including, but not limited to, the type and volume of business written, ownership and organizational structure, federal agency requests, and international supervisor requests.

(d) A non-U.S. jurisdiction is considered to “recognize and accept” the group capital calculation if it satisfies the following criteria:

(1) With respect to RSA 401-B:4, XII(b)(4):

a. The non-U.S. jurisdiction recognizes the U.S. state regulatory approach to group supervision and group capital, by providing confirmation by a competent regulatory authority, in such jurisdiction, that insurers and insurance groups whose lead state is accredited by the NAIC under the NAIC Accreditation Program shall be subject only to worldwide prudential insurance group supervision including worldwide group governance, solvency and capital, and reporting, as applicable, by the lead state and will not be subject to group supervision, including worldwide group governance, solvency and capital, and reporting, at the level of the worldwide parent undertaking of the insurance or reinsurance group by the non-U.S. jurisdiction; or

b. Where no U.S. insurance groups operate in the non-U.S. jurisdiction, that non-U.S. jurisdiction indicates formally in writing to the lead state with a copy to the International Association of Insurance Supervisors that the group capital calculation is an acceptable international capital standard. This will serve as the documentation otherwise required in Ins 1501.19(d)(1)(a).

(2) The non-U.S. jurisdiction provides confirmation by a competent regulatory authority in such jurisdiction that information regarding insurers and their parent, subsidiary, or affiliated entities, if applicable, shall be provided to the lead state commissioner in accordance with a memorandum of understanding or similar document between the commissioner and such jurisdiction, including but not limited to the International Association of Insurance Supervisors Multilateral Memorandum of Understanding or other multilateral memoranda of understanding coordinated by the NAIC. The commissioner shall determine, in consultation with the NAIC Committee Process, if the requirements of the information sharing agreements are in force.

(e) A list of non-U.S. jurisdictions that “recognize and accept” the group capital calculation will be published through the NAIC Committee Process:

(1) A list of jurisdictions that “recognize and accept” the group capital calculation pursuant to RSA 401-B:4, XII(b)(3), is published through the NAIC Committee Process to assist the lead state commissioner in determining which insurers shall file an annual group capital calculation. The list will clarify those situations in which a jurisdiction is exempted from filing under RSA 401-B:4, XII(b)(3). To assist with a determination under RSA 401-B:4, XII(b)(3), the list will also identify whether a jurisdiction that is exempted under either RSA 401:B:4, XII(b)(1) and RSA 401:B:4, XII(b)(2) requires a group capital filing for any U.S. based insurance group’s operations in that non-U.S. jurisdiction.

(2) For a non-U.S. jurisdiction where no U.S. insurance groups operate, the confirmation provided to meet the requirement of RSA 405:47, IV-b.(a)(8), RSA 405:47, IV-b.(b), RSA 405:47, IV-b.(c) and RSA 405:47, IV-b.(d) will serve as support for recommendation to be published as a jurisdiction that “recognizes and accepts” the group capital calculation through the NAIC Committee Process.

(3) If the lead state commissioner makes a determination pursuant to RSA 405:47, IV-b.(a)(8), RSA 405:47, IV-b.(b), RSA 405:47, IV-b.(c) and RSA 405:47, IV-b.(d) that differs from the NAIC List, the lead state commissioner shall provide thoroughly documented justification to the NAIC and other states.

(4) Upon determination by the lead state commissioner that a non-U.S. jurisdiction no longer meets one or more of the requirements to “recognize and accept” the group capital calculation, the lead state commissioner may provide a recommendation to the NAIC that the non-U.S. jurisdiction be removed from the list of jurisdictions that “recognize and accepts” the group capital calculation.

History

13692, eff 7-21-23

N.H. Code Admin. R. Ann. Ins 1501.20 Extraordinary Dividends and Other Distributions {#sec-ins-1501.20 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.20}

(a) Requests for approval of extraordinary dividends or any other extraordinary distribution to shareholders shall include the following:

(1) The amount of the proposed dividend;

(2) The date established for payment of the dividend;

(3) A statement as to whether the dividend or distribution is to be in cash or other property and, if in property:

a. A description thereof;

b. Its cost; and

c. Its fair market value together with an explanation of the basis for valuation;

(4) A copy of the calculations determining that the proposed dividend is extraordinary. The work paper shall include the following information:

a. The amounts, dates and form of payment of all dividends or distributions, including regular dividends but excluding distributions of the insurer's own securities, paid within the period of 12 consecutive months ending on the date fixed for payment of the proposed dividend for which approval is sought and commencing on the day after the same day of the same month in the last preceding year;

b. Surplus as regards policyholders (total capital and surplus) as of the 31st day of December next preceding;

c. If the insurer is a life insurer, the net gain from operations for the 12 month period ending the 31st day of December next preceding;

d. If the insurer is not a life insurer, the net income less realized capital gains for the 12 month period ending the 31st day of December next preceding and the 2 preceding 12 month periods; and

e. If the insurer is not a life insurer, the dividends paid to stockholders excluding distributions of the insurer’s own securities in the preceding 2 calendar years.

(5) A balance sheet and statement of income for the period intervening from the last annual statement filed with the commissioner and the end of the month preceding the month in which the request for dividend approval is submitted; and

(6) A brief statement as to the effect of the proposed dividend upon the insurer's surplus and the reasonableness of surplus in relation to the insurer's outstanding liabilities and the adequacy of surplus relative to the insurer's financial needs.

(b) Subject to RSA 401-B:5, V, each registered insurer shall report to the commissioner all dividend and other distributions to shareholders within 15 business days following the declaration thereof, including the same information required by Ins 1501.20 (a)(4).

History

#10450, eff 1-1-14 (from Ins 1501.19); ss by #13692, eff 7-21-23 (formerly Ins 1501.19)

N.H. Code Admin. R. Ann. Ins 1501.21 Adequacy of Surplus {#sec-ins-1501.21 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.21}

The factors set forth in RSA 401-B:5, IV are not intended to be an exhaustive list. In determining the adequacy and reasonableness of an insurer's surplus no single factor is necessarily controlling. The commissioner instead will consider the net effect of all of these factors plus other factors bearing on the financial condition of the insurer. In comparing the surplus maintained by other insurers, the commissioner will consider the extent to which each of these factors varies from company to company and in determining the quality and liquidity of investments in subsidiaries, the commissioner will consider the individual subsidiary and may discount or disallow its valuation to the extent that the individual investments so warrant.

History

#13692, eff 7-21-23 (formerly Ins 1501.20)

N.H. Code Admin. R. Ann. Ins 1501.22 Waiver or Suspension of Rules {#sec-ins-1501.22 omnilex-key=us-nh-regs-official--agency-ins--Ins 1501.22}

(1) Applying the rule provision would cause confusion or would be misleading to

consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule

provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) Waivers that are granted shall be in effect for the period of time requested and approved by the commissioner.

Form A

STATEMENT REGARDING THE ACQUISITION OF

CONTROL OF OR MERGER WITH A DOMESTIC INSURER

Name of Domestic Insurer

Name of Acquiring Person (Applicant)

Filed with the Insurance Department of the State of

New Hampshire

Dated: , 20___

Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning this Statement Should be Addressed:

ITEM 1. METHOD OF ACQUISITION

State the name and address of the domestic insurer to which this application relates and a brief description of how control is to be acquired.

ITEM 2. IDENTITY AND BACKGROUND OF THE APPLICANT

(a) State the name and address of the applicant seeking to acquire control over the insurer.

(b) If the applicant is not an individual, state the nature of its business operations for the past 5 years or for such lesser period as such person and any predecessors thereof shall have been in existence. Briefly describe the business intended to be done by the applicant and the applicant's subsidiaries.

(c) Furnish a chart or listing clearly presenting the identities of the interrelationships among the applicant and all affiliates of the applicant. Indicate in such chart or listing the percentage of voting securities of each such person which is owned or controlled by the applicant or by any other such person. If control of any person is maintained other than by the ownership or control of voting securities, indicate the basis of such control. As to each person specified in such chart or listing indicate the type of organization (e.g. corporation, trust, partnership) and the state or other jurisdiction of domicile. If court proceedings involving a reorganization or liquidation are pending with respect to any such person, indicate which person, and set forth the title of the court, nature of proceedings and the date when commenced.

ITEM 3. IDENTITY AND BACKGROUND OF INDIVIDUALS ASSOCIATED WITH THE APPLICANT

On the biographical affidavit, include a third party background check, and state the following with respect to (1) the applicant if (s)he is an individual or (2) all persons who are directors, executive officers or owners of 10 percent or more of the voting securities of the applicant if the applicant is not an individual.

(a) Name and business address;

(b) Present principal business activity, occupation or employment including position and office held and the name, principal business and address of any corporation or other organization in which such employment is carried on;

(c) Material occupations, positions, offices or employment during the last 5 years, giving the starting and ending dates of each and the name, principal business and address of any business corporation or other organization in which each such occupation, position, office or employment was carried on; if any such occupation, position, office or employment required licensing by or registration with any federal, state or municipal governmental agency, indicate such fact, the current status of such licensing or registration, and an explanation of any surrender, revocation, suspension or disciplinary proceedings in connection therewith.

(d) Whether or not such person has ever been convicted in a criminal proceeding (excluding minor traffic violations) during the last 10 years and, if so, give the date, nature of conviction, name and location of court, and penalty imposed or other disposition of the case.

ITEM 4. NATURE, SOURCE AND AMOUNT OF CONSIDERATION

(a) Describe the nature, source and amount of funds or other considerations used or to be used in effecting the merger or other acquisition of control. If any part of the same is represented or is to be represented by funds or other consideration borrowed or otherwise obtained for the purpose[s] of acquiring, holding or trading securities, furnish a description of the transaction, the names of the parties thereto, the relationship, if any, between the borrower and the lender, the amounts borrowed or to be borrowed, and copies of all agreements, promissory notes and security arrangements relating thereto.

(b) Explain the criteria used in determining the nature and amount of such consideration.

(c) If the source of the consideration is a loan made in the lender's ordinary course of business and if the applicant wishes the identity of the lender to remain confidential, he must specifically request that the identity be kept confidential.

ITEM 5. FUTURE PLANS OF INSURER

Describe any plans or proposals which the applicant may have to declare an extraordinary dividend, to liquidate the insurer, to sell its assets to or merge it with any person or persons or to make any other material change in its business operations or corporate structure or management.

ITEM 6. VOTING SECURITIES TO BE ACQUIRED

State the number of shares of the insurer's voting securities which the applicant, its affiliates and any person listed in Item 3 plan to acquire, and the terms of the offer, request, invitation, agreement or acquisition, and a statement as to the method by which the fairness of the proposal was arrived at.

ITEM 7. OWNERSHIP OF VOTING SECURITIES

State the amount of each class of any voting security of the insurer which is beneficially owned or concerning which there is a right to acquire beneficial ownership by the applicant, its affiliates or any person listed in Item 3.

ITEM 8. CONTRACTS, ARRANGEMENTS, OR UNDERSTANDINGS WITH RESPECT TO VOTING SECURITIES OF THE INSURER

Give a full description of any contracts, arrangements or understandings with respect to any voting security of the insurer in which the applicant, its affiliates or any person listed in Item 3 is involved, including but not limited to transfer of any of the securities, joint ventures, loan or option arrangements, puts or calls, guarantees of loans, guarantees against loss or guarantees of profits, division of losses or profits, or the giving or withholding of proxies. Such description shall identify the persons with whom the contracts, arrangements or understandings have been entered into.

ITEM 9. RECENT PURCHASES OF VOTING SECURITIES

Describe any purchases of any voting securities of the insurer by the applicant, its affiliates or any person listed in Item 3 during the 12 calendar months preceding the filing of this statement. Include in the description the dates of purchase, the names of the purchasers, and the consideration paid or agreed to be paid therefor. State whether any shares so purchased are hypothecated.

ITEM 10. RECENT RECOMMENDATIONS TO PURCHASE

Describe any recommendations to purchase any voting security of the insurer made by the applicant, its affiliates or any person listed in Item 3, or by anyone based upon interviews or at the suggestion of the applicant, its affiliates or any person listed in Item 3 during the 12 calendar months preceding the filing of this statement.

ITEM 11. AGREEMENTS WITH BROKER-DEALERS

Describe the terms of any agreement, contract or understanding made with any broker-dealer as to solicitation of voting securities of the insurer for tender and the amount of any fees, commissions or other compensation to be paid to broker-dealers with regard thereto.

ITEM 12. FINANCIAL STATEMENTS AND EXHIBITS

(a) Financial statements, exhibits and 3-year financial projections of the insurer(s) shall be attached to this statement as an appendix, but list under this item the financial statements and exhibits so attached.

(b) The financial statements shall include the annual financial statements of the persons identified in Item 2(c) for the preceding 5 fiscal years (or for such lesser period as such applicant and its affiliates and any predecessors thereof shall have been in existence), and similar information covering the period from the end of such person's last fiscal year, if the information is available. The statements may be prepared on either an individual basis, or, unless the commissioner otherwise requires, on a consolidated basis if consolidated statements are prepared in the usual course of business.

(c) The annual financial statements of the applicant shall be accompanied by the certificate of an independent public accountant to the effect that such statements present fairly the financial position of the applicant and the results of its operations for the year then ended, in conformity with generally accepted accounting principles or with requirements of insurance or other accounting principles prescribed or permitted under law. If the applicant is an insurer which is actively engaged in the business of insurance, the financial statements need not be certified, provided they are based on the annual statement of the person filed with the insurance department of the person's domiciliary state and are in accordance with the requirements of insurance or other accounting principles prescribed or permitted under the law and rules of the state.

(d) File as exhibits copies of all tender offers for, requests or invitations for, tenders of, exchange offers for, and agreements to acquire or exchange any voting securities of the insurer and (if distributed) of additional soliciting material relating thereto, any proposed employment, consultation, advisory or management contracts concerning the insurer, annual reports to the stockholders of the insurer and the applicant for the last 2 fiscal years, and any additional documents or papers required by Form A or rule Ins 1501.03 and Ins 1501.05.

ITEM 13. AGREEMENT REQUIREMENTS FOR ENTERPRISE RISK MANAGEMENT

Applicant agrees to provide, to the best of its knowledge and belief, the information required by Form F within 15 days after the end of the month in which the acquisition of control occurs.

ITEM 14. SIGNATURE AND CERTIFICATION

Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of RSA 401-B:3 __________________has caused this application to be duly signed on its behalf in the City of ___________________and State of ___________________ on the day of _________ , 20 _______ .

(SEAL) ___________________________________________

Name of Applicant

BY _______________________________________________

(Name)(Title)

Attest:

(Signature of Officer)

(Title)

CERTIFICATION

The undersigned deposes and says that (s)he has duly executed the attached application dated ________________, 20 _______, for and on behalf of ____________________ (Name of Applicant); that (s)he is the _____________________(Title of Officer) of such company and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with the instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.

(Signature) ___________________________________________

(Type or print name beneath) _____________________________

Form B

INSURANCE HOLDING COMPANY SYSTEM

ANNUAL REGISTRATION STATEMENT

Filed with the Insurance Department of the State of

New Hampshire

Name of Registrant

On Behalf of the Following Insurance Companies

Name Address

Date:________________, 20__

Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed:

ITEM 1. IDENTITY AND CONTROL OF REGISTRANT

Furnish the exact name of each insurer registering or being registered (hereinafter called "the Registrant"), the home office address and principal executive offices of each; the date on which each registrant became part of the insurance holding company system; and the method(s) by which control of each registrant was acquired and is maintained.

ITEM 2. ORGANIZATIONAL CHART

Furnish a chart or listing clearly presenting the identities of and interrelationships among all affiliated persons within the insurance holding company system. The chart or listing should show the percentage of each class of voting securities of each affiliate which is owned, directly or indirectly, by another affiliate. If control of any person within the system is maintained other than by the ownership or control of voting securities, indicate the basis of control. As to each person specified in the chart or listing indicate the type of organization (e.g., - corporation, trust, partnership) and the state or other jurisdiction of domicile.

ITEM 3. THE ULTIMATE CONTROLLING PERSON

As to the ultimate controlling person in the insurance holding company system furnish the following information:

(a) Name;

(b) Home office address;

(d) The organizational structure of the person, i.e., corporation, partnership, individual, trust, etc.;

(e) The principal business of the person;

(f) The name and address of any person who holds or owns 10 percent or more of any class of voting security, the class of such security, the number of shares held of record or known to be beneficially owned, and the percentage of class so held or owned; and

(g) If court proceedings involving a reorganization or liquidation are pending, indicate the title and location of the court, the nature of proceedings and the date when commenced.

ITEM 4. BIOGRAPHICAL INFORMATION

If the ultimate controlling person is a corporation, an organization, a limited liability company, or other legal entity, furnish the following information for the directors and executive officers of the ultimate controlling person: the individual's name and address, his or her principal occupation and all offices and positions held during the past 5 years, and any conviction of crimes other than minor traffic violations. If the ultimate controlling person is an individual, furnish the individual’s name and address, his or her principal occupation and all offices and positions held during the past 5 years, and any convictions of crimes other than minor traffic violations.

ITEM 5. TRANSACTIONS AND AGREEMENTS

Briefly describe the following statements in force, and transactions currently outstanding or which have occurred during the last calendar year between the registrant and its affiliates:

(a) Loans, other investments, or purchases, sales or exchanges of securities of the affiliates by the registrant or of the registrant by its affiliates;

(b) Purchases, sales or exchanges of assets;

(d) Guarantees or undertakings for the benefit of an affiliate which result in an actual contingent exposure of the registrant's assets to liability, other than insurance contracts entered into in the ordinary course of the registrant's business;

(e) All management agreements, service contracts and all cost-sharing arrangements;

(f) Reinsurance agreements;

(g) Dividends and other distributions to shareholders;

(h) Consolidated tax allocation agreements; and

(i) Any pledge of the registrant's stock and/or of the stock of any subsidiary or controlling affiliate, for a loan made to any member of the insurance holding company system.

No information need be disclosed if such information is not material for purposes of RSA 401-B:4.

Sales, purchases, exchanges, loans or extensions of credit, investments or guarantees involving one-half of one percent or less of the registrant's admitted assets as of the 31st day of December next preceding shall not be deemed material.

The description shall be in a manner as to permit the proper evaluation thereof by the Commissioner, and shall include at least the following: the nature and purpose of the transaction, the nature and amounts of any payments or transfers of assets between the parties, the identify of all parties to the transaction, and relationship of the affiliated parties to the registrant.

ITEM 6. LITIGATION OR ADMINISTRATIVE PROCEEDINGS

A brief description of any litigation or administrative proceedings of the following types, either then pending or concluded within the first preceding fiscal year, to which the ultimate controlling person or any of its directors or executive officers was a party or of which the property of any such person is or was the subject; give the names of the parties and the court or agency in which the litigation or proceeding is or was pending:

(a) Criminal prosecutions or administrative proceedings by any government agency or authority which may be relevant to the trustworthiness of any party thereto; and

(b) Proceedings which may have a material effect upon the solvency or capital structure of the ultimate holding company including, but not necessarily limited to, bankruptcy, receivership or other corporate reorganizations.

ITEM 7. STATEMENT REGARDING PLAN OR SERIES OF TRANSACTIONS

The insurer shall furnish a statement that transactions entered into since the filing of the prior year's annual registration statement are not part of a plan or services of like transactions, the purpose of which is to avoid statutory threshold amounts and the review that might otherwise occur.

ITEM 8. FINANCIAL STATEMENTS AND EXHIBITS

(a) Financial statements and exhibits should be attached to this statement as an appendix, but list under this item the financial statements and exhibits so attached.

(b) If the ultimate controlling person is a corporation, an organization, a limited liability company, or other legal entity, the financial statements shall include the annual financial statements of the ultimate controlling person in the insurance holding company system as of the end of the person's latest fiscal year.

If at the time of the initial registration, the annual financial statements for the latest fiscal year are not available, annual statements for the previous fiscal year may be filed and similar financial information shall be filed for any subsequent period to the extent such information is available. Such financial statements may be prepared on either an individual basis; or, unless the commissioner otherwise requires, on a consolidated basis if consolidated statements are prepared in the usual course of business.

Other than with respect to the foregoing, such financial statement shall be filed in a standard form and format adopted by the National Association of Insurance Commissioners, unless an alternative form is accepted by the commissioner. Documentation and financial statements filed with the Securities and Exchange Commissioner or audited GAAP financial statements shall be deemed to be an appropriate form and format.

Unless the commissioner otherwise permits, the annual financial statements shall be accompanied by the certificate of an independent public accountant to the effect that the statements present fairly the financial position of the ultimate controlling person and the results of its operations for the year then ended, in conformity with generally accepted accounting principles or with requirements of insurance or other accounting principles prescribed or permitted under law. If the ultimate controlling person is an insurer which is actively engaged in the business of insurance, the annual financial statements need not be certified, provided they are based on the annual statement of the insurer's domiciliary state and are in accordance with requirements of insurance or other accounting principles prescribed or permitted under the law and rules of that state.

Any ultimate controlling person who is an individual may file personal financial statements that are reviewed rather than audited by an independent public accountant. The review shall be conducted in accordance with standards for review of personal financial statements published in the Personal Financial Statements Guide by the American Institute of Certified Public Accountants. Personal financial statements shall be accompanied by the independent public accountant’s Standard Review Report stating that the accountant is not aware of any material modifications that should be made to the financial statements in order for the statements to be in conformity with generally accepted accounting principles.

(c) Exhibits shall include copies of the latest annual reports to shareholders of the ultimate controlling person and proxy material used by the ultimate controlling person; and any additional documents or papers required by Form B or Ins 1501.03 and Ins 1501.05.

ITEM 9. FORM C REQUIRED

A Form C, Summary of Registration Statement, must be prepared and filed with this Form B.

ITEM 10. SIGNATURE AND CERTIFICATION

Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of RSA 401-B:4, registrant has caused this annual registration statement to be duly signed on its behalf in the city of _________________ and state of __________________on the ______day of ______, 20.

(SEAL) _______________________________

Name of Applicant

BY ___________________________________

(Name)(Title)

Attest:

(Signature of Officer)

______________________________

(Title)

CERTIFICATION

The undersigned deposes and says that (s)he has duly executed the attached annual registration statement dated ________, 20, for and on behalf of ___________________(Name of Applicant); that (s)he is the _______________________(Title of Officer) of such company and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.

(Signature) ______________________________________

(Type or print name beneath) ________________________________

Form C

SUMMARY OF CHANGES TO REGISTRATION STATEMENT

Filed with the Insurance Department of the State of

New Hampshire

_____________________________________________ of __________________

Name of Registrant

On Behalf of the Following Insurance Companies

Name Address

Date: _________________ 20_____

Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed:

Furnish a brief description of all items in the current annual registration statement which represent changes from the prior year's annual registration statement. The description shall be in a manner as to permit the proper evaluation thereof by the commissioner, and shall include specific references to item numbers in the annual registration statement and to the terms contained therein.

Changes occurring under Item 2 of Form B insofar as changes in the percentage of each class of voting securities held by each affiliate is concerned, need only be included where such changes are ones which result in ownership or holdings of 10 percent or more of voting securities, loss or transfer of control, or acquisition or loss of partnership interest.

Changes occurring under Item 4 of Form B need only be included where an individual is, for the first time, made a director or executive officer of the ultimate controlling person; a director or executive officer terminates his or her responsibilities with the ultimate controlling person; or in the event an individual is named president of the ultimate controlling person.

If a transaction disclosed on the prior year's annual registration statement has been changed, the nature of such change shall be included. If a transaction disclosed on the prior year's annual registration statement has been effectuated, furnish the mode of completion and any flow of funds between affiliates resulting from the transaction.

The insurer shall furnish a statement that transactions entered into since the filing of the prior year's annual registration statement are not part of a plan or series of like transactions whose purpose it is to avoid statutory threshold amounts and the review that might otherwise occur.

SIGNATURE AND CERTIFICATION

Signature and certification required as follows:

Pursuant to the requirements of RSA 401-B:4, registrant has caused this annual registration statement to be duly signed on its behalf in the city of __________________and state of _____________________on the _____day of _______, 20.

(SEAL) ___________________________________

Name of Applicant

BY _______________________________________

(Name)(Title)

Attest:

(Signature of Officer)

(Title)

CERTIFICATION

The undersigned deposes and says that (s)he has duly executed the attached annual registration statement dated _______________, 20, for and on behalf of ____________________(Name of Applicant); that (s)he is the _______________________(Title of Officer) of such company and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.

(Signature) ___________________________________

(Type or print name beneath)______________________________

Form D

PRIOR NOTICE OF A TRANSACTION

Filed with the Insurance Department of the State of

New Hampshire

Name of Registrant

On Behalf of the Following Insurance Companies

Name Address

Date: _________________ 20_____

Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed:

ITEM 1. IDENTITY OF PARTIES TO TRANSACTION

Furnish the following information for each of the parties to the transaction:

(a) Name;

(b) Home office address;

(d) The organizational structure, i.e. corporation, partnership, individual, trust, etc.;

(e) A description of the nature of the parties' business operations;

(f) Relationship, if any, of other parties to the transaction to the insurer filing the notice, including any ownership or debtor/creditor interest by any other parties to the transaction in the insurer seeking approval, or by the insurer filing the notice in the affiliated parties;

(g) Where the transaction is with a non-affiliate, the name(s) of the affiliate(s) which will receive, in whole or in substantial part, the proceeds of the transaction.

ITEM 2. DESCRIPTION OF THE TRANSACTION

Furnish the following information for each transaction for which notice is being given:

(a) A statement as to whether notice is being given under RSA 401-B:5, I(b)(1), (2), (3), (4) and (5);

(b) A statement of the nature of the transaction;

(d) The proposed effective date of the transaction.

ITEM 3. SALES, PURCHASES, EXCHANGES, LOANS, EXTENSIONS OF CREDIT, GUARANTEES OR INVESTMENTS

Furnish a brief description of the amount and source of funds, securities, property or other consideration for the sale, purchase, exchange, loan, extension of credit, guarantee, or investment, whether any provision exists for purchase by the insurer filing notice, by any party to the transaction, or by any affiliate of the insurer filing notice, a description of the terms of any securities being received, if any, and a description of any other agreements relating to the transaction such as contracts or agreements for services, consulting agreements and the like. If the transaction involves other than cash, furnish a description of the consideration, its cost and its fair market value, together with an explanation of the basis for evaluation.

If the transaction involves a loan, extension of credit or a guarantee, furnish a description of the maximum amount which the insurer will be obligated to make available under such loan, extension of credit or guarantee, the date on which the credit or guarantee will terminate, and any provisions for the accrual of or deferral of interest.

If the transaction involves an investment, guarantee or other arrangement, state the time period during which the investment, guarantee or other arrangement will remain in effect, together with any provisions for extensions or renewals of such investments, guarantees or arrangements. Furnish a brief statement as to the effect of the transaction upon the insurer's surplus.

No notice need be given if the maximum amount which can at any time be outstanding or for which the insurer can be legally obligated under the loan, extension of credit or guarantee is less than (a) in the case of non-life insurers, the lesser of 3 percent of the insurer's admitted assets or 25 percent of surplus as regards policyholders, or (b) in the case of life insurers, 3 percent of the insurer's admitted assets, each as of the 31st day of December next preceding.

ITEM 4. LOANS OR EXTENSIONS OF CREDIT TO A NON-AFFILIATE

If the transaction involves a loan or extension of credit to any person who is not an affiliate, furnish a brief description of the agreement or understanding whereby the proceeds of the proposed transaction, in whole or in substantial part, are to be used to make loans or extensions of credit to, to purchase the assets of, or to make investments in, any affiliate of the insurer making such loans or extensions of credit, and specify in what manner the proceeds are to be used to loan to, extend credit to, purchase assets of or make investments in any affiliate. Describe the amount and source of funds, securities, property or other consideration for the loan or extension of credit and, if the transaction is one involving consideration other than cash, a description of its costs and its fair market value together with an explanation of the basis for evaluation. Furnish a brief statement as to the effect of the transaction upon the insurer's surplus.

No notice need be given if the loan or extension of credit is one which equals less than, in the case of non-life insurers, the lesser of 3 percent of the insurer's admitted assets or 25 percent of surplus as regards policyholders or, with respect to life insurers, 3 percent of the insurer's admitted assets, each as of the 31st day of December next preceding.

ITEM 5. REINSURANCE

If the transaction is a reinsurance agreement or modification thereto, as described by RSA 401-B:5, I(b)(3), or a reinsurance pooling agreement or modification thereto as described in RSA 401-B:5, I(b)(3), furnish a description of the known and/or estimated amount of liability to be ceded and/or assumed in each calendar year, the period of time during which the agreement will be in effect, and a statement whether an agreement or understanding exists between the insurer and non-affiliate to the effect that any portion of the assets constituting the consideration for the agreement will be transferred to one or more of the insurer's affiliates. Furnish a brief description of the consideration involved in the transaction, and a brief statement as to the effect of the transaction upon the insurer's surplus.

No notice need be given for reinsurance agreements or modifications thereto if the reinsurance premium or a change in the insurer's liabilities, or the projected reinsurance premium or change in the insurer’s liabilities in any of the next 3 years, in connection with the reinsurance agreement or modification thereto is less than 5 percent of the insurer's surplus as regards policyholders, as of the 31st day of December next preceding. Notice shall be given for all reinsurance pooling agreements include modifications thereto.

ITEM 6. MANAGEMENT AGREEMENTS, SERVICE AGREEMENTS AND COST-SHARING ARRANGEMENTS

For management and services agreements, furnish:

(a) A brief description of the managerial responsibilities, or services to be performed;

(b) A brief description of the agreement, including a statement of its duration, together with brief descriptions of the basis for compensation and the terms under which payment or compensation is to be made.

For cost-sharing arrangements, furnish:

(a) A brief description of the purpose of the agreement;

(b) A description of the period of time during which the agreement is to be in effect;

(d) A brief description of the accounting basis to be used in calculating each party's costs under the agreement.

(e) A brief statement as to the effect of the transaction upon the insurer’s policyholder surplus;

(f) A statement regarding the cost allocation methods that specifies whether proposed charges are based on “cost or market.” If market based, rationale for using market instead of cost, including justification for the company’s determination that amounts are fair and reasonable; and

(g) A statement regarding compliance with the NAIC Accounting Practices and Procedure Manual regarding expense allocation.

ITEM 7. SIGNATURE AND CERTIFICATION

Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of RSA 401-B:5, _________________has caused this application to be duly signed on its behalf in the city of ___________________________ and state of ____________________________on the _____day of __________, 20.

(SEAL) ___________________________________

Name of Applicant

BY _______________________________________

(Name)(Title)

Attest:

____________________________

(Signature of Officer)

(Title)

CERTIFICATION

The undersigned deposes and says that (s)he has duly executed the attached application dated _______________, 20 ______, for and on behalf of ________________________(Name of Applicant); that (s)he is the (Title of Officer) of such company and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.

(Signature) ___________________________________

(Type or print name beneath) ______________________________

Form E

PRE-ACQUISITION NOTIFICATION FORM

REGARDING THE POTENTIAL COMPETITIVE IMPACT

OF A PROPOSED MERGER OR ACQUISITION BY A

NON-DOMICILIARY INSURER DOING BUSINESS IN THIS STATE

OR BY A DOMESTIC INSURER

Name of Applicant

Name of Other Person

Involved in Merger or Acquisition

Filed with the Insurance Department of the State of New Hampshire

Dated: ______________________, 20 ____________

Name, title, address and telephone number of person completing this statement:

ITEM 1. NAME AND ADDRESS

State the names and addresses of the persons who hereby provide notice of their involvement in a pending acquisition or change in corporate control.

ITEM 2. NAME AND ADDRESSES OF AFFILIATED COMPANIES

State the names and addresses of the persons affiliated with those listed in Item 1. Describe their affiliations.

ITEM 3. NATURE AND PURPOSE OF THE PROPOSED MERGER OR ACQUISITION

State the nature and purpose of the proposed merger or acquisition.

ITEM 4. NATURE OF BUSINESS

State the nature of the business performed by each of the persons identified in response to Item 1 and Item 2.

ITEM 5. MARKET AND MARKET SHARE

State specifically what market and market share in each relevant insurance market the persons identified in Item 1 and Item 2 currently enjoy in this state. Provide historical market and market share data for each person identified in Item 1 and Item 2 for the past 5 years and identify the source of such data. Provide a determination as to whether the proposed acquisition or merger, if consummated, would violate the competitive standards of the state as stated in RSA 401-B:3-a, IV. If the proposed acquisition or merger would violate competitive standards, provide justification of why the acquisition or merger would not substantially lessen competition or create a monopoly in the state.

For purposes of this question, market means direct written insurance premium in this state for a line of business as contained in the annual statement required to be filed by insurers licensed to do business in this state.

Form F

ENTERPRISE RISK REPORT

Name of Registrant/Applicant

On Behalf of/Related to the Following Insurance Companies

Name Address

Date: _________________________ 20___

Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed:

ITEM 1. ENTERPRISE RISK

The Registrant/Applicant, to the best of its knowledge and belief, shall provide information regarding the following areas that could produce enterprise risk as defined in RSA 401-B:1, VII, provided such information is not disclosed in the Insurance Holding Company System Annual Registration Statement filed on behalf of itself or another insurer for which it is the ultimate controlling person:

Any material developments regarding strategy, internal audit findings, compliance or risk management affecting the insurance holding company system;

Acquisition or disposal of insurance entities and reallocating of existing financial or insurance entities within the insurance holding company system;

Any changes of shareholders of the insurance holding company system exceeding 10 percent or more of voting securities;

Developments in various investigations, regulatory activities or litigation that may have a significant bearing or impact on the insurance holding company system; Business plan of the insurance holding company system and summarized strategies for next 12 months;

Identification of material concerns of the insurance holding company system raised by supervisory college, if any, in last year;

Identification of insurance holding company system capital resources and material distribution patterns;

Identification of any negative movement, or discussions with rating agencies which may have cause, or may cause, potential negative movement in the credit ratings and individual insurer financial strength ratings assessment of the insurance holding company system (including both the rating score and outlook);

Information on corporate or parental guarantees throughout the holding company and the expected source of liquidity should such guarantees be called upon; and

Identification of any material activity or development of the insurance holding company system that, in the opinion of senior management, could adversely affect the insurance holding company system.

The Registrant/Applicant may attach the appropriate form most recently filed with the U.S. Securities and Exchange Commission, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the form provides responsive information. If the Registrant/Applicant is not domiciled in the U.S., it may attach its most recent public audited financial statement filed in its country of domicile, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the financial statement provides responsive information.

ITEM 2: OBLIGATION TO REPORT.

If the Registrant/Applicant has not disclosed any information pursuant to Item 1, the Registrant/Applicant shall include a statement affirming that, to the best of its knowledge and belief, it has not identified enterprise risk subject to disclosure pursuant to Item 1.

APPENDIX

Rule

Specific State Statute the Rule Implements

Ins 1501.01

RSA 401-B

Ins 1501.02

RSA 401-B:1

Ins 1501.03

RSA 401-B:3; 401-B:3-a; 401-B:4; 401-B:5

Ins 1501.04

RSA 401-B:3; 401-B:3-a; 401-B:4; 401-B:5

Ins 1501.05

RSA 401-B:3; 401-B:3-a; 401-B:4; 401-B:5

Ins 1501.06

RSA 401-B:3; 401-B:3-a; 401-B:4; 401-B:5

Ins 1501.07

RSA 401-B:2, II

Ins 1501.08

RSA 401-B:3

Ins 1501.09

RSA 401-B:3, IV

Ins 1501.10

RSA 401-B:3

Ins 1501.11

RSA 401-B:3-a, III

Ins 1501.12

RSA 401-B:4

Ins 1501.13

RSA 401-B:4

Ins 1501.14

RSA 401-B:4, IV

Ins 1501.15

RSA 401-B:4, VI & VII

Ins 1501.16

RSA 401-B:4, V & IX

Ins 1501.17

RSA 401-B:5; RSA 402-C

Ins 1501.18

RSA 401-B:4, XII

Ins 1501.19

RSA 401-B, XII; RSA 404-F; RSA 405:47

Ins 1501.20

RSA 401-B:5, II & II-a

Ins 1501.21

RSA 401-B:5, III

Ins 1501.22

RSA 400-A:15, I

Appendices A, B, C, D, E, F

RSA 401-B:3; 401-B:4; 401-B:5

History

#13692, eff 7-21-23

Chapter Ins 1800 Continuing Care Communities

Part Ins 1801 Purpose and Scope

N.H. Code Admin. R. Ann. Ins 1801.01 Purpose {#sec-ins-1801.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1801.01}

The purpose of this chapter is to implement RSA 420-D wherein the general court has provided for the regulation of continuing care communities (CCCs) in order to protect the citizens of the state, particularly senior citizens.

History

#4666, eff 8-22-89; ss by #5654, eff 7-1-93; ss by #7014, eff 7-1-99, EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 1801.02 Scope {#sec-ins-1801.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1801.02}

This chapter shall apply to all CCCs.

History

#4666, eff 8-22-89; ss by #5654, eff 7-1-93; ss by #7014, eff 7-1-99, EXPIRED: 7-1-07
#8991, eff 10-1-07 ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1802 Definitions

N.H. Code Admin. R. Ann. Ins 1802.01 Definitions {#sec-ins-1802.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1802.01}

(a) For the purposes of this chapter, the definitions appearing under RSA 420-D:1 shall apply whenever any word or phrase defined under RSA 420-D:1 is used in this chapter.

(b) With respect to the following words or phrases used in this chapter, but which are not defined under RSA 420-D:1, the following definitions shall apply:

(1) “Escrow date”, as used in RSA 420-D:10, III(d), means the date entrance fees subject to RSA 420-D:10 are placed in an escrow account pursuant to RSA 420-D:10;

(2) “General court” means the assembled senate and house of representatives of the state of New Hampshire as constituted by the constitution of the state of New Hampshire;

(3) “Health care provider” means any physician, hospital, nursing home, visiting nurse association, or any other institution, organization, or person who furnish health care services;

(4) “Health care services” means “health care services” as defined in RSA 420-C:2, V;

(5) “Major changes”, means any change in or affecting the operation of the CCC which causes or is estimated to cause an increase or decrease of 10 percent or more in any line item appearing on either the balance sheet, statement of income and expenses, or the statement of changes in financial position submitted as part of the CCCs annual report required by RSA 420-D:7. The term does not include an increase or decrease in any line item of less than $1,000, the percentage increase or decrease notwithstanding;

(6) “Market value” means, with respect to any security or other asset which is tradable on a recognized financial exchange, the closing price as of the last day the security or other asset was traded on the exchange where the majority of trading in the security or other asset takes place;

(7) “National Association of Insurance Commissioners (NAIC)” means the organization of insurance regulators from the 50 states, the District of Columbia, and United States territories which provides a forum for the development of uniform regulatory policy; and

(8) “Operating expenses” means total expenses less depreciation and amortization expenses.

History

#7014, eff 7-1-99, EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1803 Certificate of Authority

N.H. Code Admin. R. Ann. Ins 1803.01 Application Procedures {#sec-ins-1803.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1803.01}

(a) All CCCs seeking a certificate of authority shall file an application form, specified in (d) below, with the insurance department.

(b) In addition to the information specified in (c) below, the following additional information or supporting material shall accompany each application:

(1) The disclosure statement as described under RSA 420-D:4 and Ins 1808;

(2) A statement indicating any other state or federal licensure or certification which the continuing care facility might have or be required to have and the current status of such licensure or certification;

(3) The appropriate application fee pursuant to Ins 1809; and

(4) Notarized documents, which shall include the name, address, telephone number, and principal business activities of the escrow agent, indicating that an escrow account for entrance fees has been established, when RSA 420-D:10 requires an escrow account for these fees.

(c) As part of the application process all CCCs shall provide a biographical affidavit notarized by a notary public, from any officer, trustee, investor, owner with more than 5 percent ownership, or executive director, or equivalent title, who is not an officer or trustee, that shall include the following:

(1) Specify whether the application is for a certificate of authority, a new affiant, or a current affiant update;

(2) The name and address of the continuing care provider;

(3) The name and position of the affiant;

(4) A listing of other names used by the affiant at any time and the reason for, any name changes, if any, for the affiant;

(5) The affiant's business address, telephone number, and cell phone number;

(6) The educational background of the affiant, including the name and location of colleges or universities attended, the dates of attendance, and any degrees earned;

(7) A listing of the affiant's membership in professional societies and associations;

(8) The affiant's present or proposed position with the provider;

(9) A listing of the complete employment record of the affiant for the past 10 years, up to and including present position, and shall include the dates of employment, the name and address of each employer and the job title held, including any positions held as a company level officer or director;

(10) A statement as to whether or not the present employer may be contacted;

(11) A statement as to whether or not former employers may be contacted;

(12) A statement as to whether or not the affiant has ever been in a position which required a fidelity bond;

(13) If the answer to (12) above is affirmative, and if any claims were made on the bond, the affiant shall state the details of each such claim;

(14) A statement as to whether or not the affiant has ever been denied an individual or position schedule fidelity bond or if any such bond has ever been cancelled or revoked;

(15) If the answer to (14) above is affirmative, a statement as to the details of each denial, cancellation, or revocation;

(16) A listing of the professional, occupational, and vocational licenses issued by any public or governmental licensing agency or regulatory authority which the affiant presently holds or has held in the past, including the date the license was issued, the issuer of the license, the date the license was terminated, and the reason for termination;

(17) A statement as to whether or not the affiant has, within the last 10 years, been refused a professional, occupational, or vocational license by any public or governmental licensing agency or regulatory authority, or had any such license held suspended or revoked;

(18) If the answer to (17) above is affirmative, the affiant shall state the details of each denial, cancellation, or revocation;

(19) A listing of the continuing care providers or health care facilities in which the affiant controls, directly or indirectly, or owns legally or beneficially 10 percent or more of the outstanding voting stock, in voting power;

(20) A statement by the affiant as to whether the affiant or members of their immediate family will subscribe to or own, beneficially or of record, any shares of stock in the continuing care provider or in any affiliate of the continuing care provider;

(21) If any of the shares or stock noted in the answer to (20) above are pledged or hypothecated in any way, the affiant shall provide an explanation of these circumstances, including who the shares are pledged to, the amount of the share pledged, and the total shares issued;

(22) A statement by the affiant as to whether or not they have ever been adjudged bankrupt;

(23) A statement by the affiant, and the date, nature, and place of the charge and outcome of if affirmative, as to whether the affiant has ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended or been pardoned for conviction of or pleaded guilty or nolo contendre to an information or indictment charging any felony, or charging a misdemeanor involving embezzlement, theft, larceny, or mail fraud, or charging a violation of any corporate securities statute or any insurance law;

(24) Whether the affiant has ever been the subject of any disciplinary proceedings of any federal or state regulatory agency, and the date, nature, and place of the charge and outcome if affirmative;

(25) A statement by the affiant as to whether or not any company has ever been charged as in (23) above, allegedly as a result of any action or conduct on the part of the affiant;

(26) A statement by the affiant as to whether or not the affiant has ever been an officer, director, trustee, investment committee member, key employee, or controlling stockholder of any company or organization which, while the affiant occupied any such position or capacity with respect to it, became insolvent or was placed under supervision or in receivership, rehabilitation, liquidation, conservatorship, or filed bankruptcy;

(27) A statement by the affiant, and the date, nature of the suspension and disposition if affirmative, as to whether or not the certificate of authority or license to do business of any provider or company of which the affiant was an officer, or director or key management person has ever been suspended or revoked while the affiant occupied such position; and

(28) A dated signature of the affiant by which the affiant certifies that they are acting on their own behalf and that the foregoing statements are true and correct to the best of the affiant's knowledge and belief.

(d) The applicant shall provide, in addition to the requirements of RSA 420-D:2, III, the following information on the “Application for Permanent Certificate of Authority as a Continuing Care Facility”:

(1) The continuing care facility’s name, type of business organization, and state law under which the business is organized;

(2) The facility's home address, if within the United States, or the United States branch office if the home address is outside of the United States;

(3) The principal mailing address;

(4) Whether the department ever issued a temporary certificate of authority to the applicant and, if yes, the date of expiration;

(5) Certification that the applicant, if issued a certificate of authority, will abide by the applicable rules of the department;

(6) Certification that the applicable requirements of RSA 420-D have been met;

(7) Whether the license or authority of the CCC facility, or affiliated facility of a controlling organization, has ever been revoked, suspended, or canceled in any jurisdiction;

(8) Whether any previous application of the CCC facility, or affiliated facility of a controlling organization, for a license or authority has been denied in any jurisdiction; and

(9) If an affirmative answer is given to the information requested in (7) or (8) above, the details of any revocation, suspension, cancellation, or denial.

(e) The commissioner shall act upon applications received within a reasonable time, as set forth in RSA 541-A:29, II(a).

(f) CCCs who have applications pending shall keep their application and any accompanying information or supporting material current, and file any amendments or other changes on a timely basis.

(g) Any applicant whose application is rejected shall be entitled to a hearing in accordance with the provisions of RSA 541, RSA 541-A, and Ins 200 and shall be so notified.

History

#7014, eff 7-1-99, EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 1803.02 Revocation or Suspension {#sec-ins-1803.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1803.02}

(a) The commissioner shall not revoke or suspend a certificate of authority issued to any CCC except upon notice and hearing and written findings of fact that one or more of the conditions specified in RSA 420-D:5, I exist.

(b) Any hearing which the commissioner shall convene in order to exercise the power granted by RSA 420-D:5 shall be considered as an adjudicative proceeding as defined under RSA 541-A:1, I.

(1) In proceeding against any CCC for the purpose of revoking or suspending its certificate of authority, the commissioner shall provide the CCC with reasonable notice of hearing. Such notice of hearing shall be in accordance with RSA 541-A:31, III and Ins 200;

(2) Hearings conducted pursuant to RSA 420-D:5 and this section shall be conducted pursuant to all relevant provisions of RSA 541-A and Ins 200;

(3) Any prehearing conferences shall be held pursuant to Ins 200; and

(4) The findings of the hearing officer and any order upon such findings shall be made pursuant to RSA 541-A:35 and Ins 200.

(d) When pursuant to RSA 420-D:5, I(j) the commissioner finds that a condition that is hazardous or injurious to residents or to the general public requires emergency action, the commissioner, as authorized under RSA 541-A:30, III, shall order an immediate suspension of a certificate of authority. In so doing, the commissioner shall proceed according to Ins 200.

(e) Requests for rehearings shall be made in writing and shall be made pursuant to the provisions of RSA 541. All appeals from orders issued by the hearing officer shall be made pursuant to RSA 420-D:6 and in accordance with the provisions of RSA 541.

History

#7014, eff 7-1-99, EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1804 Annual Reports

N.H. Code Admin. R. Ann. Ins 1804.01 Annual Reports {#sec-ins-1804.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1804.01}

(a) Each CCC who uses the calendar year as its fiscal year shall submit a report on or before May 1 of each year, detailing its fiscal status as of the close of business on December 31 of the just completed calendar year.

(b) Each CCC who uses an annual period other than the calendar year as its fiscal year shall submit a report detailing its financial status as of the close of business on the last day of its fiscal year within 120 days after the close of the fiscal year.

(d) Upon written notice to the CCC, the commissioner shall require the CCC to submit any journals, ledgers, or other records which serve as back-up material for any one or more of the financial statements listed in RSA 420-D:7. The commissioner shall make such requests whenever it is necessary to verify the accuracy of the financial statements included as part of the CCCs annual report.

(e) To be considered complete upon submission, the annual reports included under (c) above shall include complete answers to all general interrogatories and all notes to the financial statements which are considered customary or necessary to full disclosure and adequate understanding of the financial statements, the financial condition of the CCC, and the operation of the CCC.

(f ) The financial statements shall be accompanied by a statement of actuarial opinion indicating whether the data and assumptions used are appropriate, whether the methods employed are consistent with sound actuarial principles and practices, and whether provisions have been made for all actuarial liabilities and related statement items which ought to be established.

(g) The actuarial opinion shall also contain appropriate comment on the CCCs perceived ability to operate the CCC as a going concern and the impact of any actuarial deficit. If the actuary is unable to form a needed opinion, or if the opinion is adverse or qualified, the statement of actuarial opinion shall specifically state the reason. The actuarial opinion shall be rendered by a qualified actuary as defined in Ins 901.02.

History

#7014, eff 7-1-99; amd by #7994, eff 12-1-03; ss by #8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 1804.02 Quarterly Reports. {#sec-ins-1804.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1804.02}

The CCC shall submit quarterly reports as provided in RSA 420-D:7-a within 45 days of the close of each quarter containing the information required by RSA 420-D:7-a.

History

#14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1805 Liquid Reserves

N.H. Code Admin. R. Ann. Ins 1805.01 Liquid Reserves {#sec-ins-1805.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1805.01}

(a) When a CCC calculates whether the value of its liquid reserves meets the amount RSA 420-D:8 requires, the CCC may include the values of the assets listed below:

(1) Cash held in an account of a financial institution; or

(2) The following assets that can be liquidated, based upon the net value after liquidation:

a. Certificates of deposit issued by a financial institution;

b. Money-market funds issued by an investment company as defined by U.S.C. Title XV, Section 80a-3;

c. Acceptable negotiable securities which shall include only United States government obligations and corporate debt obligations rated A or above in Moody's or Standard and Poor's corporate bond rating publication or a 1 or 2 rating by the NAIC valuation of securities publication;

d. Commercial paper in the form of promissory obligations of an issuer with an original maturity date not exceeding 9 months from the date of issuance, having the highest rating in a rating publication indicated in c. above;

e. Equity securities including mutual funds; and

f. Lines of credit and letters of credit.

(b) For the purpose of determining whether the assets included in the liquid reserve account of a CCC satisfy the liquid reserve requirement of RSA 420-D:8, such assets held in the form of cash shall be valued at their actual value in U.S. currency. Assets held in any other form shall be valued at their market value.

(c) For the purpose of determining the amount of the liquid reserve that a CCC shall maintain, the term “12 months principal and interest payments” appearing in RSA 420-D:8 means the CCCs liabilities which would be reported to show the statutory liquid reserve as of the end of current year on the balance sheet that would be included with the actuarial report, as required by Ins 1804, as if an actuarial report had been prepared for the 12 calendar months ending on the last day of the previous month.

(d) For the purpose of determining the amount of the liquid reserve that a CCC shall maintain, the term “that portion of 2 months' operating expenses which relates to life care residents” appearing in RSA 420-D:8 means the amount of the estimated operating expenses for the 2 calendar months following the current month.

(e) The liquid reserve required at any point in time shall be the sum of the amounts determined in accordance with (c) and (d) above. This amount shall be referred to as the minimum liquid reserve.

(f) If it is in the best interest of the residents, the commissioner shall require a CCC to maintain its liquid reserves in an escrow account if the facility is determined to be in financial difficulty. This requirement shall be integrated into the CCC's financial plan pursuant to RSA 420-D:15-a.

(g) For the purpose of (f) above, financial difficulty shall include, but not be limited to, any one or more of the following circumstances:

(1) Payments on accounts payable or notes payable being made on average 45 days or more after the due date;

(2) A tax lien is filed against the CCC;

(3) Fifty percent of accounts receivable, except Medicare or Medicaid, average more than 45 days; and

(4) Days-cash-on-hand drops below 100 days or occupancy of independent living drops below 80 percent, or both.

(h) All such escrow accounts shall comply with the rules for entrance fee escrow accounts as set forth under Ins 1807. In the course of establishing an escrow account, the CCC shall advise the commissioner as to the name, address, telephone number, and principal business activities of the escrow agent. The CCC shall notify the commissioner of any subsequent change in escrow agent by providing the name, address, telephone number, and principal business activities of the new escrow agent within 5 business days.

History

#7014, eff 7-1-99, EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 1805.02 Days-Cash-On-Hand Calculation {#sec-ins-1805.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1805.02}

(a) “UC” means unrestricted current and noncurrent cash.

(b) “BTHR” means bond or lender held reserve funds.

(d) “Ex” means operating expenses.

(e) “Dep” means depreciation.

(f) “Am” means amortization.

(g) To calculate days-cash-on-hand, the commissioner shall calculate the sum of UC and BTHR and IN and divide this result by the quotient of Ex minus Dep minus Am divided by 365, as in the following formula:

UC + BTHR + IN

(Ex-Dep-Am)/365

History

#10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1806 Procedures for Obtaining and Extending Liens

N.H. Code Admin. R. Ann. Ins 1806.01 Procedures for Obtaining and Extending Liens {#sec-ins-1806.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1806.01}

(a) If it is in the best interest of the residents, the commissioner shall file a lien on all real and personal property of a CCC, pursuant to RSA 420-D:9, whenever the commissioner has evidence showing that the CCC has breached its contracts with residents or is engaged in activity which is harmful to residents' physical or mental well-being. Any such lien shall be filed and administered in accordance with all applicable laws respecting such liens.

(b) When the commissioner forecloses a lien, the commissioner shall prepare a plan to distribute any proceeds from the foreclosure in a manner that will best permit the satisfaction of any resident contracts in effect at that time. The commissioner shall give a written copy of this plan to each contract holder affected by the foreclosure and shall allow contract holders to comment on the plan before the commissioner distributes any proceeds. The commissioner shall allow affected contract holders to submit comments for a period of at least 15 days after the date on which the commissioner mailed copies of the plan.

(c) With respect to the lien property, liens established by the commissioner shall not have priority over mortgages, security agreements, lease agreements, or installment sales agreements on property otherwise encumbered which a CCC has entered into with an issuer of bonds or notes and bonds which are secured by resolution, ordinance, or indenture of trust if such mortgages or agreements were duly recorded at least 4 months prior to the institution of rehabilitation or liquidation proceedings.

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1807 Entrance Fee Escrow Accounts

N.H. Code Admin. R. Ann. Ins 1807.01 Entrance Fee Escrow Accounts {#sec-ins-1807.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1807.01}

(a) Escrow accounts established to hold entrance fees pursuant to RSA 420-D:10, or accounts required by the commissioner to hold liquid reserves, shall comply with each of the following:

(1) Escrow account funds shall be kept and maintained in an account separate and apart from the business account of the CCC;

(2) All escrow account funds derived from entrance fees shall remain the property of the resident, prospective resident, or other person making payment on behalf of a resident or prospective resident and shall not be subject to any liens or charges by the escrow agent, or judgments, garnishments, or creditor's claims against the CCC, until the funds have been released to the CCC as provided in RSA 420-D:10;

(3) Interest in an escrow account may be released to a CCC when any portion of the corresponding entrance fee is released to the CCC or when the resident makes their first monthly payment, whichever occurs first;

(4) All records pertaining to the escrow account shall be available for inspection or audit by the commissioner at any time;

(5) Any CCC that establishes an escrow account with an escrow agent shall enter into a written agreement with the escrow agent which:

a. States that its purpose is to protect the resident or prospective resident;

b. Authorizes the commissioner to inspect the records of the escrow agent relating to the escrow account; and

c. Provides that, upon order of the commissioner or a court of competent jurisdiction, the escrow agent shall release and pay over the funds, or a portion thereof, to the CCC, resident, prospective resident, or other person entitled thereto as ordered; and

(6) A copy of each escrow agreement entered into by the CCC shall be filed with the commissioner for approval.

(b) When the escrow agent releases funds to a CCC, the agent shall adhere to the requirements of RSA 420-D:10.

(c) In lieu of maintaining entrance fee payments in escrow accounts, a CCC may, upon the commissioner's approval, post bond, negotiable securities, or a letter of credit, with the commissioner.

(d) Approval of the commissioner shall be subject to the following conditions:

(1) The institution providing the bond or the letter of credit shall be acceptable to the commissioner. In the case of a letter of credit, the institution issuing the letter of credit shall be a qualified United States financial institution as defined in RSA 406-C:2, IV. In the case of a bond, the surety institution issuing the bond shall be acceptable if it is a surety company authorized to transact business in New Hampshire;

(2) The amount of the bond, negotiable securities, or line of credit specified in the letter of credit shall be set by the commissioner as provided in (5) below;

(3) Negotiable securities posted in lieu of escrow shall, for the purpose of determining if they satisfy the amount set by the commissioner, be valued at 75 percent of their market value. After posting the initial negotiable securities, the CCC shall be responsible for monitoring the market value of the negotiable securities on deposit;

(4) Should the negotiable securities on deposit at any time be valued at less than 133.3333 percent of the amount required, the CCC shall post additional negotiable securities as required so that the negotiable securities posted shall at all times be equal to 133.3333 percent of the amount required. Negotiable securities posted shall be securities that are tradable on the New York Stock Exchange, the American Stock Exchange, or other comparable securities exchange;

(5) In setting the initial amount required for the bond, negotiable securities, or the line of credit specified in the letter of credit, whichever is to be posted, the commissioner shall take into consideration the amount of the entrance fees, interest accrued thereon, and other fees to be charged in addition to the number of life interest or long-term leases to be offered, granted, or sold. The commissioner shall revise the amount required to be held in escrow using the same procedure used to set the initial amount required upon review of the CCCs most recent financial statements;

(6) The CCC requesting that the commissioner approve posting of a bond, negotiable securities, or letter of credit in lieu of maintaining escrow accounts shall demonstrate to the commissioner that it meets a high standard of financial worthiness;

(7) To demonstrate that it meets the required standard, the CCC shall provide the commissioner with data showing either:

a. That its standard financial statement ratios are better than the industry-wide continuing care facility average by 25 percent or more; or

b. That its liquid assets as shown on the most recent balance sheet, but not including the liquid reserve as determined under Ins 1805, are equal to 300 percent of the amount set by the commissioner for the bond, negotiable securities, or letter of credit to be posted;

(8) The commissioner shall be a party to any bond posted;

(9) No bond posted shall be cancelled except with 90 days prior notice to the commissioner; and

(10) CCCs posting negotiable securities with the commissioner shall file a “Custodial Agreement”.

(e) A CCC posting negotiable securities shall deposit said securities in a custodial account to be held by the custodian in trust for the benefit and security of policyholders, claimants, or creditors of the CCC.

(f) A custodial agreement shall:

(1) Be signed by the facility and the custodian;

(2) State the amount maintained on deposit with the custodian;

(3) Hold securities placed in the custodian account exclusively for the commissioner as trustee in trust for the benefit of New Hampshire policyholders, claimants, or creditors with a claim against the facility;

(4) Provide that non-registered securities may be held as follows:

a. Coupon/bearer form;

b. At book entry in a federal reserve bank; or

c. At the depository trust company as either a direct bank or indirect depository participant;

(5) Require all registered securities be held and registered as follows:

a. Under the name “Insurance Commissioner of New Hampshire in Trusts for the Benefit and Security of all Policyholders and Claimants of the ______ in the United States”; or

b. In the name of the custodian bank’s nominee, without impairing the custodian’s responsibility to the company.

(6) Provide that the custodian is liable to the facility and the commissioner for the custodian's negligence, willful misconduct, or lack of good faith;

(7) Provide that no securities in the account nor any principal is released except upon written request of the facility and written assent to or in the name of the commissioner;

(8) Provide that the facility may withdraw securities from the account, with the approval of the commissioner;

(9) Provide that the commissioner will approve withdrawals under the circumstances in (8) above so long as other securities are deposited with the custodian with market value equal to those withdrawn;

(10) Provide that the custodian may surrender any security held under the agreement for payment upon maturity or redemption so long as the proceeds thereof are held in a principal cash account maintained as part of the custodial account in accordance with the custodial agreement;

(11) Provide that all transactions and withdrawals involving deposited securities or principal cash be consummated only upon prior receipt of instructions from the company and written assent of the commissioner as trustee;

(12) Provide that the custodian send advice to the commissioner of security and cash transactions within 10 days after a transaction, with a copy to the company;

(13) Provide that the custodian shall send advices with respect to all income transactions to the company only;

(14) Provide that the custodian send to the commissioner a certificate of account assets by February 1 for the preceding calendar year through December 31;

(15) Provide that all income collected on or received from the securities held under the agreement shall be paid to or upon the order of the company;

(16) Provide that upon the written direction of the commissioner, pursuant to an order of a court of competent jurisdiction, the custodian shall turn the deposits held under this agreement over to the commissioner or in accordance with the court order or direction of the commissioner;

(17) Provide that the custodian shall be accountable to the commissioner of insurance for the safekeeping of the securities and principal cash held by it under this agreement;

(18) Provide that, as often as the commissioner or company requests, the custodian shall prepare a certificate concerning the assets in the account as of the date of the request and deliver such certificate to the commissioner with a copy to the company;

(19) Include a provision that the custodian may cancel this agreement, effective not less than 30 days after receipt of notice thereof by the company and the commissioner, and the company may cancel this agreement at any time without any reason, effective upon the receipt of notice from the custodian and the commissioner, provided that no cancellation by either party will be effective until:

a. A new custodian agreement is executed by the company with another custodian, approved by the commissioner; and

b. The securities and principal cash in the custodian account as transferred to the newly designated custodian in accordance with written instructions from the company, provided that if no new custodian agreement is entered into, the current agreement might be cancelled and the securities and any balance in the principal cash account released to the commissioner;

(20) Include a provision that any successor in interest of the custodian, or receiver, liquidator or other public officer appointed to administer the affairs of the custodian, shall succeed to all the obligations assumed by the custodian in the agreement; and

(21) Include a provision that the agreement shall become effective when executed by the parties.

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; amd by #12912, eff 10-28-19; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1808 Standards for Resident Contract and Disclosure Statements

N.H. Code Admin. R. Ann. Ins 1808.01 Requirements for Documents {#sec-ins-1808.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1808.01}

(a) Documents given to residents and prospective residents, including contracts with residents and disclosure statements, shall:

(1) Use language that a person of average intelligence and education can read and understand;

(2) Present information in a logical sequence and in a clear and direct fashion;

(3) Avoid complex and compound sentences;

(4) Use words in a manner which shall convey their commonly understood meanings;

(5) Include definitions for words or terms which cannot properly be explained or qualified in the text;

(6) Capitalize a defined word in any contract or disclosure statement;

(7) Use frequent section headings to permit ease in locating provisions;

(8) Be printed in easily legible typeface; and

(9) Contain an index, which shall be either the first page of the document or whose location shall be noted on the first page of the document, which lists all section headings used in the document if the document is more than one page in length.

(b) If pre-existing conditions are excluded from the medical care and services available from the CCC, but are available at an additional charge or are limited as to coverage, the term pre-existing condition shall not limit coverage beyond that stated in the following:

"A pre-existing condition is a disease, illness, sickness, or physical condition for which medical care, advice, or treatment was recommended by or received from a physician within the 2 year period preceding the date the CCC committed itself to accept the individual as a resident."

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 1808.02 Resident Contract Standards {#sec-ins-1808.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1808.02}

(a) All contracts between a CCC and a resident shall be executed on a form which has been previously approved by the commissioner. To obtain approval for the contract form, the CCC shall provide the commissioner, via email, with a copy of the proposed contract form in PDF format and a cover letter. The cover letter shall provide a brief description of the main features of the contract form. Upon review of the proposed contract form, the commissioner shall notify the CCC of approval or disapproval of the form. When the contract forms are submitted, the CCC shall also submit to the commissioner the fee required by Ins 1809. After the fee has been received, the commissioner shall approve the proposed contract form if the commissioner finds that it complies with all requirements of RSA 420-D and Ins 1808.01.

(b) Each contract with a resident shall have attached a separate page notifying prospective residents of their right to rescind the contract, as follows:

(1) The notice shall indicate the date the rescission period begins;

(2) The notice shall include a statement to the effect that the prospective resident may rescind and terminate their contract or agreement, without penalty or forfeiture, within 15 days of the date the rescission period begins, as specified in (1) above;

(3) The notice shall include a statement that the prospective resident is not required to move into the CCC before the expiration of the 15 day rescission period and that no other agreement or statement signed by the prospective resident shall constitute a waiver of the right to rescind the contract or agreement within the 15 day rescission period;

(4) The notice shall include instructions advising the prospective resident who wishes to rescind their contract or agreement that:

a. The prospective resident may by mailing or delivering a signed and dated copy of the notice, or any other dated written notice, email, letter, or facsimile, stating the prospective resident’s desire to rescind the contract or agreement to the CCC; and

b. Such notice to the CCC must be sent electronically or mailed to the business address of the CCC not later than midnight of the date of the last day for rescission, as specified on the notice by the CCC; and

(5) The notice shall include a form that the prospective resident can use to notify the CCC that the prospective resident is canceling the contract or agreement, as permitted by the notice of the right to rescind. This form shall include a line where the prospective resident may place their signature and write in the date of signature.

(c) Each contract shall set forth the terms and conditions governing the return of the resident’s entrance fee. The contract shall control when the entrance fee shall be returned to the resident, except as provided in (d).

(d) If hardship exists, the entrance fee, if any, based on the terms of the contract, shall be returned as follows:

(1) No later than 12 months from the date of the termination if the CCC is at 80% or greater occupancy; or

(2) No later than 24 months from the date of the termination if the CCC is at less than 80% occupancy.

(e) For purposes of this section “hardship” means:

(1) A change in circumstances that has necessitated the termination of the contract between the resident and the CCC;

(2) The resident, as a result of a change in circumstances, cannot obtain acceptable living accommodations or health care services from the CCC; and

(3) The resident cannot otherwise pay for such necessary room, board, or health care services outside the CCC without a return of the entrance fee under the terms of the contract.

(f) For the purposes of paragraph (e), “acceptable living accommodations” means living arrangements that:

(1) Are within the financial means of the resident;

(2) Provide for needed health care services, including mental health services; and

(3) Respect and reflect the right of the resident to self-determination, dignity, religious affiliations, freedom of association, and other personal interests as those interests are described in patient and senior citizens’ bill of rights laws such as RSA 151:21 and RSA 161-M:3.

(g) Contracts subject to paragraph (d) shall state that in the event of a dispute as to the existence of hardship, the CCC shall provide the resident with a written notice stating the grounds for its denial, and shall include the following statement: “We will of course, be available to you to discuss the position we have taken. Should you, however, wish to take this matter up with the New Hampshire Insurance Department, it maintains a consumer service division to investigate resident complaints at 21 South Fruit Street, Suite 14, Concord, New Hampshire 03301. The New Hampshire Insurance Department may be reached, toll-free, by dialing 1-800-842-3416.”

(h) If the CCC contract does not provide for assisted living, skilled nursing care, or nursing home care, the contract shall state this prominently, on the first page of the contract and in at least 14-point bold capital letters. This statement shall be preceded by the following caption:

“THIS CONTRACT DOES NOT PROVIDE YOU WITH ANY RIGHT TO RECEIVE THE FOLLOWING CARE”

(i) The CCC shall submit to the commissioner for approval any revision or amendment to an approved contract form. This submission shall include a copy of the revised contract or amendment form in PDF format and a cover letter. The cover letter shall list and describe each amendment or revision to the previously approved contract form. Upon review of the amendment or revision to the contract form, the commissioner shall notify the CCC of approval or disapproval of the form. The commissioner shall approve the amendment or revision to the contract form if the commissioner finds that they comply with all requirements of RSA 420-D and this part.

(j) When submitting either a proposed contract form, amendments, or revisions to a contract form to the commissioner for approval, the CCC shall, in a supplement to the cover letter, list every instance where the contract form will use variable language. In this supplement, the CCC shall describe the complete range of variable language that will appear in the contract form for each instance listed.

(k) All contracts with residents shall be printed in 12 point type or larger and shall be prepared in a manner to ensure legibility and ease of reading.

(l) A valid and binding contract with a resident shall be signed by the CCC and each resident who is admitted to the CCC. An authorized representative may sign the contract with a resident on behalf of either party.

(m) If the resident has agreed to purchase, at an additional price, optional products or services beyond those included in the entrance and periodic fees, a separate page shall be attached specifying the product or service purchased, and the cost of each including any installation charge. Each such separate page shall be executed by the parties identified in paragraph (l).

(n) The contract with resident shall be distributed as follows:

(1) A copy of the current contract with resident form shall be attached as an appendix to each disclosure statement or amended disclosure statement filed with the commissioner;

(2) A copy of the current contract with resident form shall be attached to each disclosure statement given to a prospective resident, unless the individual previously received a disclosure statement with a current contract with resident form attached thereto;

(3) A copy of the current contract with resident form may be given to current residents; and

(4) If a contract with resident form is not attached to the disclosure statement, as authorized under paragraph (2) above, a separate page shall be attached stating that a copy of the contract with resident form was omitted.

(o) Each CCC shall maintain copies of each contract with resident form it has executed with a resident until the conclusion of the next succeeding audit by the department following the date the contract ceases to be in force.

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

N.H. Code Admin. R. Ann. Ins 1808.03 Disclosure Statements {#sec-ins-1808.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1808.03}

(a) A CCC shall submit all disclosure statements to the commissioner for prior approval. No CCC shall distribute a disclosure statement in any manner to prospective residents, residents, or residents' authorized representatives, until the commissioner has approved the format of the disclosure statement.

(b) To obtain approval for the disclosure statement, the CCC shall submit to the commissioner:

(1) A copy of the proposed disclosure statement;

(2) A cover letter, which shall briefly describe the main features of the disclosure statement; and

(3) The examination fee required by Ins 1809.

(c) The commissioner shall approve the proposed disclosure statement if the commissioner finds that it complies with all requirements of RSA 420-D and this part.

(d) The commissioner shall notify the CCC when the commissioner has approved or disapproved the disclosure form.

(e) The CCC shall submit to the commissioner for the commissioner’s approval any revision or amendment to an approved disclosure statement. This submission shall include a copy of the revised disclosure statement or amendment thereto, a cover letter, and the fee required by Ins 1809. The cover letter shall list and describe each amendment or revision made to the previously approved disclosure statement. Upon review of the amendment or revision to the disclosure statement, the commissioner shall notify the CCC of the commissioner’s approval or disapproval. The commissioner shall approve the amendment or revision to the disclosure statement if the commissioner finds that it complies with all requirements of RSA 420-D and this part.

(f) In addition to the requirements of RSA 420-D:4 and Ins 1808.01, the disclosure statement shall comply with the following rules:

(1) The disclosure statement shall include a statement advising the prospective resident that New Hampshire law requires the CCC to provide the prospective resident with a disclosure statement before the initial transfer of funds and before the prospective resident consents to any contract with the CCC; and

(2) The notice required by RSA 420-D:4, I shall appear on the cover page of the disclosure statement in a prominent location and typeface.

(g) Changes in the operation of a CCC which require an amendment to the disclosure statement shall include the following:

(1) Changes in the board of directors, officers, managing or general partners, administrators or trustees, and managers which affect the management of the CCC. The CCC shall file biographical affidavits by these individuals with the commissioner at the time the CCC submits an amended disclosure statement;

(2) Any new or additional mortgages, liens, security interests, loan commitments, long-term financing arrangements, or leases, which materially affects the real property of the CCC. The CCC shall file a copy of all pertinent documents evidencing the transactions with the commissioner at the time the CCC submits an amended disclosure statement; and

(3) Other material changes in the financial or factual information contained in the disclosure statement or any statement in support of the CCCs original application for a certificate of authority. The CCC shall file explanatory material and copies of pertinent documents concerning the material changes with the commissioner at the time the CCC submits an amended disclosure statement.

(h) All disclosure statements shall be printed in 12 point type or larger.

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1809 Fees

N.H. Code Admin. R. Ann. Ins 1809.01 Fees {#sec-ins-1809.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1809.01}

(a) Upon each application for a permanent certificate of authority, the applicant shall pay a fee of $800.00 to the state of New Hampshire.

(b) Upon each filing of the annual report as required pursuant to Ins 1804, the CCC shall pay a fee of $800 to the state of New Hampshire.

(c) A CCC shall pay a fee of $80.00 to the state of New Hampshire for each separate resident contract submitted for review by the commissioner.

(d) Upon each application for a new certificate of authority required pursuant to RSA 420-D:13, II, when management control of more than 50% of the assets of a facility are transferred to another party, the applicant shall pay a fee of $400.00 to the state of New Hampshire.

(e) When the commissioner audits or investigates a CCC pursuant to RSA 420-D:23 or RSA 420-D:21, the CCC shall bear the expense of the audit or investigation as follows:

(1) The commissioner shall present quarterly bills for the expenses charged to all CCCs who have been audited or who are scheduled for audits in the current fiscal year of the insurance department. The first 3 quarterly bills shall be estimated bills. The final quarterly bill shall be for actual charges made that fiscal year;

(2) The CCC shall be liable for the expenses associated with an audit or investigation in accordance with RSA 400-A:37. However, the per diem allowance to compensate state employees under RSA 400-A:37, VII, exclusive of expenses, shall not exceed $1,000; and

(3) All such expenses of an audit or investigation charged and billed shall be payable to the state of New Hampshire except as provided by RSA 400-A:37.

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1810 Audits

N.H. Code Admin. R. Ann. Ins 1810.01 Audits {#sec-ins-1810.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1810.01}

(a) The commissioner shall audit the books and records of each licensed CCC at least once every 5 years.

(b) Upon completion of any audit conducted by the commissioner, a written audit report shall be prepared.

(c) The audit report shall be submitted to the CCC audited. The CCC may object to the report within 30 days from the receipt thereof. Any such objection shall take the form of a request for a hearing in compliance with the procedures described under Ins 200.

(d) When the CCC has raised an objection to the audit report, the commissioner shall hold a hearing in compliance with the hearing procedure established by Ins 200 and RSA 541-A:30-a through RSA 541-A:38.

(e) The audit report and all information obtained or produced in the conduct of the audit shall be governed by the confidentiality provisions of RSA 400-A:37.

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1811 Transfer or Sale of Interest

N.H. Code Admin. R. Ann. Ins 1811.01 Transfer or Sale of Interest {#sec-ins-1811.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1811.01}

(a) When a transfer or sale of interest is proposed, the commissioner shall receive notice pursuant to RSA 420-D.

(b) Such notice shall include:

(1) A biographical affidavit, described in Ins 1803.01(c), for any proposed new officer, trustee, investor, owner with more than 5% ownership, or new executive director, or equivalent title, who is not an officer or trustee;

(2) The most recent balance sheet and income statement of any party who is proposed to acquire an ownership interest of 5% or more, if the transfer or sale of interest involves less than 50% but more than 5% of the interests of the continuing care facility;

(3) A detailed account of any changes that will occur in the debt structure of the continuing care facility or the CCC; and

(4) A detailed account of the resulting debt service requirements, with notes explaining how these debt service requirements differ from the requirements in existence prior to the proposed transfer or sale.

(c) When RSA 420-D:13, II requires a new CCC to apply for a certificate of authority, the application procedures of Ins 1803 shall apply.

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1812 Enforcement

N.H. Code Admin. R. Ann. Ins 1812.01 Violations {#sec-ins-1812.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1812.01}

Any person or CCC violating the provisions of this chapter shall be subject to the provisions of RSA 400-A:15, RSA 420-D:21, and RSA 420-D:26.

History

#7014, eff 7-1-99; EXPIRED: 7-1-07
#8991, eff 10-1-07; ss by #10944, eff 10-8-15; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Part Ins 1813 Waiver

N.H. Code Admin. R. Ann. Ins 1813.01 Waiver of Rules {#sec-ins-1813.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1813.01}

(a) The commissioner, upon the commissioner’s own initiative or upon request by a provider, shall waive any requirement of this chapter if such waiver does not contradict the objective or intent of the rule and:

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance

with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver, the duration, and proposed alternative, if any.

(e) Waivers that are granted shall be in effect for the duration approved by the commissioner.

APPENDIX A

Rule

Specific State Statute which the Rule is Intended to Implement

Ins 1801.01

RSA 420-D:17

Ins 1801.02

RSA 420-D:17

Ins 1802.01

RSA 420-D:1; RSA 420-D:17

Ins 1803.01

RSA 420-D:17; RSA 420-D:2; RSA 420-D:3; RSA 420-D:6

Ins 1803.02

RSA 420-D:2; RSA 420-D:3; RSA 420-D:5; RSA 420-D:6; RSA 420-D:17; RSA 541-A:30, III; RSA 541-A:31, III; RSA 541-A:35

Ins 1804.01

RSA 420-D:4; RSA 420-D:7; RSA 420-D:17

Ins 1804.02

RSA 420-D:17; RSA 420-D:7-a

Ins 1805.01

RSA 420-D:8; RSA 420-D:17; RSA 420-D:15-a

Ins 1805.02

RSA 420-D:8; RSA 420-D:17

Ins 1806.01

RSA 420-D:9; RSA 420-D:17; RSA 420-D:5, II

Ins 1807.01

RSA 420-D:17; RSA 420-D:10

Ins 1808.01

RSA 420-D:17; RSA 420-D:4; RSA 420-D:12

Ins 1808.02

RSA 420-D:17; RSA 420-D:4; RSA420-D:12

Ins 1808.03

RSA 420-D:17; RSA 420-D:4; RSA 420-D:12

Ins 1809.01

RSA 420-D:3, I; RSA 420-D:17; RSA 420-D:25

Ins 1810.01

RSA 400-A:37; RSA 420-D:17; RSA 420-D:23; RSA 420-D:24; RSA 420-D:25

Ins 1811.01

RSA 420-D:13; RSA 420-D:17

Ins 1812.01

RSA 400-A:15; RSA 420-D:17; RSA 420-D:21; RSA 420-D:22; RSA 420-D:23; 420-D:26

Ins 1813.01

RSA 400-A:15, I; RSA 541-A:22, IV

APPENDIX B Incorporation by Reference Information

Rule

Title

Publisher; How to Obtain; and Cost

Ins 1804.01 (d)(3)

“Actuarial Standard of Practice No. 3, Practices Relating to Continuing Care Retirement Communities”

adopted July, 1994

American Academy of Actuaries’ Actuarial Standards Board;

American Academy of Actuaries, 1100 Seventeenth Street, 7^th Floor, Washington, DC 20036; tel. 202-223-8196; www.actuary.org

Ins 1807.01 (d)(10)

“Domestic Company Custodial Agreement”

NHID-CA1, dated 1990

N.H. Insurance Department, 21 South Fruit St., Concord, NH 03301; tel. 603-271-2261; www.ins.nh.gov

History

#12912, eff 10-28-19; ss by #14640, eff 6-27-26, EXPIRES: 6-27-36

Chapter Ins 1900 Accident and Health Insurance

Part Ins 1902 Minimum Standards for Medicare Supplement Policies Issued Prior to Adoption of Insurance Regulation 1905

N.H. Code Admin. R. Ann. Ins 1902.01 Purpose {#sec-ins-1902.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.01}

The purpose of this part is to provide for the reasonable standardization of coverage and simplification of benefits of medicare supplement accident and sickness insurance policies and medicare supplement subscriber contracts in order to facilitate the public understanding and comparison and to eliminate provisions contained in such policies or contracts which may be misleading or confusing in connection either with the purchase of such policies or with the settlement of claims and to provide for full disclosures in the sale of such coverage.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93, EXPIRED: 7-1-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.02 Applicability And Scope {#sec-ins-1902.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.02}

(a) Except as provided in paragraph (b) this part shall apply to:

(1) All medicare supplement policies and subscriber contracts advertised, solicited, delivered or issued for delivery in this state prior to July 1, 1992; and

(2) All certificates issued under group medicare supplement policies or subscriber contracts, which policies or contracts have been advertised, solicited, delivered, or issued for delivery in this state prior to July 1, 1992.

(b) This part shall not apply to policies or contracts:

(1) Of one or more employers or labor organizations;

(2) Of the trustees of a fund established by one or more employers or labor organizations, or a combination thereof;

(3) For employees or former employees, or a combination thereof;

(4) For members or former members, or a combination thereof, of the labor organizations; or

(5) Medicare supplement policies and certificates subject to Ins 1905.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.03 Definitions {#sec-ins-1902.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.03}

(a) "Applicant" means:

(1) In the case of an individual medicare supplement policy or subscriber contract, the person who seeks to contract for insurance benefits; and

(2) In the case of a group medicare supplement policy or subscriber contract, the proposed certificateholder.

(b) "Certificate" means any certificate issued under a group medicare supplement policy, which policy has been advertised, solicited, delivered, or issued for delivery in this state.

(c) "Medicare supplement policy" means a group or individual policy of accident and health insurance or a subscriber contract of hospital service corporations, medical service corporations, or health service corporations which is advertised, marketed, or designed primarily as a supplement to reimbursements under medicare for the hospital, medical, or surgical expenses of persons eligible for medicare and includes:

(1) A policy or contract for one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees, or combination thereof, or for members or former members, or combination thereof, of the labor organizations; or

(2) A policy or contract of any professional, trade, or occupational association for its members or former or retired members, or a combination thereof, if such association:

a. Is composed of individuals all of whom are actively engaged in the same profession, trade, or occupation;

b. Has been maintained in good faith for purposes other than obtaining insurance; and

c. Has been in existence for at least 2 years prior to the date of its initial offering of such policy or plan to its members.

(d) "Medicare" means the "Health Insurance For The Aged Act," Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.04 Policy Definitions And Terms {#sec-ins-1902.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.04}

No medicare supplement policy subject to this part shall contain definitions or terms respecting the matters set forth herein unless such definitions or terms conform to the requirements of this section as follows:

(a) "Accident, "accidental injury," or "accidental means" shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds," or similar words of description or characterization so that:

(1) The definition shall not be more restrictive than the following: “injury or injuries, for which benefits are provided, means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause and occurrence while the insurance is in force;” and

(2) The definition may include coverage of injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, motor vehicle no-fault plan, unless prohibited by law.

(b) "Benefit period" or "medicare benefit period" shall not be defined as more restrictive than as that defined in the medicare program.

(c) "Convalescent nursing home," "extended care facility," or "skilled nursing facility" shall be defined in relation to its status, facilities, and available services so that:

(1) A definition of such home or facility shall not be more restrictive than one requiring that it:

a. Be operated pursuant to law;

b. Be approved for payment of medicare benefits or be qualified to receive such approval, if so requested;

c. Be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;

d. Provide continuous 24-hours-a-day nursing service by or under the supervision of a registered graduate professional nurse R.N.; and

e. Maintains a daily medical record of each patient ; and

(2) The definition of such home or facility may provide that such term shall not be inclusive of:

a. Any home, facility, or part thereof used primarily for rest;

b. A home or facility for the aged or for the care of drug addicts or alcoholics; or

c. A home or facility primarily used for the care and treatment of mental diseases, or disorders, or custodial or educational care.

(d) "Hospital" may be defined in relation to its status, facilities, and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals so that:

(1) The definition of the term "hospital" shall not be more restrictive than one requiring that the hospital:

a. Be an institution operated pursuant to law;

b. Be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of duly licensed physicians, medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; and

c. Provide 24-hour nursing service by or under the supervision of registered graduate professional nurses; and

(2) The definition of the term "hospital" may state that such term shall not be inclusive of:

a. Convalescent homes, convalescent, rest, or nursing facilities;

b. Facilities primarily affording custodial, educational or rehabilitory care;

c. Facilities for the aged, drug addicts, or alcoholics; or

d. Any military or veterans hospital or soldiers home or any hospital contracted for or operated by any national government or agency thereof for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis where a legal liability exists for charges made to the individual for such services.

(e) "Medicare" shall be defined as "The Health Insurance For The Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended," or "Title I, Part I of Public Laws of 89-97, as enacted by the Eighty-ninth Congress of the United States of America and popularly known as The Health Insurance For The Aged Act, as then constituted and any later amendments or substitutes thereof," or words of similar import. Medicare consists of Part A and Part B. Part A refers to hospital benefits and Part B refers to Medicaid benefits.

(f) "Issuer" shall be defined as including insurance companies, fraternal benefit societies, nonprofit health service corporations, health maintenance organizations, and any other entity advertising, soliciting, delivering or issuing for delivery in this state medicare supplement policies or certificates.

(g) "Medicare eligible expenses" shall be defined as health care expenses of the kinds covered by medicare, to the extent recognized as reasonable by medicare. Payment of benefits by insurers for medicare eligible expenses may be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity as are applicable to medicare claims.

(h) "Mental or nervous disorders" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.

(i) "Nurses" may be defined so that the description of nurse is restricted to a type of nurse, such as a registered graduate professional nurse, R.N., a licensed practical nurse, L.P.N. or a licensed vocational nurse, L.V.N. If the words "nurse," "trained nurse" or "registered nurse" are used without specific instruction, then the insurer shall recognize the services of any individual who qualified under such terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.

(j) "Physician" may be defined by including words such as "duly qualified physician" or "duly licensed physician." The use of such terms shall require an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when such services are within the scope of the provider's licensed authority and are provided pursuant to applicable laws.

(k) "Preexisting condition" shall be defined as a condition for which medical advice or treatment was recommended by or received from a physician within the 6 month period preceding the effective date of the coverage of the insured person.

(l) "Sickness" shall not be defined to be more restrictive than the following:

(1) Sickness means sickness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force; and

(2) The definition may be further modified to exclude sickness or disease for which benefits are provided under any workers' compensation, occupational disease, employer's liability, or similar law.

(m) "Health care expenses" shall be defined as expenses of health maintenance organizations associated with the delivery of health care services which are analogous to incurred losses of insurers, but the definition shall not include the following expenses:

(1) Home office and overhead costs;

(2) Advertising costs;

(3) Commissions and other acquisitional costs;

(4) Taxes;

(5) Capital costs;

(6) Administrative costs; or

(7) Claims processing cost.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.05 Prohibited Policy Provisions {#sec-ins-1902.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.05}

(a) No medicare supplement policy shall limit or exclude coverage by type of illness, accident, treatment, or medical condition, except as follows:

(1) Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;

(2) Alcoholism, drug addiction, and mental or emotional disorders except as provided in RSA 415:18-a; RSA 419:5-a; and RSA 420:5-a;

(3) Illness, treatment, or medical condition arising out of:

a. War or act of war, whether declared or undeclared;

b. Participation in a felony, riot or insurrection;

c. Service in the armed forces or units auxiliary thereto;

d. Suicide, sane or insane, attempted suicide or intentionally self-inflicted injury;

e. Aviation;

(4) Cosmetic surgery, except that "cosmetic surgery" shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection, other diseases or disorders of the involved part;

(5) Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of, or in the vertebral column;

(6) Treatment provided in a governmental hospital, benefits provided under governmental program, except Medicaid, any state or federal workers' compensation, employers' liability or occupational disease law or any motor vehicle no-fault law, services rendered by employees of hospitals, laboratories or other institutions, services performed by a member of the covered person's immediate family and services for which no charge is normally made in the absence of insurance;

(7) Dental care or treatment;

(8) Eyeglasses, hearing aids, and examinations for the prescription or fitting thereof;

(9) Rest cures, custodial care, transportation, and routine physical examinations; or

(10) Territorial limitations outside the United States provided, however, medicare supplement policies may not contain, when issued, limitations or exclusions of the type enumerated in this paragraph that are more restrictive than those of medicare. Medicare supplement policies may exclude coverage for any expense to the extent of any benefit available to the insured under medicare.

(b) No medicare supplement policy may use waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.

(c) No medicare supplement policy shall include terms which provide that the policy may be cancelled or nonrenewed by the insurer solely on the grounds of deteriorated health.

(d) The terms "medicare supplement," "medigap", and words of similar import shall not be used unless the policy is issued in compliance with this part.

(e) No medicare supplement insurance policy, contract, or certificate in force in this state shall contain benefits which duplicate benefits provided by medicare.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.06 Minimum Standards For Medicare Supplement Policies {#sec-ins-1902.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.06}

No policy or certificate shall be advertised, solicited, delivered, or issued for delivery in this state as a medicare supplement policy or certificate unless it meets or exceeds the following minimum standards:

(a) Medicare supplement policies and certificates, advertised, solicited, delivered, or issued for delivery in this state shall comply with the following:

(1) A medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 6 months from the effective date of coverage because it involved a preexisting condition and shall not define a preexisting condition more restrictively than the definition found in Ins 1902.04(k);

(2) A medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents;

(3) A medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under medicare will be changed automatically to coincide with any changes in the applicable medicare deductible amount and co-payment percentage factors. Premiums may be changed to correspond with such benefit changes, but such changes in premiums may not be implemented prior to their approval by the commissioner pursuant to RSA 415:1;

(4) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" medicare supplement policy or certificate shall not provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium;

(5) The rights of an insured with respect to or upon termination shall be as follows:

a. Except as authorized by the insurance commissioner an issuer shall neither cancel nor nonrenew a medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation;

b. If a group medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in Ins 1902.06(a)(5)e., the insurer shall give written notice to certificateholders and offer an individual medicare supplement policy with at least the following choices:

An individual medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group medicare supplement policy; and
An individual medicare supplement policy that provides only such benefits as are required to meet the minimum standards as defined in Ins 1902.06(b);

c. If membership in a group is terminated, the issuer shall give written notice and:

Offer the certificateholder such conversion opportunities as are described in Ins 1902.06(a)(5)e.; or
At the option of the group policyholders, offer the certificateholder continuation of coverage under the group policy;

d. The certificateholder shall have 30 days following receipt of written notice to apply for any conversion policy offered pursuant to this section;

e. If a group medicare supplement policy is replaced by another group medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination; and

f. Coverage under the replacement policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy that was replaced; and

(6) The termination of a medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits.

(b) Medicare supplement policies advertised, solicited, delivered, or issued for delivery in this state shall meet or exceed the following minimum benefit standards:

(1) Coverage of part A medicare eligible expenses for hospitalization to the extent not covered by medicare for the 61st day through the 90th day in any medicare benefit period;

(2) Coverage for either all or none of the medicare part A inpatient hospital deductible amount;

(3) Coverage of part A medicare eligible expenses incurred as daily hospital charges during the use of Medicare’s lifetime hospital inpatient reserve days;

(4) Upon exhaustion of all medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90 percent of all medicare part A eligible expenses for hospitalization not covered by medicare subject to a lifetime maximum benefit of an additional 365 days;

(5) Coverage under medicare part A for the reasonable cost of the first 3 pints of blood or equivalent quantities of packed red blood cells, as defined under 42 CFR Part 409.87 unless replaced in accordance with 42 CFR Part 409.87 or already paid for under part B;

(6) Coverage for coinsurance amount of medicare eligible expenses under part B regardless of hospital confinement subject to a maximum calendar year out-of-pocket amount equal to the $100 medicare part B deductible; and

(7) Coverage under medicare part B for the reasonable cost of the first 3 pints of blood or equivalent quantities of packed red blood cells, as defined under 42 CFR Part 409.87 unless replaced in accordance with 42 CFR Part 409.87 or already paid under part A, subject to the medicare deductible amount.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.07 Required Disclosure Provisions {#sec-ins-1902.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.07}

(a) All medicare supplement policies shall include the following general rules:

(1) Medicare supplement policies shall include a renewal or continuation provision which shall be consistent with the type of contract issued, captioned, and shall appear on the first page of the policy;

(2) A medicare supplement policy which provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or words of similar import, shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage;

(3) If a medicare supplement policy contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as "preexisting condition limitations";

(4) All medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate attached thereto stating that the policyholder or certificateholder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason;

(5) Except as otherwise provided in this part, the terms "medicare supplement," "medigap" and words of similar import shall not be used unless the policy is issued in compliance with Ins 1902.06; and

(6) Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured, exercises a specifically reserved right under a medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of medicare benefits, all riders or endorsements added to a medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the insured. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for medicare supplement policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.

(b) The following notice requirements shall be met:

(1) As soon as practicable, but not later than 30 days prior to the annual effective date of any medicare benefit changes, every insurer, health care service plan, or other entity providing medicare supplement insurance or benefits to a resident of this state shall notify its policyholders, contractholders and certificateholders of modifications it has made to medicare insurance policies or contracts;

(2) The notice required by (1) above shall:

a. Include a description of revisions to the medicare program and a description of each modification made to the coverage provided under the medicare supplement insurance policy or contract; and

b. Inform each covered person as to when any premium adjustment is to be made due to changes in medicare;

(3) The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension; and

(4) Such notices shall not contain or be accompanied by any solicitation.

(1) Insurers issuing medicare supplement policies or certificates for delivery in this state shall provide an outline of coverage to all applicants at the time application is made and, except for direct response policies, shall obtain an acknowledgment of receipt of such outline from the applicant; and

(2) If an outline of coverage is provided at the time of application and the medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany such policy or certificate when it is delivered and contain the following statement, in no less than 12 point type, immediately above the company name: "It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued;" and

(3) In addition to the requirements of subparagraphs (1) and (2), insurers issuing medicare supplement policies or certificates shall provide an outline of coverage for such medicare supplement policies or certificates to any prospective purchaser upon request.

(d) Notice regarding policies or subscriber contracts which are not medicare supplement policies shall include:

(1) The following in no less than 12 point type, either printed or attached to the first page of the outline of coverage delivered to insureds under the policy or subscriber contract, or if no outline of coverage is delivered, to the first page of the policy, certificate or subscriber contract delivered to insureds: "This, policy, certificate or subscriber contract, is not a medicare supplement policy or certificate. If you are eligible for medicare, review the medicare supplement buyer's guide available from the company" on the following policies issued for delivery in this state to persons eligible for medicare:

a. Any accident and sickness insurance policy or subscriber contract, other than a medicare supplement policy;

b. A policy issued pursuant to a contract under section 1876 of the Federal Social Security Act 42 U.S.C. Section 1395 et seq., disability income policy;

c. Basic, catastrophic, or major medical expense policy; and

d. Single premium nonrenewable policy or other policy identified in Ins 1902.02(b) of this part.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6405, eff 1-1-97; amd by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.08 Requirements for Application Forms and Replacement Coverage {#sec-ins-1902.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.08}

(a) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has another medicare supplement policy or certificate in force or whether a medicare policy or certificate is intended to replace any other accident and sickness policy or certificate presently in force:

(1) "Do you have another medicare supplement insurance policy or certificate in force, including either a health care service contract or a health maintenance organization contract?";

(2) "Did you have another medicare supplement policy or certificate in force during the last 12 months?" with the following additional questions:

a. "If so, with which company?"and

b. "If that policy lapsed, when did it lapse?";

(3) "Are you covered by Medicaid?"and

(4) "Do you intend to replace any of your medical or health insurance coverage with this policy, certificate?".

(b) A supplementary application or other form signed by the applicant and agent, except where the coverage is sold without an agent, containing the questions outlined in (a) may be used to satisfy the requirements set forth in (a) above.

(c) Agents shall list on the applicant's application form, supplementary application or other form, whichever is used, any other health insurance policies they have sold to the applicant. In addition, the agent shall list those policies sold which are still in force and those policies sold in the past 5 years which are no longer in force.

(d) Upon determining that a sale will involve replacement, an insurer, other than a direct response insurer, or its agent, shall furnish the applicant, prior to issuance or delivery of the medicare supplement policy or certificate, a notice regarding replacement of medicare supplement insurance. One copy of such notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the insurer. A direct response insurer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of medicare supplement insurance.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.09 Loss Ratio Standards and Refund or Credit of Premiums {#sec-ins-1902.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.09}

(a) A group medicare supplement policy form or certificate form shall not be advertised, solicited, delivered, or issued for delivery unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, on the basis of:

(1) Either:

a. Incurred claims experience; or

b. Incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis; and

(2) Earned premiums for such period in accordance with accepted actuarial principals and practices, to return to policyholders and certificateholders in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy form at least 75 percent of the aggregate amount of premiums earned.

(b) An individual medicare supplement policy shall not be advertised, solicited, delivered, or issued for delivery unless the policy form can be expected, as estimated for the entire period for which rates are computed to provide coverage, on the basis of:

(1) Incurred claims experience or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis; and

(2) Earned premiums for such period in accordance with accepted actuarial principles and practices, to return to policyholders in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy form at least 65 percent of the aggregate amount of premiums earned.

(c) The return to policyholders and certificateholders in the form of aggregate benefits of at least 75 percent of the aggregate amount of premiums earned in the case of group policies and of at least 65 percent of the aggregate amount of premiums earned in the case of individual policies shall be deemed the loss ratio standards established by this rule.

(d) All filings of rates and rating schedules shall:

(1) Demonstrate that expected claims in relation to premiums comply with the requirements of this section when combined with actual experience to date; and

(2) Demonstrate if the filing is for a rate revision, that the anticipated loss ratio over the entire future period for which the revised premiums are computed to provide coverage can be expected to meet the appropriate loss ratio standard as determined by reference to Ins 1902.09 (a) in the case of a group policy or to Ins 1902.09 (b) in the case of an individual policy.

(e) For policies issued prior to July 1, 1992, expected claims in relation to premium shall meet:

(1) The originally filed anticipated loss ratio when combined with the actual experience since inception;

(2) The appropriate loss ratio requirement from Ins 1902.09 (a) or Ins 1902.09 (b) when combined with actual experience; and

(3) The appropriate loss ratio requirement from Ins 1902.09 (a) or Ins 1902.09 (b) over the entire future period for which the rates are computed to provide coverage.

(f) Rules applicable to refund or credit calculation reporting shall be as follows:

(1) With respect to Medicare supplement policies or certificates issued prior to July 1, 1992, the issuer shall make one refund or credit calculation combining the experience of all the issuer's individual policies beginning with experience after 12/31/96 and one refund or credit calculation combining the experience of all the issuer's group policies beginning with experience after December 31, 1996;

(2) Each issuer shall collect the data contained in the applicable reporting form contained in Table 1900.03 and, using this reporting form, file the data with the commissioner;

(3) Reports shall be due on May 31 of each year;

(4) If, on the basis of the experience as reported, the benchmark ratio since inception of the reporting requirement, ratio 1 from line 7 of the reporting form contained in Table 1900.03, exceeds the adjusted experience ratio since inception of the same reporting requirement, ratio 3 from line 11 of the reporting form contained in Table 1900.03, then a refund or credit calculation shall be required. The refund calculation shall be done on a statewide basis;

(5) A refund or credit shall be made only when the benchmark loss ratio exceeds the adjusted experience loss ratio and the amount to be refunded or credited exceeds a de minimis level of $5.00 per individual policy or each individual certificate;

(6) The refund shall include interest pursuant to Ins 1905.13 (b)(4) from the end of the calendar year to the date of the refund or credit at a rate specified by the U.S. Secretary of Health and Human Services but in no event shall it be less than the average rate of interest for 13-week Treasury notes; and

(7) A refund or credit against premiums due shall be made by September 30 following the experience year upon which the refund or credit is based.

(g) An issuer of medicare supplement policies and certificates in this state shall file annually its premium rates, rating schedule, and supporting documentation including ratios of incurred to earned premiums by policy duration.

(h) For the purpose of this section, policy forms shall be deemed to comply with the loss ratio standards if:

(1) For the most recent year, the ratio of the incurred losses to earned premiums, for policies or certificates which have been in force for 3 years or more is greater than or equal to the applicable percentages contained in this section;

(2) The expected losses in relation to premiums over the entire period for which the policy is rated comply with the requirements of this section; and

(3) An expected 3rd year loss ratio which is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than 3 years.

(i) As soon as practicable, but prior to the effective date of enhancements in medicare benefits, every issuer of medicare supplement policies or certificates in this state shall file with the commissioner in accordance with the applicable filing procedures of this state the following items:

(1) Appropriate premium adjustments necessary to produce loss ratios as anticipated for the current premium for the applicable policies or certificates;

(2) Such supporting documents as necessary to justify the premium adjustments; and

(3) Any appropriate riders, endorsements or policy forms needed to accomplish the medicare supplement policy or certificate modification necessary to eliminate benefit duplications with medicare.

(j) An insurer shall make such premium adjustments as are necessary to produce an expected loss ratio under such policy or certificate as will conform with minimum loss ratio standards for medicare supplement policies.

(k) Such premium adjustments shall be expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current premiums by the issuer for such medicare policies or certificates.

(l) No premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described herein shall be made with respect to a policy or certificate at any time other than upon its renewal date or anniversary date.

(m) Riders, endorsements, or policy forms filed pursuant to this section shall provide a clear description of the medicare supplement benefits provided by the policy or certificate.

(n) If presented with a request from an issuer for an increase in a rate for a policy or certificate form for which the experience under the form for the previous reporting period is not in compliance with the applicable loss ratio standard, the commissioner, in order to gather information, shall, prior to any approval or disapproval of the request, conduct a public hearing in accordance with RSA 400-A:17 when:

(1) The issuer requests a public hearing, or

(2) At least 10 policyholders or certificate holders request a public hearing.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.10 Standard for Claims Payment {#sec-ins-1902.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.10}

(a) An issuer shall comply with section 1882(c)(3) of the Social Security Act, as enacted by section 4081(b)(2)(c) of the Omnibus Budget Reconciliation Act of 1987, OBRA, 1987, Public Law No. 100-203, by:

(1) Accepting a notice from a medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;

(2) Notifying the participating physicians or supplier and the beneficiary of the payment determination;

(3) Paying the participating physician or supplier directly;

(4) Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number and a central mailing address to which notices from a medicare carrier may be sent;

(5) Paying user fees for claim notices that are transmitted electronically or otherwise; and

(6) Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by medicare carriers.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #6405, eff 1-1-97, EXPIRED: 1-1-05
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.11 Permitted Compensation Arrangements {#sec-ins-1902.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.11}

(a) An insurer or other entity may provide commission or other compensation to an agent or other representative for the sale of a medicare supplement policy or certificate only if the first year commission or other first year compensation is no more than 200 percent of the commission or other compensation paid for selling or servicing the policy or certificate in the second year or period.

(b) The commission or other compensation provided in subsequent renewal years shall be the same as that provided in the second year or period.

(c) No entity shall provide compensation to its agents or other producers and no agent or producer shall receive compensation greater than the renewal compensation payable by the replacing insurer on renewal policies or certificates if an existing policy or certificate is replaced unless benefits of the new policy or certificate are substantially more favorable than the benefits under the replaced policy.

(d) For purposes of this section, "compensation" shall include pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate, including but not limited to bonuses, gifts, prizes, awards, and finders' fees.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.12 Appropriations of Recommended Purchase and Excessive Insurance {#sec-ins-1902.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.12}

(a) In recommending the purchase or replacement of any medicare supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.

(b) Any sale of medicare supplement coverage which will provide an individual more than one medicare supplement policy or certificate shall be prohibited; provided, however, that additional medicare supplement coverage may be sold if, when combined with that individual's health coverage already in force, it would insure no more than 100 percent of the individual's actual medical expenses covered under the combined policies.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.13 Reporting of Multiple Policies {#sec-ins-1902.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.13}

(a) On or before March 1 of each year, every insurer or other entity providing medicare supplement insurance coverage in this state shall report the following information for every individual resident of this state for which the insurer or entity has in force more than one medicare supplement insurance policy or certificate:

(1) Policy and certificate number; and

(2) Date of issuance.

(b) The items set forth above shall be grouped by individual policyholder.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.14 Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies or Certificates {#sec-ins-1902.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.14}

If a medicare supplement policy or certificate replaces another medicare supplement policy or certificate, the replacing insurer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods in the new medicare supplement policy for similar benefits to the extent such time was spent under the original policy.

History

#5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 1902.15 Benefit Conversion Requirements During Transition {#sec-ins-1902.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 1902.15}

(a) Benefits eliminated by operation of the Medicare Catastrophic Coverage Act of 1988 transition provisions shall be restored.

(b) For medicare supplement policies subject to the minimum standards adopted by the states pursuant to Medicare Catastrophic Coverage Act of 1988, the minimum benefits shall be:

(1) Coverage of part A medicare eligible expenses for hospitalization to the extent not covered by medicare from the 61st day through the 90th day in any medicare benefit period;

(2) Coverage of either all or none of the medicare part A inpatient hospital deductible amount;

(3) Coverage of part A medicare eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days;

History

#5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8555, eff 2-1-06, EXPIRED: 2-1-14
#11014, eff 1-8-16

Part Ins 1903 Medicare Supplement Insurance

N.H. Code Admin. R. Ann. Ins 1903.01 Purpose {#sec-ins-1903.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1903.01}

The purpose of this part is to assure the orderly implementation and conversion of medicare supplement insurance benefits and premiums due to changes in the federal medicare program.

History

#4553, eff 12-7-88; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8556, eff 2-1-06, EXPIRED: 2-1-14

N.H. Code Admin. R. Ann. Ins 1903.02 Applicability and Scope {#sec-ins-1903.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1903.02}

(a) This part shall take precedence over other rules and requirements relating to medicare supplement policies or contracts only to the extent necessary to assure that benefits are not duplicated, that applicants receive adequate notice and disclosure of changes in medicare supplement policies and contracts, that appropriate premium adjustments are made in a timely manner, and that premiums are reasonable in relation to benefits.

(b) This part shall apply to:

(1) All medicare supplement policies and subscriber contracts advertised, solicited, delivered or issued for delivery in this state, or which are otherwise subject to the jurisdiction of this state and issued prior to July 1, 1992; and

(2) All certificates issued under group medicare supplement policies or subscriber contracts, which policies or contracts have been advertised, solicited, delivered or issued for delivery in this state, or which are otherwise subject to the jurisdiction of this state and issued prior to July 1, 1992.

History

#8556, eff 2-1-06, EXPIRED: 2-1-14

N.H. Code Admin. R. Ann. Ins 1903.03 Definitions {#sec-ins-1903.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1903.03}

(a) "Applicant" means:

(1) In the case of an individual medicare supplement policy or subscriber contract, the person who seeks to contract for insurance benefits; and

(2) In the case of group medicare supplement policy or subscriber contract, the proposed certificateholder.

(b) "Certificate" means any certificate issued under a group medicare supplement policy, which policy has been advertised, solicited, delivered, or issued for delivery in this state.

(c) "Insurer" means an insurance company, hospital service corporation, medical service corporation, health service corporation, health maintenance organization or other entity subject to Title XXXVII of the New Hampshire code.

(d) "Medicare supplement policy" means either a group or individual policy of accident and health insurance or a subscriber contract of an insurer that is designed primarily to supplement coverage for hospital, medical or surgical expenses incurred by an insured person which are not covered by medicare. Such term does not include:

(1) A policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, or for members or former members, or combination thereof, of the labor organizations; or

(2) A policy or contract of any professional, trade or occupational association for its members or former or retired members, or combination thereof, if such association:

a. Is composed of individuals all of whom are actively engaged in the same profession, trade or occupation;

b. Has been maintained in good faith for purposes other than obtaining insurance; and

c. Has been in existence for at least 2 years prior to the date of its initial offering of such policy or plan to its members.

History

#8556, eff 2-1-06, EXPIRED: 2-1-14

N.H. Code Admin. R. Ann. Ins 1903.04 Benefit Conversion Requirements {#sec-ins-1903.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1903.04}

(a) No medicare supplement insurance policy, contract or certificate in force in this state shall contain benefits which duplicate benefits provided by medicare.

(b) No later than 30 days prior to the annual effective date of medicare benefit changes mandated by the Medicare Catastrophic Coverage Act of 1988, every insurer providing medicare supplement insurance or benefits to a resident of this state shall notify its policyholders, contractholders and certificateholders of modifications it has made to medicare supplement insurance policies or contracts.

(c) The notice required in (b) above shall include a description of revisions to the medicare program and a description of each modification made to the coverage provided under the medicare supplement insurance policy or contract. The notice shall inform each covered person as to when any premium adjustment due to changes in medicare benefits will be made. The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension. Such notice shall not contain or be accompanied by any solicitation.

(d) No modifications to an existing medicare supplement contract or policy shall be made at the time of or in connection with the notice requirements of this part except to the extent necessary to eliminate duplication of medicare benefits and any modifications necessary under the policy or contract to provide indexed benefit adjustment.

(e) As soon as practicable, but no longer than 45 days after the effective date of the medicare benefit changes, every insurer providing medicare supplement insurance or contracts in this state shall file with the commissioner, the following:

(1) The appropriate premium adjustments necessary to produce loss ratios as originally anticipated for the applicable policies or contracts. Such supporting documents as necessary to justify the adjustment shall accompany the filing; and

(2) Any appropriate riders, endorsements or policy forms needed to accomplish the medicare supplement insurance modifications necessary to eliminate benefit duplications with medicare. Any such riders, endorsements or policy forms shall provide a clear description of the medicare supplement benefits provided by the policy or contract.

(f) Every insurer providing medicare supplement insurance in this state shall provide each covered person with any rider, endorsement or policy form necessary to eliminate any benefit duplications under the policy or contract with benefits provided by medicare.

(g) No insurer shall require any person covered under a medicare supplement policy or contract which was in force prior to January 1, 1989 to purchase additional coverage under such policy or contract unless additional coverage was provided for in the policy or contract.

(h) Every insurer providing medicare supplement insurance or benefits to a resident of this state shall make such premium adjustments as are necessary to produce an expected loss ratio under such policy or contract as will conform with minimum loss ratio standards for medicare supplement policies and which is expected to result in a loss ratio at least as great as the originally anticipated by the insurer for such medicare supplement insurance policies or contracts. No premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described herein shall be made with respect to a policy at any time other than upon its renewal date. Premium adjustments shall be in the form of refunds or premium credits and shall be made no later than upon renewal if a credit is given, or within 60 days of the renewal date if a refund is provided to premium payer.

History

#8556, eff 2-1-06, EXPIRED: 2-1-14

N.H. Code Admin. R. Ann. Ins 1903.05 Requirements for New Policies and Certificates {#sec-ins-1903.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1903.05}

(a) No medicare supplement policy, contract or certificate shall be issued or issued for delivery in this state which provides benefits which duplicate benefits provided by medicare. No such policy, contract or certificate shall provide less benefits than those required under Ins 1902 except where duplication of medicare benefits would result.

(b) Every applicant for a medicare supplement insurance policy or certificate shall be provided with an outline of coverage which simplifies and accurately describes benefits provided by medicare, the benefits provided by the policy or contract being applied for, and the benefit limitations applicable to the policy or contract for which application is being made.

History

#8556, eff 2-1-06, EXPIRED: 2-1-14

N.H. Code Admin. R. Ann. Ins 1903.06 Separability {#sec-ins-1903.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1903.06}

If any provision of this part or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of this part and the application of such provision to other persons or circumstances shall not be affected thereby.

History

#8556, eff 2-1-06, EXPIRED: 2-1-14

Part Ins 1904 Group Coordination of Benefits

N.H. Code Admin. R. Ann. Ins 1904.01 Scope {#sec-ins-1904.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.01}

This part applies to all group or blanket insurance plans subject to RSA 415, RSA 420-A and RSA 420-B, except those coverages listed under RSA 415-A:3, I(d), (g), (h), (i), (j), (k) and (m).

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12=23

N.H. Code Admin. R. Ann. Ins 1904.02 Accident and Health Insurance {#sec-ins-1904.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.02}

Purpose. The purpose of this rule is to:

(a) Establish a uniform order of benefit determination under which plans pay claims;

(b) Reduce duplication of benefits by permitting a reduction of the benefits to be paid by plans that, pursuant to rules established by this rule, do not have to pay their benefits first; and

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12-23

N.H. Code Admin. R. Ann. Ins 1904.03 Definitions {#sec-ins-1904.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.03}

As used in this rule, these words and terms have the following meanings, unless the context clearly indicates otherwise:

(a) "Allowable Expense", except as set forth below or where a statute requires a different definition, means:

(1) Any health care expense, including coinsurance or copayments and without reduction for any applicable deductible, that is covered in full or in part by any of the plans covering the person;

(2) If a plan is advised by a covered person that all plans covering the person are high-deductible health plans and the person intends to contribute to a health savings account established in accordance with Section 223 of the Internal Revenue Code of 1986, the primary high-deductible health plan's deductible is not an allowable expense, except for any health care expense incurred that may not be subject to the deductible as described in Section 223(c)(2)(C) of the Internal Revenue Code of 1986;

(3) An expense or a portion of an expense that is not covered by any of the plans is not an allowable expense;

(4) Any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a covered person is not an allowable expense;

(5) The following are examples of expenses that are not allowable expenses:

a. If a person is confined in a private hospital room, the difference between the cost of a semi-private room in the hospital and the private room is not an allowable expense, unless one of the plans provides coverage for private hospital room expenses;

b. If a person is covered by 2 or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement or other similar reimbursement methodology, any amount charged by the provider in excess of the highest reimbursement amount for a specified benefit is not an allowable expense;

c. If a person is covered by 2 or more plans that provide benefits or services on the basis of negotiated fees, any amount in excess of the highest of the negotiated fees is not an allowable expense; and

d. If a person is covered by one plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement or other similar reimbursement methodology and another plan that provides its benefits or services on the basis of negotiated fees, the primary plan's payment arrangement shall be the allowable expenses for all plans. However, if the provider has contracted with the secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary plan's payment arrangement and if the provider's contract permits, that negotiated fee or payment shall be the allowable expense used by the secondary plan to determine its benefits;

(6) The definition of "allowable expense" may exclude certain types of coverage or benefits such as dental care, vision care, prescription drug or hearing aids. A plan that limits the application of COB to certain coverages or benefits may limit the definition of allowable expense in its contract to expenses that are similar to the expenses that it provides. When COB is restricted to specific coverages or benefits in a contract, the definition of allowable expense shall include similar expenses to which COB applies;

(7) When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid;

(8) The amount of the reduction may be excluded from allowable expense when a covered person's benefits are reduced under a primary plan:

a. Because the covered person does not comply with the plan provisions concerning second surgical opinions or precertification of admissions or services; or

b. Because the covered person has a lower benefit because the covered person did not use a preferred provider.

(b) "Birthday" means only the month and day in a calendar year and does not include the year in which the individual is born.

(1) Services (including supplies);

(2) Payment for all or a portion of the expenses incurred;

(3) A combination of (1) and (2) above; or

(4) An indemnification.

(d) "Closed panel plan" means a plan that provides health benefits to covered persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member.

(e) "Consolidated Omnibus Budget Reconciliation Act of 1985" or "COBRA" means coverage provided under a right of continuation pursuant to federal law.

(f) "Coordination of Benefits" or "COB" means a provision establishing an order in which plans pay their claims, and permitting secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total allowable expenses.

(g) "Custodial Parent" means:

(1) The parent awarded custody of a child by a court decree; or

(2) In the absence of a court decree, the parent with whom the child resides more than one half of the calendar year without regard to any temporary visitation.

(h) "Group-type Contract" means:

(1) A contract that is not available to the general public and is obtained and maintained only because of membership in or a connection with a particular organization or group, including blanket coverage; and

(2) "Group-type contract" does not include an individually underwritten and issued guaranteed renewable policy even if the policy is purchased through payroll deduction at a premium savings to the insured since the insured would have the right to maintain or renew the policy independently of continued employment with the employer.

(i) "High-deductible Health Plan" means the meaning given the term under Section 223 of the Internal Revenue Code of 1986, as amended by the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

(j) "Hospital Indemnity Benefits" means:

(1) Benefits not related to expenses incurred; and

(2) "Hospital indemnity benefits" does not include reimbursement-type benefits even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.

(k) "Plan" means:

(1) A form of coverage with which coordination is allowed. Separate parts of a plan for members of a group that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are considered one plan and there is not COB among the separate parts of the plan.

(2) If a plan coordinates benefits, its contract shall state the types of coverage that will be considered in applying the COB provision of that contract. Whether the contract uses the term "plan" or some other term such as "program", the contractual definition may be no broader than the definition of "plan" in this subsection. The definition of "plan" in the model COB provision in Appendix A is an example.

(3) "Plan" includes:

a. Group and nongroup insurance contracts and subscriber contracts;

b. Uninsured arrangements of group or group-type coverage;

c. Group and nongroup coverage through closed panel plans;

d. Group-type contracts;

e. The medical care components of long-term care contracts, such as skilled nursing care;

f. The medical benefits coverage in automobile "no fault" or "personal injury protection" (PIP) type contracts, not including medical payments coverage, also known as Part B in the personal automobile policy or med pay;

g. Medicare or other governmental benefits, as permitted by law, except as provided in (4)h. below. That part of the definition of plan may be limited to the hospital, medical and surgical benefits of the governmental program; and

h. Group insurance contracts and subscriber contracts that pay or reimburse for the cost of dental care.

(4) "Plan" does not include:

a. Hospital indemnity coverage or benefits or other fixed indemnity coverage;

b. Accident only coverage;

c. Specified disease or specified accident coverage;

d. Limited benefits health coverage, except dental plans permitted in Ins 1904.03(k)(3)h. above;

e. School accident-type coverages that cover students for accidents only, including athletic injuries, either on a 24 hour basis or on a "to and from school" basis;

f. Medical payments coverage in a personal automobile policy, also known as Part B or med pay;

g. Benefits provided in long-term care insurance policies for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services;

h. Medicare supplement policies;

i. A state plan under Medicaid; or

j. A governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental plan.

(l) "Policyholder" means the primary insured named in a nongroup insurance policy.

(m) "Primary plan" means a plan whose benefits for a person's health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if:

(1) The plan either has no order of benefit determination rules, or its rules differ from those permitted by this rule; or

(2) All plans that cover the person use the order of benefit determination rules required by this rule, and under those rules the plan determines its benefits first.

(n) "Secondary plan" means a plan that is not a primary plan.

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12-23

N.H. Code Admin. R. Ann. Ins 1904.04 Use of Model COB Contract Provision {#sec-ins-1904.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.04}

(a) Appendix A contains a model COB provision for use in contracts. The use of this model COB provision is subject to the provisions of (b), (c) and (d) below and the provisions of Ins 1904.05.

(b) Appendix B is a plain language description of the COB process that explains to the covered person how health plans will implement coordination of benefits. It is not intended to replace or change the provisions that are set forth in the contract. Its purpose is to explain the process by which the 2 or more plans will pay for or provide benefits.

(c) The COB provision contained in Appendix A and the plain language explanation in Appendix B do not have to use the specific words and format shown in Appendix A or Appendix B. Changes may be made to fit the language and style of the rest of the contract or to reflect differences among plans that provide services, that pay benefits for expenses incurred and that indemnify. No substantive changes are permitted.

(d) A COB provision may not be used that permits a plan to reduce its benefits on the basis that:

(1) Another plan exists and the covered person did not enroll in the plan;

(2) A person is or could have been covered under another plan, except with respect to Part B of Medicare; or

(3) A person has elected an option under another plan providing a lower level of benefits than another option that could have been elected.

(e) No plan may contain a provision that its benefits are "always excess" or "always secondary" except in accordance with the rules permitted by this rule.

(f) Under the terms of a closed panel plan, benefits are not payable if the covered person does not use the services of a closed panel provider. In most instances, COB does not occur if a covered person is enrolled in 2 or more closed panel plans and obtain services from a provider in one of the closed panel plans because the other closed panel plan (the one whose providers were not used) has no liability. However, COB may occur during the plan year when the covered person received emergency services that would have been covered by both plans. Then the secondary plan shall use the provisions of Ins 1904.06 to determine the amount it should pay for the benefit.

(g) No plan may use a COB provision, or any other provision that allows it to reduce its benefits with respect to any other coverage its insured may have that does not meet the definition of plan under Ins 1904.03 (k).

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12-23

N.H. Code Admin. R. Ann. Ins 1904.05 Rules for Coordination of Benefits {#sec-ins-1904.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.05}

When a person is covered by 2 or more plans:

(a) The rules for determining the order of benefit payments are as follows:

(1) The primary plan shall pay or provide its benefits as if the secondary plan or plans did not exist;

(2) If the primary plan is a closed panel plan and the secondary plan is not a closed panel plan, the secondary plan shall pay or provide benefits as if it were the primary plan when a covered person uses a non-panel provider, except for emergency services or authorized referrals that are paid or provided by the primary plan;

(3) When multiple contracts providing coordinated coverage are treated as a single plan under this rule, this section applies only to the plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the plan, the carrier designated as primary within the plan shall be responsible for the plan's compliance with this rule; and

(4) If a person is covered by more than one secondary plan, the order of benefit determination rules of this rule decide the order in which secondary plans benefits are determined in relation to each other. Each secondary plan shall take into consideration the benefits of the primary plan or plans and the benefits of any other plan, which, under the rules of this rule, has its benefits determined before those of that secondary plan.

(b) Except as provided in paragraph (2) below:

(1) A plan that does not contain order of benefit determination provisions that are consistent with this rule is always the primary plan unless the provisions of both plans, regardless of the provisions of this paragraph, state that the complying plan is primary; and

(2) Coverage that is obtained by virtue of membership in a group and designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits.

(c) A plan may take into consideration the benefits paid or provided by another plan only when, under the rules of this rule, it is secondary to that other plan.

(d) Order of Benefit Determination. Each plan determines its order of benefits using the first of the following rules that applies:

(1) Non-Dependent or Dependent.

a. Subject to subparagraph b. of this paragraph, the plan that covers the person other than as a dependent, for example as an employee, member, subscriber, policyholder or retiree, is the primary plan and the plan that covers the person as a dependent is the secondary plan.

b. If the person is a Medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, Medicare is:

Secondary to the plan covering the person as a dependent; and
Primary to the plan covering the person as other than a dependent (e.g. a retired employee). Then the order of benefits is reversed so that the plan covering the person as an employee, member, subscriber, policyholder or retiree is the secondary plan and the other plan covering the person as a dependent is the primary plan.

(2) Dependent Child Covered Under More Than One Plan. Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows:

a. For a dependent child whose parents are married or are living together, whether or not they have ever been married:

The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or
If both parents have the same birthday, the plan that has covered the parent longest is the primary plan.

b. For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:

If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with responsibility has no health care coverage for the dependent child's health care expenses, but that parent's spouse does, that parent's spouse's plan is the primary plan. This item shall not apply with respect to any plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision;
If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of subparagraph a. of this paragraph shall determine the order of benefits;
If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subparagraph a. of this paragraph shall determine the order of benefits; or
If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows:

(i) The plan covering the custodial parent;

(ii) The plan covering the custodial parent's spouse;

(iii) The plan covering the non-custodial parent; and then

(iv) The plan covering the non-custodial parent's spouse; and

c. For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under subparagraph a. or b. of this paragraph as if those individuals were parents of the child.

(3) Active Employee or Retired or Laid-Off Employee.

a. The plan that covers a person as an active employee that is, an employee who is neither laid off nor retired or as a dependent of an active employee is the primary plan. The plan covering that same person as a retired or laid-off employee or as a dependent of a retired or laid-off employee is the secondary plan.

b. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored; and

c. This rule does not apply if the rule in paragraph (1) can determine the order of benefits.

(4) COBRA or State Continuation Coverage.

a. If a person whose coverage is provided pursuant to COBRA or under a right of continuation pursuant to state or other federal law is covered under another plan, the plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member, subscriber or retiree is the primary plan and the plan covering that same person pursuant to COBRA or under a right of continuation pursuant to state or other federal law is the secondary plan.

b. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored; and

c. This rule does not apply if the rule in paragraph (1) can determine the order of benefits.

(5) Longer or Short Length of Coverage.

a. If the preceding rules do not determine the order of benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary plan.

b. To determine the length of time a person has been covered under a plan, two successive plans shall be treated as one if the covered person was eligible under the second plan within 24 hours after coverage under the first plan ended.

c. The start of a new plan does not include:

A change in the amount or scope of a plan's benefits;
A change in the entity that pays, provides or administers the plan's benefits; or
A change from one type of plan to another, such as, from a single employer plan to a multiple employer plan; and

d. The person's length of time covered under a plan is measured from the person's first date of coverage under that plan. If that date is not readily available for a group plan, the date the person first became a member of the group shall be used as the date from which to determine the length of time the person's coverage under the present plan has been in force; and

(6) If none of the preceding rules determines the order of benefits, the allowable expenses shall be shared equally between the plans.

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12-23

N.H. Code Admin. R. Ann. Ins 1904.06 Procedure to be Followed by Secondary Plan to Calculate Benefits and Pay a Claim {#sec-ins-1904.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.06}

In determining the amount to be paid by the secondary plan on a claim, should the plan wish to coordinate benefits, the secondary plan shall calculate the benefits it would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not exceed 100 percent of the total allowable expense for that claim. In addition, the secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12-23

N.H. Code Admin. R. Ann. Ins 1904.07 Notice to Covered Persons {#sec-ins-1904.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.07}

A plan shall, in its explanation of benefits provided to covered persons, include the following language; "If you are covered by more than one health benefit plan, you should file all your claims with each plan."

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-13-23

N.H. Code Admin. R. Ann. Ins 1904.08 Miscellaneous Provisions {#sec-ins-1904.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.08}

(a) A secondary plan that provides benefits in the form of services may recover the reasonable cash value of the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by the primary plan. Nothing in this provision shall be interpreted to require a plan to reimburse a covered person in cash for the value of services provided by a plan that provides benefits in the form of services.

(b) Order of Benefit Determination Rules.

(1) A plan with order of benefit determination rules that comply with this rule (complying plan) may coordinate its benefits with a plan that is "excess" or "always secondary" or that uses order of benefit determination rules that are inconsistent with those contained in this rule (noncomplying plan) on the following basis:

a. If the complying plan is the primary plan, it shall pay or provide its benefits first;

b. If the complying plan is the secondary plan, it shall pay or provide its benefits first, but the amount of the benefits payable shall be determined as if the complying plan were the secondary plan. In such a situation, the payment shall be the limit of the complying plan's liability; and

c. If the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within a reasonable time after it is requested to do so, the complying plan shall assume that the benefits of the noncomplying plan are identical to its own, and shall pay its benefits accordingly. If, within 2 years of payment, the complying plan receives information as to the actual benefits of the noncomplying plan, it shall adjust payments accordingly.

(2) If the noncomplying plan reduces its benefits so that the covered person receives less in benefits than the covered person would have received had the complying plan paid or provided its benefits as the secondary plan and the noncomplying plan paid or provided its benefits as the primary plan, and governing state law allows the right of subrogation set forth below, then the complying plan shall advance to the covered person or on behalf of the covered person an amount equal to the difference; and

(3) In no event shall the complying plan advance more than the complying plan would have paid had it been the primary plan less any amount it previously paid for the same expense or service. In conditions of the advance, the complying plan shall be subrogated to all rights of the covered person against the noncomplying plan. The advance by the complying plan shall also be without prejudice to any claim it may have against a noncomplying plan in the absence of subrogation.

(c) COB differs from subrogation. Provisions for one may be included in health care benefits contracts without compelling the inclusion or exclusion of the other.

(d) If the plans cannot agree on the order of benefits within 30 calendar days after the plans have received all of the information needed to pay the claim, the plans shall immediately pay the claim in equal shares and determine their relative liabilities following payment, except that no plan shall be required to pay more than it would have paid had it been the primary plan.

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12-23

N.H. Code Admin. R. Ann. Ins 1904.09 Effective Date for Existing Contracts {#sec-ins-1904.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.09}

(a) A contract that provides health care benefits and that was issued before the effective date of this rule shall be brought into compliance with this rule by:

(1) The later of:

a. The next anniversary date or renewal date of the contract; or

b. Twelve months following the effective date of this rule; or

(2) The expiration of any applicable collectively bargained contract pursuant to which it was written.

(b) For the transition period between the adoption of this rule and the timeframe for which plans are to be in compliance pursuant to Subsection A, a plan that is subject to the prior COB requirements shall not be considered a noncomplying plan by a plan subject to the new COB requirements if there is a conflict between the prior COB requirements under the prior rule and the new COB requirements under the amended rule, the prior COB requirements shall apply.

History

#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12-23

N.H. Code Admin. R. Ann. Ins 1904.10 Accident and Health Insurance {#sec-ins-1904.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.10}

Penalties. Any insurer, producer, or any person, firm, association or corporation who knowingly violates any provision of this part shall be subject to the provisions of RSA 400-A:15, III.

History

#8402, eff 8-1-05; ss by #10371, eff 8-1-13; ss by #13779, eff 10-12-23

N.H. Code Admin. R. Ann. Ins 1904.11 Waiver or Suspension of Rules {#sec-ins-1904.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 1904.11}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance

with the rule would be onerous without promoting the objective or intent of the rule

provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) Waivers that are granted shall be in effect for the period of time requested and approved by the commissioner.

APPENDIX A

MODEL COB CONTRACT PROVISIONS

COORDINATION OF THIS CONTRACT'S BENEFITS

WITH OTHER BENEFITS

The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one Plan. Plan is defined below.

The order of benefit determination rules govern the order in which each Plan will pay a claim for benefits. The Plan that pays first is called the Primary plan. The Primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the Primary plan is the Secondary plan. The Secondary plan may reduce the benefits it pays so that payments from all Plans does not exceed 100% of the total Allowable expense.

DEFINITIONS

(a) A Plan is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts.

(1) Plan includes: group and nongroup insurance contracts, health maintenance organization (HMO) contracts, closed panel plans or other forms of group or group-type coverage (whether insured or uninsured); medical care components of long-term care contracts, such as skilled nursing care; medical benefits under "no-fault" or "personal injury protection" (PIP) automobile contracts; and Medicare or any other federal governmental plan, as permitted by law.

(2) Plan does not include: hospital indemnity coverage or other fixed indemnity coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; medical payments coverage in a personal automobile policy, also known as Part B or med pay coverage; benefits for non-medical components of long-term care policies; Medicare supplement policies; Medicaid policies; or coverage under other federal governmental plans, unless permitted by law.

Each contract for coverage under (1) or (2) is a separate Plan. If a Plan has two parts and COB rules apply only to one of the 2, each of the parts is treated as a separate Plan.

(b) This plan means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits to other plans. Any other part of the contract providing health care benefits is separate from this plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits.

(c) The order of benefit determination rules determine whether This plan is a Primary plan or Secondary plan when the person has health care coverage under more than one plan.

When This plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other Plan's benefits. When This plan is secondary, it determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable expense.

(d) Allowable expense is a health care expense, including deductibles, coinsurance and copayments, that is covered at least in part by a Plan covering the person. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable expense and a benefit paid. An expense that is not covered by any Plan covering the person is not an Allowable expense. In addition, any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a covered person is not an Allowable expense.

The following are examples of expenses that are not Allowable expenses:

(1) The difference between the cost of a semi-private hospital room and a private hospital room is not an Allowable expense, unless one of the Plans provides coverage for private hospital room expenses.

(2) If a person is covered by 2 or more Plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology, any amount in excess of the highest reimbursement amount for a specific benefit is not an Allowable expense.

(3) If a person is covered by 2 or more Plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable expense.

(4) If a person is covered by one Plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary plan's payment arrangement shall be the Allowable expense for all Plans. However, if the provider has contracted with the Secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the Primary plan's payment arrangement and if the provider's contract permits, the negotiated fee or payment shall be the Allowable expense used by the Secondary plan to determine its benefits.

(5) The amount of any benefit reduction by the Primary plan because a covered person has failed to comply with the Plan provisions is not an Allowable expense. Examples of these types of plan provisions include second surgical opinions, precertification of admissions, and preferred provider arrangements.

(e) Closed panel plan is a Plan that provides health care benefits to covered persons primarily in the form of services through a panel or providers that have contracted with or are employed by the Plan, and that excludes coverage for services provided by other providers, except in cases of emergency or referral by a panel member.

(f) Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation.

ORDER OF BENEFIT DETERMINATION RULES

When a person is covered by 2 or more Plans, the rules for determining the order of benefit payments are as follows:

(a) The Primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other Plan.

(b) Except as provided in paragraph (2),

(1) A Plan that does not contain a coordination of benefits provision that is consistent with this rule is always primary unless the provisions of both Plans state that the complying plan is primary.

(2) Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage shall be excess to any other parts of the Plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverages that are written in connection with a Closed panel plan to provide out-of-network benefits.

(c) A Plan may consider the benefits paid or provided by another Plan in calculating payment of its benefits only when it is secondary to that other Plan.

(d) Each Plan determines its order of benefits using the first of the following rules that apply:

(1) Non-Dependent or Dependent. The Plan that covers the person other than as a dependent, for example as an employee, member, policyholder, subscriber or retiree is the Primary plan and the Plan that covers the person as a dependent is the Secondary plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a dependent; and primary to the Plan covering the person as other than a dependent (e.g. a retired employee); then the order of benefits between the 2 Plans is reversed so that the Plan covering the person as an employee, member, policyholder, subscriber or retiree is the Secondary plan and the other Plan is the Primary plan.

(2) Dependent Child Covered Under More Than One Plan. Unless there is a court decree stating otherwise, when a dependent child is covered by more than one Plan the order of benefits is determined as follows:

a. For a dependent child whose parents are married or are living together, whether or not they have ever been married:

The Plan of the parent whose birthday falls earlier in the calendar year is the Primary plan; or
If both parents have the same birthday, the Plan that has covered the parent the longest is the Primary plan.

b. For a dependent child whose parents are divorced or separated or not living together, whether or not they have ever been married:

If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the Plan of that parent has actual knowledge of those terms, that Plan is primary. This rule applies to plan years commencing after the Plan is given notice of the court decree;
If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of subparagraph (a) above shall determine the order of benefits;
If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subparagraph (a) above shall determine the order of benefits; or
If there is no court decree allocating responsibility for the dependent child's health care expenses or health care coverage, the order of benefits for the child are as follows:

The Plan covering the Custodial parent;

The Plan covering the spouse of the Custodial parent;

The Plan covering the non-custodial parent; and then

The Plan covering the spouse of the non-custodial parent.

c. For a dependent child covered under more than one Plan of individuals who are the parents of the child, the provisions of subparagraph (a) or (b) above shall determine the order of benefits as if those individuals were the parents of the child.

(3) Active Employee or Retired or Laid-off Employee. The Plan that covers a person as an active employee, that is, an employee who is neither laid-off nor retired, is the Primary plan. The Plan covering that same person as a retired or laid-off employee is the Secondary plan. The same would hold true if a person is a dependent of an active employee and that same person is a dependent of a retired or laid-off employee. If the other Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled (d) (1) can determine the order of benefits.

(4) COBRA or State Continuation Coverage. If a person whose coverage is provided pursuant to COBRA or under a right of continuation provided by state or other federal law is covered under another Plan, the Plan cover the person as an employee, member, subscriber or retiree covering the person as a dependent of an employee, member, subscriber or retiree is the Primary plan and the COBRA or state or other federal continuation coverage is the Secondary plan. If the other Plan does not have this rule, and as a result the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled (d)(1) can determine the order of benefits.

(5) Longer or Shorter Length of Coverage. The Plan that covered the person as an employee, member, policyholder, subscriber or retiree longer is the Primary plan and the Plan that covered the person the shorter period of time is the Secondary plan.

(6) If the preceding rules do not determine the order of benefits, the Allowable expenses shall be shared equally between the Plans meeting the definition of Plan. In addition, This plan will not pay more than it would have paid had it been the Primary plan.

EFFECT ON THE BENEFITS OF THIS PLAN

(a) When This plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all Plans during a plan year are not more than the total Allowable expenses. In determining the amount to be paid for any claim, the Secondary plan will calculate the benefits it would have paid in the absence of other health care coverage and apply that calculated amount to any Allowable expense under its Plan that is unpaid by the Primary plan. The Secondary plan may then reduce its payment by the amount so that, when combined with the amount paid by the Primary plan, the total benefits paid or provided by all Plans for the claim do not exceed the total Allowable expense for that claim. In addition, the Secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.

(b) If a covered person is enrolled in two or more Closed panel plans and if, for any reason, including the provision of service by a non-panel provider, benefits are not payable by one Closed panel plan, COB shall not apply between that Plan and other Closed panel plans.

RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION

Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under This plan and other Plans. [Organization responsibility for COB administration] may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under This plan and other Plans covering the person claiming benefits. [Organization responsibility for COB administration] need not tell, or get the consent of, any person to do this. Each person claiming benefits under This plan must give [Organization responsibility for COB administration] any facts it needs to apply those rules and determine benefits payable.

FACILITY OF PAYMENT

A payment made under another Plan may include an amount that should have been paid under This plan. If it does, [Organization responsibility for COB administration] may pay that amount to the organization that made that payment. That amount will then be treated as though it were a benefit paid under This plan. [Organization responsibility for COB administration] will not have to pay that amount again. The term "payment made" includes providing benefits in the form of service, in which case "payment made" means the reasonable cash value of the benefits provided in the form of services.

RIGHT OF RECOVERY

If the amount of the payments made by [Organization responsibility for COB administration] is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid; or any other person or organization that may be responsible for the benefits or services provided for the covered person. The "amount of the payments made" includes the reasonable cash value of any benefits provided in the form of services.

APPENDIX B

CONSUMER EXPLANATORY BOOKLET

COORDINATION OF BENEFITS

| IMPORTANT NOTICE This is a summary of only a few of the provisions of your health plan to help you understand coordination of benefits, which can be very complicated. This is not a complete description of all of the coordination rules and procedures, and does not change or replace the language contained in your insurance contract, which determines your benefits. | | --- |

Double Coverage

It is common for family members to be covered by more than one health care plan. This happens, for example, when a husband and wife both work and choose to have family coverage through both employers.

When you are covered by more than one health plan, state law permits your insurers to follow a procedure called "coordination of benefits" to determine how much each should pay when you have a claim. The goal is to make sure that the combined payments of all plans do not add up to more than your covered health care expenses.

Coordination of benefits (COB) is complicated, and covers a wide variety of circumstances. This is only an outline of some of the most common ones. If your situation is not described, read your evidence of coverage or contact your state insurance department.

Primary or Secondary?

You will be asked to identify all the plans that cover members of your family. We need this information to determine whether we are the "primary" or "secondary" benefit payer. The primary plan always pays first when you have a claim.

Any plan that does not contain your state's COB rules will always be primary.

When This Plan is Primary

If you or a family member are covered under another plan in addition to this one, we will be primary when:

Your Own Expenses

The claim is for your own health care expenses, unless you are covered by Medicare and both you and your spouse are retired.

Your Spouse's Expenses

The claim is for your spouse, who is covered by Medicare, and you are not both retired.

Your Child's Expenses

The claim is for the health care expenses of your child who is covered by this plan and
You are married and your birthday is earlier in the year than your spouse's or you are living with another individual, regardless of whether or not you have ever been married to that individual, and your birthday is earlier than that other individual's birthday. This is known as the "birthday rule";

You are separated or divorced and you have informed us of a court decree that makes you responsible for the child's health care expenses;

There is no court decree, but you have custody of the child.

Other Situations

We will be primary when any other provisions of state or federal law require us to be.

How We Pay Claims When We Are Primary

When we are the primary plan, we will pay the benefits in accordance with the terms of your contract, just as if you had no other health care coverage under any other plan.

How We Pay Claims When We Are Secondary

We will be secondary whenever the rules do not require us to be primary.

How We Pay Claims When We Are Secondary

When we are the secondary plan, we do not pay until after the primary plan has paid its benefits. We will then pay part or all of the allowable expenses left unpaid, as explained below. An "allowable expense" is a health care expense covered by one of the plans, including copayments, coinsurance and deductibles.

If there is a difference between the amount the plans allow, we will base our payment on the higher amount. However, if the primary plan has a contract with the provider, our combined payments will not be more than the amount called for in our contract or the amount called for in the contract of the primary plan, whichever is higher. Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) usually have contracts with their providers.
We will determine our payment by subtracting the amount the primary plan paid from the amount we would have paid if we had been primary. We may reduce our payment by any amount so that, when combined with the amount paid by the primary plan, the total benefits paid do not exceed the total allowable expense for your claim. We will credit any amount we would have paid in the absence of your other health care coverage toward our own plan deductible.
If the primary plan covers similar kinds of health care expenses, but allows expenses that we do not cover, we may pay for those expenses.
We will not pay an amount the primary plan did not cover because you did not follow its rules and procedures. For example, if your plan has reduced its benefits because you did not obtain pre-certification, as required by that plan, we will not pay the amount of the reduction, because it is not an allowable expense.

Questions About Coordination of Benefits?

Contact Your State Insurance Department

History

#13779, eff 10-12-23

Part Ins 1905 Minimum Standards for Medicare Supplement Policies

N.H. Code Admin. R. Ann. Ins 1905.01 Purpose {#sec-ins-1905.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.01}

The purpose of this part is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement policies, to facilitate public understanding and comparison of such policies, to eliminate provisions contained in such policies which may be misleading or confusing in connection with the purchase of such policies or with the settlement of claims, and to provide for full disclosures in the sale of accident and sickness insurance coverages to persons eligible for Medicare.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.02 Applicability and Scope {#sec-ins-1905.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.02}

(a) Except as otherwise specifically provided in Ins 1905.06, Ins 1905.15, Ins 1905.16, Ins 1905.19, and Ins 1905.24, this part shall apply to:

(1) All Medicare supplement policies delivered or issued for delivery in this state on or after the effective date of this part; and

(2) All certificates issued under group Medicare supplement policies, which certificates have been delivered or issued for delivery in this state.

(b) This part shall not apply to a policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.03 Definitions {#sec-ins-1905.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.03}

(a) “Applicant” means:

(1) In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and

(2) In the case of a group Medicare supplement policy, the proposed certificate holder.

(b) “Bankruptcy” means when a Medicare Advantage organization that is not an issuer:

(1) Has filed, or has had filed against it, a petition for declaration of bankruptcy; and

(2) Has ceased doing business in the state.

(c) “Certificate” means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

(d) “Certificate form” means the form on which the certificate is delivered or issued for delivery by the issuer.

(e) “Continuous period of creditable coverage” means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual had no breaks in coverage greater than 63 days.

(f) “Creditable coverage” means, with respect to an individual, coverage of the individual provided under any of the following:

(1) A group health plan;

(2) Health insurance coverage;

(3) Part A or Part B of Title XVIII of the Social Security Act (Medicare);

(4) Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928;

(5) Chapter 55 of Title 10 United States Code (CHAMPUS);

(6) A medical care program of the Indian Health Service or of a tribal organization;

(7) A state health benefits risk pool;

(8) A health plan offered under Chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program;

(9) A public health plan as defined in federal regulation; or

(10) A health benefit plan under 22 United States Code 2504 (e) (Peace Corps Act).

(g) "Creditable coverage" shall not include:

(1) One or more, or any combination of, the following:

a. Coverage only for accident or disability income insurance, or any combination thereof;

b. Coverage issued as a supplement to liability insurance;

c. Liability insurance, including general liability insurance and automobile liability insurance;

d. Workers' compensation or similar insurance;

e. Automobile medical payment insurance;

f. Credit-only insurance;

g. Coverage for on-site medical clinics; and

h. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits;

(2) The following benefits, if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan:

a. Limited scope dental or vision benefits;

b. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and

c. Such other similar, limited benefits as are specified in federal regulations;

(3) The following benefits if offered as independent, non-coordinated benefits:

a. Coverage only for a specified disease or illness; and

b. Hospital indemnity or other fixed indemnity insurance; and

(4) The following, if it is offered as a separate policy, certificate, or contract of insurance:

a. Medicare supplemental health insurance as defined under section 1882 (g)(1) of the Social Security Act;

b. Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; and

c. Similar supplemental coverage provided to coverage under a group health plan.

(h) “Employee welfare benefit plan” means a plan, fund, or program of employee benefits as defined in 29 U.S.C. Chapter 18 Section 1002 (Employee Retirement Income Security Act).

(i) “Insolvency” means when an issuer, licensed to transact the business of insurance in this state, has had a final order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer's state of domicile.

(j) “Issuer” includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.

(k) “Medicare” means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

(l) “Medicare Advantage plan” means a plan of coverage for health benefits under Medicare Part C as defined in (refer to definition of Medicare Advantage plan in 42 U.S.C. Chapter 7 Section 1395w-28(b)(1)), and includes:

(1) Coordinated care plans that provide health care services, including but not limited to:

a. Health maintenance organization plans, with or without a point-of-service option;

b. Plans offered by provider-sponsored organizations; and

c. Preferred provider organization plans;

(2) Medical savings account plans coupled with a contribution into a Medicare Advantage plan medical savings account; and

(3) Medicare Advantage private fee-for-service plans.

(m) “Medicare supplement policy” means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service associations or health maintenance organizations, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395 et. seq.) or an issued policy under a demonstration project specified in 42 U.S.C. Section 1395 ss (g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. "Medicare supplement policy" does not include Medicare Advantage plans established under Medicare Part C, Outpatient Prescription Drug plans established under Medicare Part D, or any Health Care Prepayment Plan (HCPP) that provides benefits pursuant to an agreement under Section 1833 (a)(1)(A) of the Social Security Act.

(n) "Pre-Standardized Medicare supplement benefit plan," "Pre-Standardized benefit plan" or "Pre-Standardized plan" means a group or individual policy of Medicare supplement insurance issued prior to July 1, 1992.

(o) "1990 Standardized Medicare supplement benefit plan," "1990 Standardized benefit plan", or "1990 plan" means a group or individual policy of Medicare supplement insurance issued on or after July 1, 1992 and prior to June 1, 2010 and includes Medicare supplement insurance policies and certificates renewed on or after that date which are not replaced by the issuer at the request of the insured.

(p) "2010 Standardized Medicare supplement benefit plan," "2010 Standardized benefit plan", or "2010 plan" means a group or individual policy of Medicare supplement insurance issued on or after June 1, 2010.

(q) “Policy form” means the form on which the policy is delivered or issued for delivery by the issuer.

(r) “Secretary” means the secretary of the United States Department of Health and Human Services.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.04 Policy {#sec-ins-1905.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.04}

Definitions and Terms. No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless the policy or certificate contains definitions or terms that conform to the requirements of this section as follows:

(a) "Accident”, "accidental injury”, or “accidental means” shall be defined to employ "result" language and shall not include words that establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization and shall not be more restrictive than the following:

(1) "Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force"; and

(2) The definition in (a) above may provide that injuries shall not include injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law.

(b) “Benefit period” or “Medicare benefit period” shall not be defined more restrictively than as defined in the Medicare program.

(c) “Convalescent nursing home,” “extended care facility,” or “skilled nursing facility” shall not be defined more restrictively than as defined in the Medicare program.

(d) “Health care expenses” means, for purposes of Ins 1905.16, expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers.

(e) “Hospital” may be defined in relation to its status, facilities and available services or to reflect its accreditation by the joint commission on accreditation of hospitals, but not more restrictively than as defined in the Medicare program.

(f) “Medicare” shall be defined in the policy and certificate. Medicare may be substantially defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof," or words of similar import.

(g) “Medicare eligible expenses” shall mean expenses of the kinds covered by Medicare Part A and B, to the extent recognized as reasonable and medically necessary by Medicare.

(h) “Physician” shall not be defined more restrictively than as defined in the Medicare program.

(i) “Sickness” shall not be defined to be more restrictive than the following:

(1) "Sickness" means illness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force; and

(2) The definition in (1) above may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers' compensation, occupational disease, employer's liability or similar law.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.05 Policy Provisions {#sec-ins-1905.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.05}

(a) Except for permitted preexisting condition clauses as described in Ins 1905.06 (b)(1) and (2), Ins 1905.07 (b)(1), and Ins 1905.08 (a)(1) of this rule, no policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy if the policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.

(b) No Medicare supplement policy or certificate shall use waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.

(c) No Medicare supplement policy or certificate in force in the state shall contain benefits that duplicate benefits provided by Medicare.

(d) Subject to Ins 1905.06 (b)(5), (6), and (8) and Ins 1905.07 (b)(4) and (5), a Medicare supplement policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006 shall be renewed for current policyholders who do not enroll in Part D at the option of the policyholder.

(e) A Medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.

(f) After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:

(1) The policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Part D plan; and

(2) Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.06 Minimum Benefit Standards for Pre-Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery Prior To July 1, 1992 {#sec-ins-1905.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.06}

(a) No policy or certificate shall be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy or certificate unless it meets or exceeds the minimum standards set forth in this section. These are minimum standards and do not preclude the inclusion of other provisions or benefits which are not inconsistent with these standards.

(b) General Standards. The following standards shall apply to Medicare supplement policies and certificates and are in addition to all other requirements of this part:

(2) The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage;

(3) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents;

(4) A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, co-payment, or coinsurance amounts. Premiums may be modified to correspond with such changes;

(5) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewal" Medicare supplement policy shall not:

a. Provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium; or

b. Be cancelled or non-renewed by the issuer solely on the grounds of deterioration of health;

(6) Except as authorized by the commissioner of this state, an issuer shall neither cancel nor nonrenew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation.

a. If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in Ins 1905.06(b)(6)c., the issuer shall offer certificate holders an individual Medicare supplement policy. The issuer shall offer the certificate holder at least the following choices:

An individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; or
An individual Medicare supplement policy which provides only such benefits as are required to meet the minimum standards as defined in Ins 1905.08(b) of this rule;

b. If membership in a group is terminated, the issuer shall:

Offer the certificate holder the conversion opportunities described in subparagraph (6)(a); or
At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy; and

c. If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced;

(7) Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss; and

(8) If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subsection.

(1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

(2) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

(3) Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

(4) Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90% of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional 365 days;

(5) Coverage under Medicare Part A for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations or already paid for under Medicare Part B;

(6) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Medicare Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible ($147); and

(7) Effective January 1, 1990, coverage under Medicare Part B for the reasonable cost of the first 3 pints of blood or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations or already paid for under Medicare Part A, subject to the Medicare deductible amount.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.07 Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued or Delivered on or after July 1, 1992 and Prior to June 1, 2010 {#sec-ins-1905.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.07}

(a) The standards set forth in this section are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after July 1, 1992 and prior to June 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards.

(b) General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this rule:

(1) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 6 months from the effective date of coverage because it involved a preexisting condition. The policy or certificate may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage;

(2) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents;

(3) A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment, or coinsurance amounts. Premiums may be modified to correspond with such changes;

(4) No Medicare supplement policy or certificate shall provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium;

(5) Each Medicare supplement policy shall be guaranteed renewable and:

a. The issuer shall not cancel or non-renew the policy solely on the ground of health status of the individual;

b. The issuer shall not cancel or non-renew the policy for any reason other than nonpayment of premium or material misrepresentation;

c. If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under Ins 1905.07(b)(5)e., the issuer shall offer certificate holders an individual Medicare supplement policy which, at the option of the certificate holder:

Provides for continuation of the benefits contained in the group policy, or
Provides for benefits that otherwise meet the requirements of this subsection;

d. If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

Offer the certificate holder the conversion opportunity described in Ins 1905.07(b)(5) c.; or
At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy;

e. If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced; and

f. If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this paragraph;

(6) Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be conditioned upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss;

(7) A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificate holder for the period, not to exceed 24 months, in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to assistance; and

a. If suspension occurs and if the policyholder or certificate holder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted, effective as of the date of termination of entitlement, as of the termination of entitlement if the policyholder or certificate holder provides notice of loss of entitlement within 90 days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement;

b. Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended, for any period that may be provided by federal regulation, at the request of the policyholder if the policyholder is entitled to benefits under Section 226 (b) of the Social Security Act and is covered under a group health plan, as defined in Section 1862 (b)(1)(A)(v) of the Social Security Act. If suspension occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy shall be automatically reinstituted, effective as of the date of loss of coverage, if the policyholder provides notice of loss of coverage within 90 days after the date of the loss; and

c. Reinstitution of coverages as described in subparagraphs a. and b. shall:

Not provide for any waiting period with respect to treatment of preexisting conditions;
Provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension. If the suspended Medicare supplement policy provided coverage for outpatient prescription drugs, reinstitution of the policy for Medicare Part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and
Provide for classification of premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that would have applied to the policyholder or certificate holder had the coverage not been suspended;

(8) If an issuer makes a written offer to the Medicare Supplement policyholders or certificate holders of one or more of its plans to exchange during a specified period from his or her 1990 Standardized plan, as described in Ins 1905.07 of this part, to a 2010 Standardized plan, as described in Ins 1905.08 of this part, the offer and subsequent exchange shall comply with the following requirements:

a. An issuer need not provide justification to the commissioner if the insured replaces a 1990 Standardized policy or certificate with an issue age rated 2010 Standardized policy or certificate at the insured's original issue age and duration. If an insured's policy or certificate to be replaced is priced on an issue age rate schedule at the time of such offer, the rate charged to the insured for the new exchanged policy shall recognize the policy reserve buildup, due to the prefunding inherent in the use of an issue age rate basis, for the benefit of the insured. The method proposed to be used by an issuer shall be filed with the commissioner according to Ins 1905.17;

b. The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage;

c. An issuer may not apply new preexisting condition limitations or a new incontestability period to the new policy for those benefits contained in the exchanged 1990 Standardized policy or certificate of the insured, but may apply preexisting condition limitations of no more than 6 months to any added benefits contained in the new 2010 Standardized policy or certificate not contained in the exchanged policy; and

d. The new policy or certificate shall be offered to all policyholders or certificate holders within a given plan, except where the offer or issue would be in violation of state or federal law.

(c) Standards for Basic Core Benefits Common to All Benefit Plans A – J. Every issuer shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured and may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it:

(1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

(2) Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used;

(3) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

(4) Coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations; and

(5) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible.

(d) Standards for Additional Benefits. The following additional benefits shall be included in Medicare supplement benefit plans “B” through “J” only as provided by Ins 1905.09 of this rule:

(1) Medicare Part A deductible shall be coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period;

(2) Skilled nursing facility care shall be coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in a Medicare benefit period for post hospital skilled nursing facility care eligible under Medicare Part A;

(3) Medicare Part B deductible shall be coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement;

(4) Eighty percent of the Medicare Part B excess charges shall be coverage for 80% of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge;

(5) One hundred percent of the Medicare Part B excess charges shall be coverage for all of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge;

(6) Basic outpatient prescription drug benefit: Coverage for 50% of outpatient prescription drug charges, after a $250 calendar year deductible, to a maximum of $1,250 in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006;

(7) Extended outpatient prescription drug benefit: Coverage for 50% of outpatient prescription drug charges, after a $250 calendar year deductible to a maximum of $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006;

(8) Medically necessary emergency care in a foreign country: Coverage to the extent not covered by Medicare for 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset;

(9) Preventive medical care benefit: Coverage for the following preventive health services not covered by Medicare:

a. An annual clinical preventive medical history and physical examination that may include tests and services from subparagraph b., below, and patient education to address preventive health care measures;

b. Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician; and

c. Reimbursement shall be for the actual charges up to 100% of the Medicare-approved amount for each service, as if Medicare were to cover the service as identified in “American Medical Association Current Procedural Terminology” (AMA CPT) codes, to a maximum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare; and

(10) At-home recovery benefit: Coverage for services to provide short-term, at-home assistance with activities of daily living for those recovering from an illness, injury or surgery:

a. For purposes of this benefit, the following definitions shall apply:

“Activities of daily living” include, but are not limited to bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings;
“Care provider” means a duly qualified or licensed home health aide or homemaker, personal care aide or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses registry;
“Home” shall mean any place used by the insured as a place of residence, provided that the place would qualify as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility shall not be considered the insured's place of residence; and
“At-home recovery visit” means the period of a visit required to provide at-home recovery care, without limit on the duration of the visit, except each consecutive 4 hours in a 24-hour period of services provided by a care provider is one visit;

b. Coverage requirements and limitations:

At-home recovery services provided shall be primarily services which assist in activities of daily living;
The insured's attending physician shall certify that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment was approved by Medicare;
Coverage shall be limited to:

(i) No more than the number and type of at-home recovery visits certified as necessary by the insured's attending physician. The total number of at-home recovery visits shall not exceed the number of Medicare approved home health care visits under a Medicare approved home care plan of treatment;

(ii) The actual charges for each visit up to a maximum reimbursement of $40 per visit;

(iii) Sixteen hundred dollars ($1600) per calendar year;

(iv) Seven visits in any one week;

(v) Care furnished on a visiting basis in the insured's home;

(vi) Services provided by a care provider as defined in (10) a. 2. above;

(vii) At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded; and

(viii) At-home recovery visits received during the period the insured is receiving Medicare approved home care services or no more than 8 weeks after the service date of the last Medicare approved home health care visit; and

c. Coverage shall be excluded for:

Home care visits paid for by Medicare or other government programs; and
Care provided by family members, unpaid volunteers, or providers who are not care providers.

(e) Standards for Plans K and L shall be as follows:

(1) Standardized Medicare supplement benefit plan "K" shall consist of the following:

a. Coverage of 100% of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

b. Coverage of 100% of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;

c. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

d. Medicare Part A Deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subparagraph j., below;

e. Skilled Nursing Facility Care: Coverage for 50% of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subparagraph j., below;

f. Hospice Care: Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph j., below;

g. Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subparagraph j., below;

h. Except for coverage provided in subparagraph i. below, coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described in subparagraph j., below;

i. Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Medicare Part B deductible; and

j. Coverage of 100% of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services; and

(2) Standardized Medicare supplement benefit plan "L" shall consist of the following:

a. The benefits described in paragraphs (1) a., b., c., and i.;

b. The benefits described in paragraphs (1) d., e., f., g., and h., but substituting 75% for 50%; and

c. The benefit described in paragraph (1) j., but substituting $2000 for $4000.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.08 Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After June 1, 2010 {#sec-ins-1905.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.08}

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards. No issuer may offer any 1990 Standardized Medicare supplement benefit plan for sale on or after June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates issued before June 1, 2010 remain subject to the requirements of Ins 1905.07.

(a) General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this part:

(1) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 6 months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage;

(2) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents;

(5) Each Medicare supplement policy shall be guaranteed renewable and:

a. The issuer shall not cancel or non-renew the policy solely on the ground of health status of the individual;

b. The issuer shall not cancel or non-renew the policy for any reason other than nonpayment of premium or material misrepresentation;

c. If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under Ins 1905.08(5)(e), the issuer shall offer certificate holders an individual Medicare supplement policy which, at the option of the certificate holder:

Provides for continuation of the benefits contained in the group policy; or
Provides for benefits that otherwise meet the requirements of this subsection;

d. If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

Offer the certificate holder the conversion opportunity described in Ins 1905.08(a)(5)c.; or
At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy; and

(7) a. A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificate holder for the period, not to exceed 24 months, in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to assistance;

b. If suspension occurs and if the policyholder or certificate holder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted, effective as of the date of termination of entitlement, as of the termination of entitlement if the policyholder or certificate holder provides notice of loss of entitlement within 90 days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement;

c. Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended, for any period that may be provided by federal regulation, at the request of the policyholder if the policyholder is entitled to benefits under Section 226 (b) of the Social Security Act and is covered under a group health plan, as defined in Section 1862 (b)(1)(A)(v) of the Social Security Act. If suspension occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy shall be automatically reinstituted, effective as of the date of loss of coverage, if the policyholder provides notice of loss of coverage within 90 days after the date of loss; and

d. Reinstitution of coverages as described in subparagraphs b. and c above:

Shall not provide for any waiting period with respect to treatment of preexisting conditions;
Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and
Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that would have applied to the policyholder or certificate holder had the coverage not been suspended.

(b) Standards for Basic Core Benefits Common to Medicare Supplement Insurance Benefit Plans A, B, C, D, E, F, F with High Deductible, G, M, and N. Every issuer of Medicare supplement insurance benefit plans shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured and may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it:

(1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

(2) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used;

(5) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Medicare Part B regardless of hospital confinement, subject to the Medicare Part B deductible; and

(6) Hospice Care: Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.

(c) Standards for Additional Benefits. The following additional benefits shall be included in Medicare supplement benefit plans B, C, D, E, F, F with High Deductible, G, M and N as provided by Ins 1905.10:

(1) Medicare Part A Deductible: Coverage for 100% of the Medicare Part A inpatient hospital deductible amount per benefit period;

(2) Medicare Part A Deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period;

(3) Skilled Nursing Facility Care: Coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A;

(4) Medicare Part B Deductible: Coverage for 100% of the Medicare Part B deductible amount per calendar year regardless of hospital confinement;

(5) One hundred percent of the Medicare Part B Excess Charges: Coverage for all of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge; and

(6) Medically Necessary Emergency Care in a Foreign Country: Coverage to the extent not covered by Medicare for 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.09 Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and Prior to June 1, 2010 {#sec-ins-1905.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.09}

(a) An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic core benefits, as defined in Ins 1905.07(c) of this rule.

(b) No groups, packages or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this state, except as may be permitted in Ins 1905.09(f) and Ins 1905.12.

(c) Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans "A" through "L" listed in this subsection and conform to the definitions in Ins 1905.03. Each benefit shall be structured in accordance with the format provided in Ins 1905.07(c), (d), and (e) and list the benefits in the order shown in this subsection. For purposes of this section, "structure, language, and format" means style, arrangement and overall content of a benefit.

(d) An issuer may use, in addition to the benefit plan designations required in paragraph (c) above, other designations to the extent permitted by law.

(e) Make-up of benefit plans:

(1) Standardized Medicare supplement benefit plan "A" shall be limited to the basic core benefits common to all benefit plans, as defined in Ins 1905.07(c);

(2) Standardized Medicare supplement benefit plan "B" shall include only the following:

a. The core benefit as specified in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

(3) Standardized Medicare supplement benefit plan "C" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c); plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Medicare Part B deductible as defined in Ins 1905.07(d)(3); and

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

(4) Standardized Medicare supplement benefit plan "D" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8); and

e. The at-home recovery benefit as defined in Ins 1905.07(d)(10);

(5) Standardized Medicare supplement benefit plan "E" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.07 (d)(8); and

e. Preventive medical care as defined in Ins 1905.07(d)(9);

(6) Standardized Medicare supplement benefit plan "F" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. The skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. The Part B deductible as defined in Ins 1905.07(d)(3);

e. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5); and

f. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

(7) Standardized Medicare supplement benefit high deductible plan "F" shall include only the following:

a. 100% of covered expenses following the payment of the annual high deductible plan F deductible. The covered expenses include:

The core benefit as defined in Ins 1905.07(c) of this rule; plus
The Medicare Part A deductible as defined in Ins 1905.07(d)(1);
Skilled nursing facility care as defined in Ins 1905.07(d)(2);
The Medicare Part B deductible as defined in Ins 1905.07(d)(3);
One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5); and
Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

b. The annual high deductible plan "F" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan F policy; and shall be in addition to any other specific benefit deductibles;

c. The annual high deductible plan "F" deductible shall be $1500 for 1998 and 1999, and shall be based on the calendar year; and

d. It shall be adjusted annually thereafter by the Secretary to reflect the change in the consumer price index for all urban consumers for the 12 month period ending with August of the preceding year, and rounded to the nearest multiple of $10;

(8) Standardized Medicare supplement benefit plan "G" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Eighty percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(4);

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8); and

f. The at-home recovery benefit as defined in Ins 1905.07(d)(10);

(9) Standardized Medicare supplement benefit plan "H" shall consist of only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Basic prescription drug benefit as defined in Ins 1905.07(d)(6); and

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8); and

f. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005;

(10) Standardized Medicare supplement benefit plan "I" shall consist of only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5);

e. Basic prescription drug benefit as defined in Ins 1905.07(d)(6);

f. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

g. At-home recovery benefits as defined in Ins 1905.07 (d)(10); and

h. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005;

(11) Standardized Medicare supplement benefit plan "J" shall consist of only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Medicare Part B deductible as defined in Ins 1905.07(d)(3);

e. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5);

f. Extended prescription drug benefit as defined in Ins 1905.07(d)(7);

g. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

h. Preventive medical care as defined in Ins 1905.07(d)(9);

i. At-home recovery benefit as defined in Ins 1905.07(d)(10); and

j. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005;

(12) Standardized Medicare supplement benefit high deductible plan "J" shall consist of only the following:

a. One hundred percent of covered expenses, following the payment of the annual high deductible plan “J” deductible. The covered expenses include:

The core benefit as defined in Ins 1905.07(c) of this rule; plus
The Medicare Part A deductible as defined in Ins 1905.07(d)(1);
Skilled nursing facility care as defined in Ins 1905.07(d)(2);
Medicare Part B deductible as defined in Ins 1905.07(d)(3);
One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5);
Extended outpatient prescription drug benefit as defined in Ins 1905.07(d)(7);
Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);
Preventive medical care benefit as defined in Ins 1905.07(d)(9); and
At-home recovery benefit as defined in Ins 1905.07(d)(10);

b. The annual high deductible plan “J” deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan “J” policy, and shall be in addition to any other specific benefit deductibles;

c. The annual deductible shall be $1500 for 1998 and 1999, and shall be based on a calendar year;

e. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005; and

(13) Make-up of two Medicare supplement plans mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA):

a. Standardized Medicare supplement benefit plan "K" shall consist of only those benefits described in Ins 1905.07(e)(1); and

b. Standardized Medicare supplement benefit plan "L" shall consist of only those benefits described in Ins 1905.07(e)(2).

(f) New or Innovative Benefits. An issuer may, with the prior approval of the commissioner, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefit shall not include an outpatient prescription drug benefit.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.10 Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After June 1, 2010 {#sec-ins-1905.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.10}

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit plan standards. Benefit plan standards applicable to Medicare supplement policies and certificates issued before June 1, 2010 remain subject to the requirements of Ins 1905.07:

(a) (1) An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic core benefits, as defined in Ins 1905.08(b).

(2) If an issuer makes available any of the additional benefits described in Ins 1905.08(c) or offers standardized benefit plans “K” or “L”, as described in Ins 1905.10(e)(8) and (9), then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic core benefits as described in Ins 1905.10(a)(1) above, a policy form or certificate form containing either standardized benefit plan “C”, as described in Ins 1905.10(e)(3) or standardized benefit plan “F”, as described in Ins 1905.10(e)(5).

(b) No groups, packages, or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this state, except as may be permitted in Ins 1905.10 (f) and Ins 1905.12.

(c) Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans listed in this subsection and conform to the definitions in Ins 1905.03. Each benefit shall be structured in accordance with the format provided in Ins 1905.08(b); or, in the case of plans “K” or “L”, in Ins 1905.10(e)(8) or (9) and list the benefits in the order shown. For purposes of this section, "structure, language, and format" means style, arrangement, and overall content of a benefit.

(d) In addition to the benefit plan designations required in Ins 1905.10(c), an issuer may use other designations to the extent permitted by law.

(e) Make-up of 2010 Standardized Benefit Plans:

(1) Standardized Medicare supplement benefit plan “A” shall include only the following:

a. The basic core benefits as defined in Ins 1905.08(b);

(2) Standardized Medicare supplement benefit plan “B” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

(3) Standardized Medicare supplement benefit plan “C” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3);

d. One hundred percent of the Medicare Part B deductible as defined in Ins 1905.08(c)(4); and

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6);

(4) Standardized Medicare supplement benefit plan “D” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3); and

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6);

(5) Standardized Medicare supplement (regular) plan “F” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. The skilled nursing facility care as defined in Ins 1905.08(c)(3);

d. One hundred percent of the Medicare Part B deductible as defined in Ins 1905.08(c)(4);

e. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.08(c)(5); and

f. Medically necessary care in a foreign country as defined in Ins 1905.08(c)(6);

(6) Standardized Medicare supplement plan “F” with high deductible shall include only the following:

a. One hundred percent of covered expenses following the payment of the annual deductible set forth in subparagraph h;

b. The basic core benefit as defined in Ins 1905.08(b); plus

c. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

d. Skilled nursing facility care as defined in Ins 1905.08(c)(3);

e. One hundred percent of the Medicare Part B deductible as defined in Ins 1905.08(c)(4);

f. One hundred percent of the Medicare Part B excess charges as defined in Ins 2905.08(c)(5);

g. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6); and

h. The annual deductible in plan “F” with high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by regular plan “F”, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $1,500 and shall be adjusted annually from 1999 by the Secretary of the U.S. Department of Health and Human Services to reflect the change in the consumer price index for all urban consumers for the 12 month period ending with August of the preceding year, and rounded to the nearest multiple of 10 dollars;

(7) Standardized Medicare supplement benefit plan “G” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3);

d. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.08(c)(5);

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6); and

f. Effective January 1, 2020, the standardized benefit plans describe in Ins 1905.11(a)(4) – redesignated Plan G High Deductible – may be offered to any individual who was eligible for Medicare prior to January 1, 2020.

(8) Standardized Medicare supplement plan “K” is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

a. Part A Hospital Coinsurance, 61st through 90th days: Coverage of 100% of the Part A hospital coinsurance amount for each day from the 61st through the 90th day in any Medicare benefit period;

b. Part A Hospital Coinsurance, 91st through 150th days: Coverage of 100% of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;

c. Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

f. Hospice Care: Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph j., below;

g. Blood: Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, and defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subparagraph j., below;

h. Part B Cost Sharing: Except for coverage provided in subparagraph i, coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subparagraph j., below;

i. Part B Preventive Services: Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

j. Cost Sharing After Out-of-Pocket Limits: Coverage of 100% of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services;

(9) Standardized Medicare supplement plan “L” is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

a. The benefits described in Ins 1905.10(e)(8)a., b., c., and i.;

b. The benefits described in Ins 1905.10(e)(8)d., e., f., g., and h., but substituting 75% for 50%; and

c. The benefits described in Ins 1905.10(e)(8)j., but substituting $2,000 for $4,000;

(10) Standardized Medicare supplement plan “M” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. Fifty percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(2);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3); and

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6); and

(11) Standardized Medicare supplement plan “N” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3); and

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6), with co-payments in the following amounts:

The lesser of $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit, including visits to medical specialists; and
The lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit, however, this copayment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.

(f) New or Innovative Benefits: An insurer may, with the prior approval of the commissioner, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits shall not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.11 Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare On or After January 1, 2020 {#sec-ins-1905.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.11}

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires that the following standards are applicable to all Medicare supplement policies or certificates delivered, or issued for delivery in this state, to individuals newly eligible for Medicare on or after January 1, 2020. No policy or certificate that provides coverage of the Medicare Part B deductible may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate to individuals newly eligible for Medicare on or after January 1, 2020. All policies must comply with the following benefit standards. Benefit plan standards applicable to Medicare supplement policies and certificates issued to individuals eligible for Medicare before January 1, 2020, remain subject to the requirements of Ins 1905.10:

(a) Benefit Requirements. The standards and requirements of Section Ins 1905.10 shall apply to all Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020, with the following exceptions:

(1) Standardized Medicare supplement benefit Plan C is redesignated as Plan D and shall provide the benefits contained in Ins 1905.10(e)(3) but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible;

(2) Standardized Medicare supplement benefit Plan F is redesignated as Plan G and shall provide the benefits contained in Ins 1905.10(e)(5) but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible;

(3) Standardized Medicare supplement benefit plans C, F, and F with High Deductible may not be offered to individuals newly eligible for Medicare on or after January 1, 2020;

(4) Standardized Medicare supplement benefit Plan F With High Deductible is redesignated as Plan G With High Deductible and shall provide the benefits contained in Ins 1905.10(e)(6) but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible, provided further that the Medicare Part B deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual high deductible; and

(5) The reference to Plans C or F contained in Ins 1905.10(a)(2) is deemed a reference to Plans D or G for purposes of this section.

(b) Applicability to Certain Individuals. Ins 1905.11 applies to only individuals that are newly eligible for Medicare on or after January 1, 2020:

(1) By reason of attaining age 65 on or after January 1, 2020; or

(2) By reason of entitlement to benefits under part A pursuant to Section 226(b) or 226A of the Social Security Act, available as referenced in Appendix A, or who is deemed to be eligible for benefits under Section 226(a) of the Social Security Act on or after January 1, 2020.

(c) Guaranteed Issue for Eligible Persons. For purposes of Ins 1905.14(e), in the case of any individual newly eligible for Medicare on or after January 1, 2020, any reference to a Medicare supplement policy C or F (including F With High Deductible) shall be deemed to be a reference to Medicare supplement policy D or G (including G With High Deductible), respectively, that meet the requirements of Ins 1905.11(a).

(d) Applicability to Waivered States. In the case of a state described in Section 1882(p)(6) of the Social Security Act (“waivered” alternative simplification states), MACRA prohibits the coverage of the Medicare Part B deductible for any Medicare supplement policy sold or issued to an individual that is newly eligible for Medicare on or after January 1, 2020.

(e) Offer of Redesignated Plans to Individuals Other Than Newly Eligible. On or after January 1, 2020, the standardized benefit plans described in subparagraph Ins 1905.11(a)(4), above, may be offered to any individual who was eligible for Medicare prior to January 1, 2020, in addition to the standardized plans described in Ins 1905.10(e).

History

#12370, eff 10-13-17

N.H. Code Admin. R. Ann. Ins 1905.12 Medicare Select Policies and Certificates {#sec-ins-1905.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.12}

(a) This section shall apply to Medicare Select policies and certificates, as defined in this section.

(b) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section.

(1) "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers;

(2) "Grievance" means dissatisfaction expressed in writing by an individual insured under a Medicare Select policy or certificate with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers;

(3) "Medicare Select issuer" means an issuer offering, or seeking to offer, a Medicare Select policy or certificate;

(4) "Medicare Select policy" or "Medicare Select certificate" means respectively a Medicare supplement policy or certificate that contains restricted network provisions;

(5) "Network provider" means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits insured under a Medicare Select policy;

(6) "Restricted network provision" means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers; and

(7) "Service area" means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare Select policy.

(d) The commissioner may authorize an issuer to offer a Medicare Select policy or certificate, pursuant to this section and Section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the commissioner finds that the issuer has satisfied all of the requirements of this rule.

(e) A Medicare Select issuer shall not issue a Medicare Select policy or certificate in this state until its plan of operation has been approved by the commissioner.

(f) A Medicare Select issuer shall file a proposed plan of operation with the commissioner in a format prescribed by the commissioner. The plan of operation shall contain at least the following information:

(1) Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

a. Services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation and after-hour care. The hours of operation and availability of after-hour care shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community;

b. The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either:

To deliver adequately all services that are subject to a restricted network provision; or
To make appropriate referrals;

c. There are written agreements with network providers describing specific responsibilities;

d. Emergency care is available 24 hours per day and 7 days per week; and

e. In the case of covered services that are subject to a restricted network provision and are provided on a prepaid basis, there are written agreements with network providers prohibiting the providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate. This paragraph shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or certificate;

(2) A statement or map providing a clear description of the service area;

(3) A description of the grievance procedure to be utilized;

(4) A description of the quality assurance program, including:

a. The formal organizational structure;

b. The written criteria for selection, retention and removal of network providers; and

c. The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted;

(5) A list and description, by specialty, of the network providers;

(6) Copies of the written information proposed to be used by the issuer to comply with paragraph (k) below; and

(7) Any other information requested by the commissioner.

(g) A Medicare Select issuer shall file any proposed changes to the plan of operation, except for changes to the list of network providers, with the commissioner prior to implementing the changes. Changes shall be considered approved by the commissioner after 30 days unless specifically disapproved.

(h) An updated list of network providers shall be filed with the commissioner at least quarterly.

(i) A Medicare Select policy or certificate shall not restrict payment for covered services provided by non-network providers if:

(1) The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and

(2) It is not reasonable to obtain services through a network provider.

(j) A Medicare Select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers.

(k) A Medicare Select issuer shall make full and fair disclosure in writing of the provisions, restrictions and limitations of the Medicare Select policy or certificate to each applicant. This disclosure shall include at least the following:

(1) An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare Select policy or certificate with:

a. Other Medicare supplement policies or certificates offered by the issuer; and

b. Other Medicare Select policies or certificates;

(2) A description, including address, phone number and hours of operation, of the network providers, including primary care physicians, specialty physicians, hospitals and other providers;

(3) A description of the restricted network provisions, including payments for coinsurance and deductibles when providers other than network providers are utilized. Except to the extent specified in the policy or certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in plans “K” and “L”;

(4) A description of coverage for emergency and urgently needed care and other out-of-service area coverage;

(5) A description of limitations on referrals to restricted network providers and to other providers;

(6) A description of the policyholder's rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer; and

(7) A description of the Medicare Select issuer's quality assurance program and grievance procedure.

(l) Prior to the sale of a Medicare Select policy or certificate, a Medicare Select issuer shall obtain from the applicant a signed and dated form stating that the applicant has received the information provided pursuant to subsection (k) of this section and that the applicant understands the restrictions of the Medicare Select policy or certificate.

(m) A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers. The procedures shall be aimed at mutual agreement for settlement may include arbitration procedures and:

(1) The grievance procedure shall be described in the policy and certificates and in the outline of coverage;

(2) At the time the policy or certificate is issued, the issuer shall provide detailed information to the policyholder describing how a grievance may be registered with the issuer;

(3) Grievances shall be considered in a timely manner and shall be transmitted to appropriate decision-makers who have authority to fully investigate the issue and take correction action;

(4) If a grievance is found to be valid, corrective action shall be taken promptly;

(5) All concerned parties shall be notified about the results of a grievance; and

(6) The issuer shall report no later than each March 31st to the commissioner regarding its grievance procedure. The report shall be in a format prescribed by the commissioner and shall contain the number of grievances filed in the past year and a summary of the subject, nature and resolution of such grievances.

(n) At the time of initial purchase, a Medicare Select issuer shall make available to each applicant for a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate otherwise offered by the issuer.

(o) At the request of an individual insured under a Medicare Select policy or certificate, a Medicare Select issuer shall:

(1) Make available to the individual insured the opportunity to purchase a Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make the policies or certificates available without requiring evidence of insurability after the Medicare Select policy or certificate has been in force for 6 months; and

(2) For the purposes of this subsection, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services, or coverage for Part B excess charges.

(p) Medicare Select policies and certificates shall provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare Select policies and certificates issued pursuant to this section should be discontinued due to either the failure of the Medicare Select Program to be reauthorized under law or its substantial amendment.

(1) Each Medicare Select issuer shall make available to each individual insured under a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make the policies and certificates available without requiring evidence of insurability; and

(q) A Medicare Select issuer shall comply with reasonable requests for data made by state or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare Select Program.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17 (from Ins 1905.11)

N.H. Code Admin. R. Ann. Ins 1905.13 Open Enrollment {#sec-ins-1905.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.13}

(a) An issuer shall not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this state, nor discriminate in the pricing of a policy or certificate because of the health status, claims experience, receipt of health care, or medical condition of an applicant in the case of an application for a policy or certificate that is submitted prior to or during the 6 month period beginning with the first day of the first month in which an individual is enrolled for benefits under Medicare Part B and when each Medicare supplement policy and certificate currently available from an insurer shall be made available to all applicants who qualify under this subsection without regard to age.

(b) If an applicant qualifies under (a) and submits an application during the time period referenced in (a) and, as of the date of application, has had a continuous period of creditable coverage of at least 6 months, the issuer shall not exclude benefits based on a preexisting condition.

(c) If the applicant qualifies under (a) and submits an application during the time period referenced in (a) and, as of the date of application, has had a continuous period of creditable coverage that is less than 6 months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The Secretary shall specify the manner of the reduction under this subsection.

(d) Except as provided in (b) and Ins 1905.25, (a) shall not be construed as preventing the exclusion of benefits under a policy, during the first 6 months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the 6 months before the coverage became effective.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.10); ss by #12370, eff 10-13-17 (from Ins 1905.12)

N.H. Code Admin. R. Ann. Ins 1905.14 Guaranteed Issue for Eligible Persons {#sec-ins-1905.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.14}

(a) Guaranteed issue shall be for:

(1) Eligible persons are those individuals described in (b) who:

a. Seek to enroll under the policy during the period specified in Ins 1905.14(c); and

b. Submit evidence of the date of termination or disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy;

(2) With respect to eligible persons, an issuer shall not:

a. Deny or condition the issuance or effectiveness of a Medicare supplement policy described below that is offered and is available for issuance to new enrollees by the issuer;

b. Discriminate in the pricing of such a Medicare supplement policy because of:

Health status;
Claims experience;
Receipt of health care; or
Medical condition; and

c. Impose an exclusion of benefits based on a preexisting condition under such a Medicare supplement policy.

(b) An eligible person is an individual described in any of the following subparagraphs:

(1) The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare; and the plan terminates, or the plan ceases to provide all such supplemental health benefits to the individual;

(2) The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, and any of the following circumstances apply, or the individual is 65 years of age or older and is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under Section 1894 of the Social Security Act, and there are circumstances similar to those described below that would permit discontinuance of the individual's enrollment with such provider if such individual were enrolled in a Medicare Advantage plan:

a. The certification of the organization or plan has been terminated;

b. The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides;

c. The individual is no longer eligible to elect the plan because of a change in the individual’s place of residence or other change in circumstances specified by the secretary, but not including termination of the individual’s enrollment on the basis described in section 1851(g)(3)(B) of the federal Social Security Act, where the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under section 1856, or the plan is terminated for all individuals within a residence area;

d. The individual demonstrates, in accordance with guidelines established by the secretary, that:

The organization offering the plan substantially violated a material provision of the organization’s contract under this part in relation to the individual, including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide such covered care in accordance with applicable quality standards; or
The organization, or agent, or other entity acting on the organization’s behalf, materially misrepresented the plan’s provisions in marketing the plan to the individual; or

e. The individual meets such other exceptional conditions as the Secretary may provide;

(3) The individual is enrolled with:

a. An eligible organization under a contract under Section 1876 of the Social Security Act (Medicare cost);

b. A similar organization operating under demonstration project authority, effective for periods before April 1, 1999;

c. An organization under an agreement under Section 1833 (a)(1)(A) of the Social Security Act (health care prepayment plan); or

d. An organization under a Medicare Select policy; and

e. The enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under Ins 1905.14(b)(2);

(4) The individual is enrolled under a Medicare supplement policy and the enrollment ceases because:

a. Of the insolvency of the issuer or bankruptcy of the nonissuer organization;

b. Of other involuntary termination of coverage or enrollment under the policy;

c. The issuer of the policy substantially violated a material provision of the policy; or

d. The issuer, or an agent or other entity acting on the issuer's behalf, materially misrepresented the policy's provisions in marketing the policy to the individual;

(5) The individual was enrolled under a Medicare supplement policy and:

a. Terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, any eligible organization under a contract under Section 1876 of the Social Security Act (Medicare cost), any similar organization operating under demonstration project authority, any PACE provider under Section 1894 of the Social Security Act,or a Medicare Select policy; and

b. The subsequent enrollment under a. is terminated by the enrollee during any period within the first 12 months of such subsequent enrollment during which the enrollee is permitted to terminate such subsequent enrollment under Section 1851 (e) of the federal Social Security Act;

(6) The individual, upon first becoming eligible for benefits under Part A of Medicare at age 65, enrolls in a Medicare Advantage plan under Part C of Medicare, or with a PACE provider under Section 1894 of the Social Security Act and disenrolls from the plan or program by not later than 12 months after the effective date of enrollment; or

(7) The individual enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolled under a Medicare supplement policy that covers outpatient prescription drugs and the individual terminates enrollment in the Medicare supplement policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in (e)(4) below.

(1) Ins 1905.14(b)(1), the guaranteed issue period begins on the later of:

a. The date the individual receives a notice of termination or cessation of all supplemental health benefits or, if a notice is not received, notice that a claim has been denied because of such a termination or cessation; or

b. The date that the applicable coverage terminates or ceases; and ends 63 days thereafter;

(2) Ins 1905.14(b)(2),(3), (5), or (6) whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the individual receives a notice of termination and ends 63 days after the date the applicable coverage is terminated;

(3) Ins 1905.14(b)(4) a. and b., the guaranteed issue period begins on the earlier of:

a. The date that the individual receives a notice of termination, a notice of the issuer's bankruptcy or insolvency, or other such similar notice if any, and

b. The date that the applicable coverage is terminated, and ends on the date that is 63 days after the date the coverage is terminated;

(4) Ins 1905.14(b)(2), (4) c. and d., (5), or (6) who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date;

(5) In the case of an individual described in subsection (b) (7), the guaranteed issue period begins on the date the individual receives notice pursuant to Section 1882 (v)(2)(B) of the Social Security Act from the Medicare supplement issuer during the 60 day period immediately preceding the initial Part D enrollment period and ends on the date that is 63 days after the effective date of the individual's coverage under Medicare Part D; and

(6) Ins 1905.14(b) but not described in the preceding provisions of this subsection, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date;

(d) Extended Medigap access for interrupted trial periods:

(1) In the case of an individual described in Ins 1905.14(b)(5), or deemed to be so described, pursuant to this paragraph, whose enrollment with an organization or provider described in Ins 1905.14(b)(5)a. is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls with another such organization or provider, the subsequent enrollment shall be deemed to be an initial enrollment described in Ins 1905.14(b)(5);

(2) In the case of an individual described in Ins 1905.14(b)(6), or deemed to be so described, pursuant to this paragraph, whose enrollment with a plan or in a program described in Ins 1905.14(b)(6) is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to be an initial enrollment described in Ins 1905.14(b)(6); and

(3) For purposes of Ins 1905.14(b)(5) and (6), no enrollment of an individual with an organization or provider described in Ins 1905.14(b)(5) a., or with a plan or in a program described in Ins 1905.14(b)(6), may be deemed to be an initial enrollment under this paragraph after the two-year period beginning on the date on which the individual first enrolled with such an organization, provider, plan or program.

(e) Products to which eligible persons are entitled. The Medicare supplement policy to which eligible persons are entitled under:

(1) Ins 1905.14(b)(1), (2), (3), and (4) is a Medicare supplement policy which has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K, or L offered by any issuer;

(2) Ins 1905.14(b)(5) is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy described in Ins 1905.14(c)(1);

(3) After December 31, 2005, if the individual was most recently enrolled in a Medicare supplement policy with an outpatient prescription drug benefit, a Medicare supplement policy described in this subparagraph is:

a. The policy available from the same issuer but modified to remove outpatient prescription drug coverage; or

b. At the election of the policyholder, an A, B, C, F (including F with a high deductible), K, or L policy that is offered by any issuer;

(4) Ins 1905.14(b)(6) shall include any Medicare supplement policy offered by any issuer; and

(5) Ins 1905.14(b)(7) is a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L, and that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy with outpatient prescription drug coverage.

(f) Notification provisions at the time of an event:

(1) Described in Ins 1905.14(b) of this section because of which an individual loses coverage or benefits due to the termination of a contract or agreement, policy, or plan, the organization that:

a. Terminates the contract or agreement, the issuer terminating the policy, or the administrator of the plan being terminated, respectively, shall notify the individual of his or her rights under this section, and of the obligations of issuers of Medicare supplement policies under Ins 1905.14(a). Such notice shall be communicated contemporaneously with the notification of termination; and

(2) Described in Ins 1905.14(b) of this section because of which an individual ceases enrollment under a contract or agreement, policy, or plan, the organization that:

a. Offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy, or the administrator of the plan, respectively, shall notify the individual of his or her rights under this section, and of the obligations of issuers of Medicare supplement policies under Ins 1905.14 (a). Such notice shall be communicated within 10 working days of the issuer receiving notification of disenrollment.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.11) ); ss by #12370, eff 10-13-17 (from Ins 1905.13)

N.H. Code Admin. R. Ann. Ins 1905.15 Standards for Claims Payment {#sec-ins-1905.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.15}

(a) An issuer shall comply with Section 1882(c)(3) of the Social Security Act, as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987, OBRA, 1987, Public Law No. 100-203 by:

(1) Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;

(2) Notifying the participating physician or supplier and the beneficiary of the payment determination;

(3) Paying the participating physician or supplier directly;

(4) Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number and a central mailing address to which notices from a Medicare carrier may be sent;

(5) Paying user fees for claim notices that are transmitted electronically or otherwise; and

(6) Providing to the secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.

(b) Compliance with the requirements set forth in subsection (a) above shall be certified on the Medicare supplement insurance experience reporting form.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.12); ss by #12370, eff 10-13-17 (from Ins 1905.14)

N.H. Code Admin. R. Ann. Ins 1905.16 Loss Ratio Standards and Refund or Credit of Premium {#sec-ins-1905.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.16}

(a) Loss ratio standards shall be as follows:

(1) A Medicare supplement policy or certificate form shall not be delivered or issued for delivery unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return to policyholders and certificate holders in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy form or certificate form:

a. At least 75% of the aggregate amount of premiums earned in the case of group policies; or

b. At least 65% of the aggregate amount of premiums earned in the case of individual policies;

(2) Calculated on the basis of incurred claims experience or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis and earned premiums for the period and in accordance with accepted actuarial principles and practices. Incurred health care expenses where coverage is provided by a health maintenance organization shall not include:

a. Home office and overhead costs;

b. Advertising costs;

c. Commissions and other acquisition costs;

d. Taxes;

e. Capital costs;

f. Administrative costs; and

g. Claims processing costs;

(3) All filings of rates and rating schedules shall demonstrate that expected claims in relation to premiums comply with the requirements of this section when combined with actual experience to date. Filings of rate revisions shall also demonstrate that the anticipated loss ratio over the entire future period for which the revised rates are computed to provide coverage can be expected to meet the appropriate loss ratio standards;

(4) For purposes of applying Ins 1905.16(a)(1) and (2) of this section and Ins 1905.17(d)(2) only, policies issued as a result of solicitations of individuals through the mails or by mass media advertising, including both print and broadcast advertising, shall be deemed to be individual policies; and

(5) For policies issued prior to July 1, 1992 expected claims in relation to premiums shall meet:

a. The originally filed anticipated loss ratio when combined with the actual experience since inception;

b. The appropriate loss ratio requirement from Ins 1905.16(a)(1)a. and b. when combined with actual experience beginning with the effective date of this rule to date; and

c. The appropriate loss ratio requirement from Ins 1905.16(a)(1)a. and b. over the entire future period for which the rates are computed to provide coverage.

(b) Refund or credit calculation requirements shall be as follows:

(1) An issuer shall collect and file with the commissioner by May 31 of each year the data contained in the applicable reporting form contained in Appendix A for each type in a standard Medicare supplement benefit plan;

(2) If on the basis of the experience as reported the benchmark ratio since inception, ratio 1, exceeds the adjusted experience ratio since inception, ratio 3, then a refund or credit calculation is required. The refund calculation shall be done on a statewide basis for each type in a standard Medicare supplement benefit plan. For purposes of the refund or credit calculation, experience on policies issued within the reporting year shall be excluded;

(3) For the purposes of this section, policies or certificates issued prior to July 1, 1992, the issuer shall make the refund or credit calculation separately for all individual policies, including all group policies subject to an individual loss ratio standard when issued, combined and all other group policies combined for experience after July 1, 1992. The first report shall be due by May 31, 1994; and

(4) A refund or credit shall be made only when the benchmark loss ratio exceeds the adjusted experience loss ratio and the amount to be refunded or credited exceeds a de minimis level. The refund shall include interest from the end of the calendar year to the date of the refund or credit at a rate specified by the secretary of Health and Human Services, but in no event shall it be less than the average rate of interest for 13-week Treasury notes. A refund or credit against premiums due shall be made by September 30 following the experience year upon which the refund or credit is based.

(1) Issuers of Medicare supplement policies and certificates advertised, solicited, delivered or issued in this state shall file their rates, rating schedules, and supporting documentation with the commissioner in accordance with the general filing requirements and procedures described in Ins 4100;

(2) Carriers shall use the calendar year as the rate effective period. Rates shall not vary during the rate effective period based on either the policy's date of issue or the policy's renewal date. Rates shall be guaranteed to policyholders for the 12 month period between policy anniversary or renewal dates. The policy anniversary date or renewal date shall be the anniversary of the policy's date of issue. Rates shall be filed and approved according to the procedures set forth in Ins 1905.16 and Ins 1905.17 before their intended effective date. Carriers shall make the annual required rate filing no later than August 15;

(3) All approved rates shall be available to the public on October 15 preceding the rate effective period;

(4) The department shall not approve rates for policyholders less than age 65 that are greater than the highest rate proposed for a policyholder greater than age 65;

(5) The department shall not approve changes in premium relativities between plans unless such changes are demonstrated to be consistent with the NAIC Medicare Supplement Insurance Compliance Manual, dated March 25, 2010 and available as referenced in Appendix 2, or are necessary to prevent a policy from requiring refunds pursuant to this chapter;

(6) The supporting documentation provided pursuant to (a) above shall include a one-page exhibit which:

a. Shows New Hampshire-specific monthly premium rates, as would be billed to the policyholder or certificate holder, for each form approved, pursuant to the requirements of Ins 1905.17;

b. Indicates the preexisting condition limitation provisions applicable to each form;

c. Includes the name, address and telephone number of the issuer;

d. Shows whether the forms are generally available to all Medicare recipients in the state or whether availability is restricted, and, if availability is restricted, lists and explains the restrictions that apply; and

e. Rates shown in the one page exhibit shall be only those rates applicable during open enrollment;

(7) An issuer of Medicare supplement policies and certificates issued before or after the effective date of July 1, 1992 in this state shall file annually its rates, rating schedule and supporting documentation including ratios of incurred losses to earned premiums by policy duration for approval by the commissioner in accordance with the filing requirements and procedures prescribed by the commissioner. The supporting documentation shall also demonstrate in accordance with actuarial standards of practice using reasonable assumptions that the appropriate loss ratio standards can be expected to be met over the entire period for which rates are computed. The demonstration shall exclude active life reserves. An expected third-year loss ratio which is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than 3 years;

(8) As soon as practicable, but prior to the effective date of enhancements in Medicare benefits, every issuer of Medicare supplement policies or certificates in this state shall file with the commissioner, in accordance with the applicable filing procedures of this state:

a. Appropriate premium adjustments necessary to produce loss ratios as anticipated for the current premium for the applicable policies or certificates. The supporting documents necessary to justify the adjustment shall accompany the filing;

b. An issuer shall make premium adjustments necessary to produce an expected loss ratio under the policy or certificate to conform to minimum loss ratio standards for Medicare supplement policies and which are expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current premiums by the issuer for the Medicare supplement policies or certificates. No premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described herein shall be made with respect to a policy at any time other than upon its renewal date or anniversary date; and

c. If an issuer fails to make premium adjustments acceptable to the commissioner, the commissioner may order premium adjustments, refunds or premium credits deemed necessary to achieve the loss ratio required by this section; and

(9) Any appropriate riders, endorsements or policy forms needed to accomplish the Medicare supplement policy or certificate modifications necessary to eliminate benefit duplications with Medicare. The riders, endorsements or policy forms shall provide a clear description of the Medicare supplement benefits provided by the policy or certificate.

(d) Public Hearings. The commissioner may conduct a public hearing to gather information concerning a request by an issuer for an increase in a rate for a policy form or certificate form issued before or after the effective date of Ins 1905 if the experience of the form for the previous reporting period is not in compliance with the applicable loss ratio standard. The determination of compliance is made without consideration of any refund or credit for the reporting period. Public notice of the hearing shall be furnished in a manner deemed appropriate by the commissioner.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.13); amd by #10559, eff 4-1-14; ss by #12370, eff 10-13-17 (from Ins 1905.15)

N.H. Code Admin. R. Ann. Ins 1905.17 Filing and Approval of Policies and Certificates and Premium Rates {#sec-ins-1905.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.17}

(a) An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this state unless the policy form or certificate form has been filed with and approved by the commissioner in accordance with filing requirements and procedures prescribed by the commissioner in Ins 4100.

(b) An issuer shall file any riders or amendments to policy or certificate forms to delete outpatient prescription drug benefits as required by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 only with the commissioner in the state in which the policy or certificate was issued.

(c) An issuer shall not use or change premium rates for a Medicare supplement policy or certificate unless the rates, rating schedule and supporting documentation have been filed with and approved by the commissioner in accordance with the filing requirements and procedures prescribed by the commissioner in Ins 4100.

(d) Except as provided in (1) below, an issuer shall not file for approval more than one form of a policy or certificate of each type for each standard Medicare supplement benefit plan.

(1) An issuer may offer, with the approval of the commissioner, up to 4 additional policy forms or certificate forms of the same type for the same standard Medicare supplement benefit plan, one for each of the following cases:

a. The inclusion of new or innovative benefits;

b. The addition of either direct response or agent marketing methods;

c. The addition of either guaranteed issue or underwritten coverage; and

d. The offering of coverage to individuals eligible for Medicare by reason of disability; and

(2) For the purposes of this section, a "type" means an individual policy, a group policy, an individual Medicare Select policy, or a group Medicare Select policy.

(e) Except as provided in (1) below, an issuer shall continue to make available for purchase any policy form or certificate form issued after the effective date of this part that has been approved by the commissioner. A policy form or certificate form shall not be considered to be available for purchase unless the issuer has actively offered it for sale in the previous 12 months.

(1) An issuer may discontinue the availability of a policy form or certificate form if the issuer provides to the commissioner in writing its decision at least 30 days prior to discontinuing the availability of the form of the policy or certificate. After receipt of the notice by the commissioner, the issuer shall no longer offer for sale the policy form or certificate form in this state; and

(2) An issuer that discontinues the availability of a policy form or certificate form pursuant to (1) shall not file for approval a new policy form or certificate form of the same type for the same standard Medicare supplement benefit plan as the discontinued form for a period of 5 years after the issuer provides notice to the commissioner of the discontinuance. The period of discontinuance may be reduced if the commissioner determines that a shorter period is appropriate.

(f) The sale or other transfer of Medicare supplement business to another issuer shall be considered a discontinuance for the purposes of this section.

(g) A change in the rating structure or methodology shall be considered a discontinuance under (d) unless the issuer complies with the following requirements:

(1) The issuer provides an actuarial memorandum, in a form and manner prescribed by the commissioner, describing the manner in which the revised rating methodology and resultant rates differ from the existing rating methodology and existing rates; and

(2) The issuer does not subsequently put into effect a change of rates or rating factors that would cause the percentage differential between the discontinued and subsequent rates as described in the actuarial memorandum to change. The commissioner may approve a change to the differential which is in the public interest.

(h) Except as provided in (i) below, the experience of all policy forms or certificate forms of the same type in a standard Medicare supplement benefit plan shall be combined for purposes of the refund or credit calculation prescribed in Ins 1905.16.

(i) Forms assumed under an assumption reinsurance agreement shall not be combined with the experience of other forms for purposes of the refund or credit calculation.

(j) An issuer shall present for filing or approval a rate structure for its Medicare supplement policies or certificates issued after the effective date of the amendment of this rule based upon issue age only.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.14); ss by #12370, eff 10-13-17 (from Ins 1905.16)

N.H. Code Admin. R. Ann. Ins 1905.18 Permitted Compensation Arrangements {#sec-ins-1905.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.18}

(a) An issuer or other entity may provide commission or other compensation to an agent or other representative for the sale of a Medicare supplement policy or certificate only if the first year commission or other first year compensation is no more than 200% of the commission or other compensation paid for selling or servicing the policy or certificate in the second year or period.

(b) The commission or other compensation provided in subsequent renewal years shall be the same as that provided in the second year or period and shall be provided for no fewer than 5 renewal years.

(c) No issuer or other entity shall provide compensation to its agents or other producers, and no agent or producer shall receive compensation greater than the renewal compensation payable by the replacing issuer on renewal policies or certificates if an existing policy or certificate is replaced.

(d) For purposes of this section, "compensation" includes pecuniary or non-pecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate, including but not limited to bonuses, gifts, prizes, awards, and finders fees.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.15); ss by #12370, eff 10-13-17 (from Ins 1905.17)

N.H. Code Admin. R. Ann. Ins 1905.19 Required Disclosure Provisions {#sec-ins-1905.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.19}

(a) General rules shall be as follows:

(1) Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of the provision shall be consistent with the type of contract issued. The provision shall be appropriately captioned and shall appear on the first page of the policy, and shall include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age;

(2) Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured, exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy;

(3) Medicare supplement policies or certificates shall not provide for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import;

(4) If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as "preexisting condition limitations”;

(5) Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason; and

(6) Issuers of accident and sickness policies or certificates which provide hospital or medical expense coverage on an expense incurred or indemnity basis to persons eligible for Medicare shall provide to those applicants a “Guide to Health Insurance for People with Medicare” in the form developed jointly by the National Association of Insurance Commissioners and CMS and in a type size no smaller than 12 point type:

a. Delivery of the Guide shall be made whether or not the policies or certificates are advertised, solicited, or issued as Medicare supplement policies or certificates as defined in this rule. Except in the case of direct response issuers, delivery of the Guide shall be made to the applicant at the time of application and acknowledgement of receipt of the Guide shall be obtained by the issuer. Direct response issuers shall deliver the Guide to the applicant upon request but not later than at the time the policy is delivered; and

b. For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.

(b) Notice Requirements shall be as follows:

(l) As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificate holders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the commissioner. The notice shall:

a. Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate; and

b. Inform each policyholder or certificate holder as to when any premium adjustment is to be made due to changes in Medicare;

(2) The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension; and

(3) The notices shall not contain or be accompanied by any solicitation.

(c) MMA Notice Requirements. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

(d) Outline of Coverage Requirements for Medicare Supplement Policies.

(1) Issuers shall provide an outline of coverage to all applicants at the time application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgment of receipt of the outline from the applicant;

(2) If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany the policy or certificate when it is delivered and contain the following statement, in no less than 12-point type, immediately above the company name:

"NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued."

(3) The outline of coverage provided to applicants pursuant to this section shall consist of 4 parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage shall be in the language and format prescribed below in no less than 12 point type. All plans A-L shall be shown on the cover page, and the plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated; and

(4) The following items shall be included in the outline of coverage in the order prescribed below:

Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company shall make Plan “A” available. Some plans may not be available in your state.

Basic Benefits:

· Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

· Medical Expenses - Part B coinsurance (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or co-payments.

· Blood - First three pints of blood each year.

· Hospice - Part A coinsurance

Basic, incl.

100%

Part B co-

insurance

Basic, incl.

100%

Part B co-insurance

Basic, incl. 100%

Part B co-

insurance

Basic, incl.

100%

Part B co-insurance

Basic, incl.

100%

Part B co-insurance

Basic, incl.

100%

Part B co-insurance

Basic, incl.

100%

Part B co-insurance

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%

Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%

Basic, incl. 100% Part B co-insurance

Basic, incl. 100% Part B co-insurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

Skilled Nursing Facility Co-insurance

50% Skilled Nursing Facility Co-insurance

75% Skilled Nursing Facility Co-insurance

Skilled Nursing Facility Co-insurance

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

50% Part A

Deductible

75% Part A

Deductible

50%

Part A

Deductible

Part A

Deductible

Part B

Deductible

Part B

Deductible

Part B

Excess

(100%)

Part B

Excess

(100%)

Part B

Excess

(100%)

Foreign

Travel

Emergency

Foreign

Travel Emergency

Foreign

Travel Emergency

Foreign Travel Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel Emergency

Out-of-Pocket limit $[5120] paid at 100% after limit reached

Out-of-Pocket limit $[2560] paid at 100% after limit reached

*Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2200] deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed [$2200]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

PREMIUM INFORMATION [Boldface Type]

We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this State. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]

DISCLOSURES [Boldface Type]

Use this outline to compare benefits and premiums among policies.

This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. [This paragraph shall not appear after June 1, 2011.]

READ YOUR POLICY VERY CAREFULLY [Boldface Type]

This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.

RIGHT TO RETURN POLICY [Boldface Type]

If you find that you are not satisfied with your policy, you may return it to [insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

POLICY REPLACEMENT [Boldface Type]

If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NOTICE [Boldface Type]

This policy may not fully cover all of your medical costs.

[for agents:]

Neither [insert company's name] nor its agents are connected with Medicare.

[for direct response:]

[insert company's name] is not connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this rule. An issuer may use additional benefit plan designations on these charts pursuant to Ins 1905.10(d) of this rule.]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.]

Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020

This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.

Note: A ü means 100% of the benefit is paid.

Benefits

Plans Available to All Applicants

Medicare

first

eligible

before

G¹

F¹

Medicare Part A coinsurance and hospital coverage (up to an addition 365 days after

Medicare benefits are used

up)

Medicare Part B

coinsurance or Copayment

50%

75%

copays

apply³

Blood (first three pints)

50%

75%

Part A hospice care

coinsurance or copayment

50%

75%

Skilled nursing facility

coinsurance

50%

75%

Medicare Part A deductible

50%

75%

50%

Medicare Part B deductible

Medicare Part B excess

Charges

Foreign travel emergency

(up to plan limits)

Out-of-pocket limit in

[2017]²

[$5120]²

[$2560]²

1Plans F and G also have a high deductible option which require first paying a plan deductible of [$2200] before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

2Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

3Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.

PLAN A

MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and

board, general nursing

and miscellaneous

services and supplies

First 60 days

61st thru 90th day

91st day and after:

—While using 60 lifetime reserve days

—Once lifetime reserve

days are used:

—Additional 365 days

—Beyond the

additional 365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[329] a day

$[658] a day

100% of Medicare eligible expenses

$[1316] (Part A deductible)

$0**

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility

Within 30 days after leaving the hospital

First 20 days

21^st thru 100th day

101st day and after

All approved amounts

All but $[164.50] a day

Up to $[164.50] a day

All costs

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

BLOOD First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

Medicare co-payment/coinsurance

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

PLAN A

MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

Generally 80%

Generally 20%

$[183](Part B deductible)

Part B Excess Charges

(Above Medicare Approved Amounts)

All costs

BLOOD

First 3 pints

Next $[183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

80%

All costs

20%

$[183] (Part B deductible)

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES

100%

PLAN A

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled

care services and medical

supplies

Durable medical equipment

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

80%

20%

$[183] (Part B deductible)

PLAN B

MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and

board, general nursing

and miscellaneous

services and supplies

First 60 days

61^st thru 90th day

91^st day and after:

—While using 60 lifetime reserve days

—Once lifetime reserve

days are used:

Additional 365 days
Beyond the additional

365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[1316] (Part A deductible)

$[329] a day

$[658] a day

100% of Medicare eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including

having been in a hospital

for at least 3 days and entered

a Medicare-approved facility within 30 days after leaving

the hospital

First 20 days

21^st thru 100^th day

101st day and after

All approved amounts

All but $[164.50] a day

Up to $[164.50] a day

All costs

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

BLOOD First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

Medicare co-payment/coinsurance

PLAN B

MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

Generally 80%

Generally 20%

$[183] (Part B deductible)

Part B Excess Charges

(Above Medicare Approved Amounts)

All costs

BLOOD First 3 pints

Next $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

80%

All costs

20%

$[183] (Part B deductible)

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES

100%

PLAN B

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

Durable medical equipment

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

80%

20%

$[183] (Part B deductible)

PLAN C

MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing

and miscellaneous

services and supplies

First 60 days

61^st thru 90th day

91^st day and after:

While using 60 lifetime reserve days
Once lifetime reserve days are used:
Additional 365 days
Beyond the additional 365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[1316] (Part A deductible)

$[329] a day

$[658] a day

100% of Medicare eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days

21^st thru 100th day

101st day and after

All approved amounts

All but $[164.50] a day

Up to $[164.50] a day

All costs

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

BLOOD

First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

Medicare co-payment/coinsurance

MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

Generally 80%

$[183] (Part B deductible)

Generally 20%

Part B Excess Charges

(Above Medicare Approved Amounts)

All Costs

BLOOD

First 3 pints

Next $[183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

80%

All costs

$[183] (Part B deductible)

20%

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES

100%

PLAN C

PARTS A & B

HOME HEALTH CARE MEDICARE APPROVED

SERVICES

Medically necessary skilled

care services and medical

supplies

Durable medical equipment

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

80%

$[183] (Part B deductible)

20%

PLAN C

OTHER BENEFITS - NOT COVERED BY MEDICARE

FOREIGN TRAVEL— NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year

Remainder of Charges

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum

PLAN D

MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and

board, general nursing

and miscellaneous

services and supplies

First 60 days

61st thru 90th day

91st day and after:

—While using 60 lifetime reserve days

—Once lifetime reserve

days are used:

Additional 365 days
Beyond the additional

365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[1316] (Part A deductible)

$[329] a day

$[658] a day $0

100% of Medicare eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30

days after leaving the hospital

First 20 days

21^st thru 100th day

101st day and after

All approved amounts

All but $[164.50] a day

Up to $[164.50] a day

All costs

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

BLOOD

First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited

co-payment/

coinsurance for out-patient drugs and inpatient respite care

Medicare co-payments/coinsurance

PLAN D

MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

Generally 80%

Generally 20%

$[183] (Part B deductible)

Part B Excess Charges

(Above Medicare Approved Amounts)

All costs

BLOOD

First 3 pints

Next $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

80%

All costs

20%

$[183] (Part B deductible)

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES

100%

PLAN D

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED

SERVICES

Medically necessary skilled

care services and medical

supplies

Durable medical equipment

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

80%

20%

$[183] (Part B deductible)

PLAN D

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL—NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year

Remainder of charges

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum

PLAN F or HIGH DEDUCTIBLE PLAN F

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

[**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2200] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2200]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2200] DEDUCTIBLE,] PLAN PAYS**

[IN ADDITION TO $[2200] DEDUCTIBLE,] YOU PAY**

HOSPITALIZATION* Semiprivate room and

board, general nursing

and miscellaneous

services and supplies

First 60 days

61st thru 90^th day

91st day and after:

While using 60 Lifetime

reserve days

Once lifetime reserve days

are used:

Additional 365 days
Beyond the additional

365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[1316] (Part A deductible)

$[329] a day

$[658] a day

100% of Medicare

eligible expenses

$0***

All costs

First 20 days

21st thru 100th day

101^st day and after

All approved amounts

All but $[164.50] a day

Up to $[164.50] a day

All costs

BLOOD First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

Medicare co-payment/coinsurance

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

PLAN F or HIGH DEDUCTIBLE PLAN F

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year [$2200] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2200]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2200] DEDUCTIBLE,] PLAN PAYS**

[IN ADDITION TO $[2200] DEDUCTIBLE,] YOU PAY**

MEDICAL EXPENSES - IN OR OUT OF THE

HOSPITAL AND OUTPATIENT

HOSPITAL TREATMENT,

Such as physician's

Services, inpatient and

Outpatient medical and

Surgical services and

Supplies, physical and

Speech therapy,

Diagnostic tests,

Durable medical

Equipment

First $[183] of Medicare

Approved amounts*

Remainder of Medicare

Approved amounts

Generally 80%

$[183] (Part B

deductible)

Generally 20%

Part B Excess Charges

(Above Medicare Approved Amounts)

100%

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2200] DEDUCTIBLE,] PLAN PAYS**

[IN ADDITION TO $[2200] DEDUCTIBLE,] YOU PAY**

BLOOD

First 3 pints

Next $[183] of Medicare

Approved amounts*

Remainder of Medicare

Approved amounts

80%

All costs

$[183] (Part B

deductible

20%

CLINICAL LABORATORY SERVICES —TESTS

FOR DIAGNOSTIC SERVICES

100%

PLAN F or HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES

MEDICARE PAYS

AFTER YOU PAY $[2200] DEDUCTIBLE, PLAN PAYS**

IN ADDITION TO $[2200] DEDUCTIBLE, YOU PAY**

HOME HEALTH CARE MEDICARE APPROVED

SERVICE

Medically necessary skilled

care services and medical

supplies

Durable medical equipment

First $[183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

100%

80%

$[183] (Part B

deductible)

20%

PLAN F or HIGH DEDUCTIBLE PLAN F

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

AFTER YOU PAY $[2200] DEDUCTIBLE, PLAN PAYS**

IN ADDITION TO $[2200] DEDUCTIBLE, YOU PAY**

FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during

the first 60 days of each trip outside the USA

First $250 each calendar year

Remainder of charges

80% to a lifetime

maximum benefit

of $50,000

$250

20% and amounts

over the $50,000 life-time maximum

PLAN G or HIGH DEDUCTIBLE PLAN G

MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

[**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2200] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2200]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2200] DEDUCTIBLE,] PLAN PAYS**

[IN ADDITION TO $[2200] DEDUCTIBLE,] YOU PAY**

HOSPITALIZATION* Semiprivate room and

board, general nursing and miscellaneous services and supplies

First 60 days

61st thru 90th day

91st day and after:

—While using 60 lifetime reserve days

—Once lifetime reserve

days are used:

—Additional 365 days

—Beyond the additional 365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[1316] (Part A deductible)

$[329] a day

$[658] a day

100% of Medicare eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within

30 days after leaving the hospital

First 20 days

21^st thru 100th day

101st day and after

All approved amounts

All but $[164.50] a day

Up to $[164.50] a day

All costs

BLOOD

First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

Medicare co-payment/coinsurance

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

PLAN G or HIGH DEDUCTIBLE PLAN G

MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2200] DEDUCTIBLE,] PLAN PAYS**

[IN ADDITION TO $[2200] DEDUCTIBLE,] YOU PAY**

MEDICAL EXPENSES

— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services,

inpatient and outpatient medical and surgical services and supplies,

physical and speech

therapy, diagnostic tests, durable medical equipment

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

Generally 80%

Generally 20%

$[183] (Unless Part B deductible has been met)

Part B Excess Charges

(Above Medicare Approved Amounts)

100%

BLOOD

First 3 pints

Next $[183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

80%

All costs

20%

$[183] (UnlessPart B deductible has been met)

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2200] DEDUCTIBLE,] PLAN PAYS**

[IN ADDITION TO $[2200] DEDUCTIBLE,] YOU PAY**

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES

100%

PLAN G or HIGH DEDUCTIBLE PLAN G

PARTS A & B

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2200] DEDUCTIBLE,] PLAN PAYS**

[IN ADDITION TO $[2200] DEDUCTIBLE,] YOU PAY**

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary

skilled care services

and medical supplies

Durable medical equipment

First $[183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

80%

20%

$[183] (UnlessPart B deductible has been met)

PLAN G or HIGH DEDUCTIBLE PLAN G

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2200] DEDUCTIBLE,] PLAN PAYS**

[IN ADDITION TO $[2200] DEDUCTIBLE,] YOU PAY**

FOREIGN TRAVEL— NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year

Remainder of Charges

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum

PLAN K

You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[5120] each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOSPITALIZATION**

Semiprivate room and

board, general nursing and miscellaneous services and supplies

First 60 days

61st thru 90th day

91st day and after:

While using 60

lifetime reserve days

Once lifetime reserve

days are used:

-- Additional 365 days

-- Beyond the additional

365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[658](50% of Part A deductible)

$[329] a day

$[658] a day

100% of Medicare eligible expenses

$[658](50% of Part A deductible) ♦

$0***

All costs

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

SKILLED NURSING FACILITY CARE**

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days

21st thru 100th day

101st day and after

All approved amounts

All but $[164.50] a day

Up to $[82.25] a day (50% of Part A Coinsurance)

Up to $[82.25] a day (50% of Part A Coinsurance) ♦

All costs

BLOOD

First 3 pints

Additional amounts

100%

50%

50% ♦

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited co-payment/coinsurance for outpatient drugs and inpatient respite care

50% of co-payment/coinsurance

50% of Medicareco-payment/coinsurance ♦

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

PLAN K

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

MEDICAL EXPENSES –

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $[183] of Medicare Approved Amounts****

Preventive Benefits for Medicare covered services

Remainder of Medicare Approved Amounts

Generally 80% or more of Medicare approved amounts

Generally 80%

Remainder of Medicare approved amounts

Generally 10%

$[183] (Part B deductible)**** ♦

All costs above Medicare approved amounts

Generally 10% ♦

Part B Excess Charges

(Above Medicare Approved Amounts)

All costs (and they do not count toward annual out-of-pocket limit of $[5120])*

BLOOD

First 3 pints

Next $[183] of Medicare Approved Amounts****

Remainder of Medicare Approved Amounts

Generally 80%

50%

Generally 10%

50% ♦

$[183] (Part B deductible)**** ♦

Generally 10% ♦

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[5120] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PLAN K

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

Durable medical equipment

First $[183] of Medicare Approved Amounts****
Remainder of Medicare Approved Amounts

100%

80%

10%

$[183] (Part B deductible) ♦

10% ♦

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

PLAN L

You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[2560] each calendar year. The amounts that count toward your annual limit are notice with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for payment this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOSPITALIZATION**

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61st thru 90th day

91st day and after:

While using 60 lifetime reserve days

Once lifetime reserve days are used:

-- Additional 365 days

-- Beyond the additional 365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[987] (75% of Part A deductible)

$[329] a day

$[658] a day

100% of Medicare eligible expenses

$[329] (25% of Part A deductible) ♦

$0***

All costs

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

SKILLED NURSING FACILITY CARE**

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days

21st thru 100th day

101st day and after

All approved amounts

All but $[164.50] a day

Up to $[123.38]

a day (75% of Part A Coinsurance)

Up to $[41.13] a day (25% of Part A Coinsurance) ♦

All costs

BLOOD

First 3 pints

Additional amounts

100%

75%

25% ♦

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

75% of co-payment/coinsurance

25% of co-payment/coinsurance ♦

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

PLAN L

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

****Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

MEDICAL EXPENSES –

First $[183] of Medicare Approved Amounts

Preventive Benefits for Medicare covered services

Remainder of Medicare Approved Amounts

Generally 80% or more of Medicare approved amounts

Generally 80%

Remainder of Medicare approved amounts

Generally 15%

$[183] (Part B deductible)**** ♦

All costs above Medicare approved amounts

Generally 5% ♦

Part B Excess Charges

(Above Medicare Approved Amounts)

All costs (and they do not count toward annual out-of-pocket limit of [$2560])*

BLOOD

First 3 pints

Next $[183] of Medicare Approved Amounts****

Remainder of Medicare Approved Amounts

Generally 80%

75%

Generally 15%

25% ♦

$[183] (Part B deductible) ♦

Generally 5% ♦

CLINICAL LABORATORY SERVICES – TEST FOR DIAGNOSTIC SERVICES

100%

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2560] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PLAN L

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

Durable medical equipment

First $[183] of Medicare Approval Amounts*****
Remainder of Medicare Approved Amounts

100%

80%

15%

$[183] (Part B deductible) ♦

5% ♦

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

PLAN M

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61st thru 90th day

91st day and after:

While using 60 lifetime reserve days

Once lifetime reserve days are used:

-- Additional 365 days

-- Beyond the additional 365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[658] (50% of Part A deductible)

$[329] a day

$[658] a day

100% of Medicare eligible expenses

$[658] (50% of Part A deductible)

$0**

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days

21st thru 100th day

101st day and after

All approved amount

All but $[164.50] a day

Up to $[164.50] a day

All costs

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

BLOOD

First 3 pints

Additional amounts

100%

3 Pints

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

Medicare co-payment/coinsurance

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

PLAN M

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

MEDICAL EXPENSES –

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT , such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $[183] of Medicare Approved Amounts

Remainder of Medicare Approved Amounts

Generally 80%

Generally 20%

$[183] (Part B deductible)

Part B Excess Charges

(Above Medicare Approved Amounts)

All costs

BLOOD

First 3 pints

Next $[183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

80%

All costs

20%

$[183] (Part B deductible)

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

PLAN M

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

Durable medical equipment

First $[183] of Medicare Approval Amounts*

Remainder of Medicare Approved Amounts

100%

80%

20%

$[183] (Part B deductible)

OTHER BENEFITS -- NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL -NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year

Remainder of Charges

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum

PLAN N

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61st thru 90th day

91day and after:

While using 60 lifetime reserve days

Once lifetime reserve days are used:

-- Additional 365 days

-- Beyond the additional 365 days

All but $[1316]

All but $[329] a day

All but $[658] a day

$[1316] (Part A deductible)

$[329] a day

$[658] a day

100% of Medicare eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days

21st thru 100th day

101st day and after

All approved amounts

All but $[164.50] a day

Up to $[164.50] a day

All costs

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

BLOOD

First 3 pints

Additional amounts

100%

3 Pints

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

Medicare co-payment/coinsurance

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

PLAN N

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

MEDICAL EXPENSES -

First $[183] of Medicare Approved Amounts

Remainder of Medicare Approved Amounts

Generally 80%

Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

$[183] (Part B deductible)

Up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

Part B Excess Charges

(Above Medicare Approved Amounts)

All costs

BLOOD

First 3 pints

Next $[183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

80%

All costs

20%

$[183] (Part B deductible)

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

PLAN N

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

Durable medical equipment

First $[183] of Medicare Approval Amounts*
Remainder of Medicare Approved Amounts

100%

80%

20%

$[183] (Part B deductible)

PLAN N

OTHER BENEFITS -- NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL -NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year

Remainder of Charges

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum

(e) Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies.

(1) Any accident and sickness insurance policy or certificate, other than a Medicare supplement policy, a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act, 42 U.S.C. § 1395 et seq., disability income policy, or other policy identified in Ins 1905.02(b) issued for delivery in this state to persons eligible for Medicare shall notify insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy or certificate delivered to insureds.

The notice shall be in no less than 12 point type and shall contain the following language:

"THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."

(2) Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in Ins 1905.19(d)(1) shall disclose, using the applicable statement in Appendix C, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.16); ss by #12370, eff 10-13-17 (from Ins 1905.18)

N.H. Code Admin. R. Ann. Ins 1905.20 Requirements for Application Forms and Replacement Coverage {#sec-ins-1905.20 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.20}

(a) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare supplement, Medicare Advantage, Medicaid coverage, or another health insurance policy or certificate in force or whether a Medicare supplement policy or certificate is intended to replace any other accident and sickness policy or certificate presently in force. A supplementary application or other form to be signed by the applicant and agent containing such questions and statements may be used.

(1) [Statements]:

a. You do not need more than one Medicare supplement policy.

b. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.

c. You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.

d. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy or, if that is no longer available, a substantially equivalent policy, will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.

e. If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.

f. Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a qualified Medicare beneficiary (QMB) and a specified low-income Medicare beneficiary (SLMB).

(2) [Questions]:

a. If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.

[Please mark Yes or No below with an "X"]

To the best of your knowledge,

Did you turn age 65 in the last 6 months?

Yes_____ No_____

Did you enroll in Medicare Part B in the last 6 months?

Yes_____ No_____

If yes, what is the effective date? ____________________
Are you covered for medical assistance through the state Medicaid program?

[NOTE TO APPLICANT: If you are participating in a "Spend-Down Program" and have not met your "Share of Cost," please answer NO to this question.]

Yes_____ No_____

Will Medicaid pay your premiums for this Medicare supplement policy?

Yes_____ No_____

Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?

Yes_____ No_____

If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave "END" blank.

START //__ END //__

If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy?

Yes_____ No_____

Was this your first time in this type of Medicare plan?

Yes_____ No_____

Did you drop a Medicare supplement policy to enroll in the Medicare plan?

Yes_____ No_____

Do you have another Medicare supplement policy in force?

Yes_____ No_____

If so, with what company, and what plan do you have [option for Direct Mailers]?

If so, do you intend to replace your current Medicare supplement policy with this policy?

Yes_____ No_____

Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan)

Yes_____ No_____

If so, with what company and what kind of policy?

What are you dates of coverage under the other policy?

START //__ END //__

(If you are still covered under the other policy, leave "END" blank.)

(b) Agents shall list any other health insurance policies they have sold to the applicant.

(1) List policies sold which are still in force.

(2) List policies sold in the past 5 years that are no longer in force.

(c) In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant, and acknowledged by the insurer, shall be returned to the applicant by the insurer upon delivery of the policy.

(d) Upon determining that a sale will involve replacement of Medicare supplement coverage, any issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of the notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant, and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of Medicare supplement coverage.

(e) The notice required by (d) above for an issuer shall be provided in substantially the following form in no less than 12-point type:

NOTICE TO APPLICANT REGARDING REPLACEMENT

OF MEDICARE SUPPLEMENT INSURANCE

OR MEDICARE ADVANTAGE

[Insurance company's name and address]

SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.

According to [your application] [information you have furnished], you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by [Company Name] Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.

You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.

STATEMENT TO APPLICANT BY ISSUER, AGENT [BROKER OR OTHER REPRESENTATIVE]:

I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason (check one):

____ Additional benefits.

____ No change in benefits, but lower premiums.

____ Fewer benefits and lower premiums.

____ My plan has outpatient prescription drug coverage and I am enrolling in Part D.

____ Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment.

[optional only for Direct Mailers.]

____ Other. (please specify)___________________________________________________________

Note: If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing pre-existing condition limitations, please skip to statement 2 below. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.
State law provides that your replacement policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
If, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.

______________________________________________________ (Signature of Agent, Broker or Other Representative)*

[Typed Name and Address of Issuer, Agent or Broker]

______________________________________________________ (Applicant's Signature)

_______________________ (Date)

*Signature not required for direct response sales.

(f) Paragraphs 1 and 2 of the replacement notice (applicable to preexisting conditions) may be deleted by an issuer if the replacement does not involve application of a new preexisting condition limitation

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.17); ss by #12370, eff 10-13-17 (from Ins 1905.19)

N.H. Code Admin. R. Ann. Ins 1905.21 Filing Requirement for Advertising {#sec-ins-1905.21 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.21}

An issuer shall provide a copy of any Medicare supplement advertisement intended for use in this state whether through written, radio or television medium to the commissioner of insurance of this state for review or approval by the commissioner to the extent it may be required under state law.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.18); ss by #12370, eff 10-13-17 (from Ins 1905.20)

N.H. Code Admin. R. Ann. Ins 1905.22 Standards for Marketing {#sec-ins-1905.22 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.22}

(a) An issuer, directly or through its producers, shall:

(1) Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate;

(2) Establish marketing procedures to assure excessive insurance is not sold or issued;

(3) Display prominently by type, stamp or other appropriate means, on the first page of the policy the following:

"Notice to buyer: This policy may not cover all of your medical expenses."

(4) Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for Medicare supplement insurance already has accident and sickness insurance and the types and amounts of any such insurance; and

(5) Establish auditable procedures for verifying compliance with Ins 1905.22 (a).

(b) In addition to the practices prohibited in RSA 417, the following acts and practices are prohibited:

(1) Twisting. Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out a policy of insurance with another insurer;

(2) High pressure tactics. Employing any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance; and

(3) Cold lead advertising. Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company.

(c) The terms “Medicare supplement,” “Medigap,” “Medicare wrap around”, and words of similar import shall not be used unless the policy is issued in compliance with this part.

History

#5390, eff 7-1-92; ss by #5656, eff 7-1-93; moved by #6406, eff 1-1-97 (from Ins 1905.20); ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.19); ss by #12370, eff 10-13-17 (from Ins 1905.21)

N.H. Code Admin. R. Ann. Ins 1905.23 Appropriateness of Recommended Purchase and Excessive Insurance {#sec-ins-1905.23 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.23}

(a) In recommending the purchase or replacement of any Medicare supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.

(b) Any sale of a Medicare supplement policy or certificate that will provide an individual more than one Medicare supplement policy or certificate is prohibited.

(c) An issuer shall not issue a Medicare supplement policy or certificate to an individual enrolled in Medicare Part C unless the effective date of the coverage is after the termination date of the individual's Part C coverage.

History

#6406, eff 1-1-97 (from Ins 1905.21, originally #5656, eff 7-1-93); ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.20); ss by #12370, eff 10-13-17 (from Ins 1905.22)

N.H. Code Admin. R. Ann. Ins 1905.24 Reporting of Multiple Policies {#sec-ins-1905.24 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.24}

(a) On or before March 1 of each year, an issuer shall report the following information for every individual resident of this state for which the issuer has in force more than one Medicare supplement policy or certificate:

(1) Policy and certificate number; and

(2) Date of issuance.

(b) The items set forth above shall be grouped by individual policyholder.

History

#6880, EMERGENCY, eff 11-5-98, EXPIRED: 3-5-99
#7174, eff 12-22-99; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.21); ss by #12370, eff 10-13-17 (from Ins 1905.23)

N.H. Code Admin. R. Ann. Ins 1905.25 Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods, and Probationary Periods in Replacement Policies or Certificates {#sec-ins-1905.25 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.25}

(a) If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods in the new Medicare supplement policy or certificate for similar benefits to the extent such time was spent under the original policy.

(b) If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate which has been in effect for at least 6 months, the replacing policy shall not provide any time

period applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods for benefits similar to those contained in the original policy or certificate.

History

#8619, eff 5-1-06; ss by #9559, eff 10-13-09 (from Ins 1905.22); ss by #12370, eff 10-13-17 (from Ins 1905.24)

N.H. Code Admin. R. Ann. Ins 1905.26 Prohibition Against Use of Genetic Information and Requests for Genetic Testing {#sec-ins-1905.26 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.26}

This section applies to all policies with policy years beginning on or after May 21, 2009.

(a) An issuer of a Medicare supplement policy or certificate:

(1) Shall not deny or condition the issuance or effectiveness of the policy or certificate, including the imposition of any exclusion of benefits under the policy based on a preexisting condition, on the basis of the genetic information with respect to such individual; and

(2) Shall not discriminate in the pricing of the policy or certificate, including the adjustment of premium rates, of an individual on the basis of the genetic information with respect to such individual.

(b) Nothing in (a) shall be construed to limit the ability of an issuer, to the extent otherwise permitted by law, from:

(1) Denying or conditioning the issuance or effectiveness of the policy or certificate or increasing the premium for a group based on the manifestation of a disease or disorder of an insured or applicant; or

(2) Increasing the premium for any period issued to an individual based on the manifestation of a disease or disorder of an individual who is covered under the policy, in such case, the manifestation of a disease or disorder in one individual cannot also be used as genetic information about other group members and to further increase the premium for the group.

(c) An issuer of a Medicare supplement policy or certificate shall not request or require an individual or a family member of such individual to undergo a genetic test.

(d) Paragraph (c) shall not be construed to preclude an issuer of a Medicare supplement policy or certificate from obtaining and using the results of a genetic test in making a determination regarding payment, as defined for the purposes of applying the regulations promulgated under Part C of title XI and section 264 of the Health Insurance Portability and Accountability Act of 1996, as may be revised from time to time, and consistent with subsection (a).

(e) For purposes of carrying out paragraph (d), an issuer of a Medicare supplement policy or certificate may request only the minimum amount of information necessary to accomplish the intended purpose.

(f) Notwithstanding (c), an issuer of a Medicare supplement policy may request, but not require, that an individual or a family member of such individual undergo a genetic test if each of the following conditions is met:

(1) The request is made pursuant to research that complies with Part 46 of Title 45, Code of Federal Regulations, or equivalent Federal regulations, and any applicable state or local law or regulations for the protection of human subjects in research;

(2) The issuer clearly indicates to each individual, or in the case of a minor child, to the legal guardian of such child, to whom the request is made that:

a. Compliance with the request is voluntary; and

b. Non-compliance will have no effect on enrollment status or premium or contribution amounts;

(3) No genetic information collected or acquired under this subsection shall be used for underwriting, determination of eligibility to enroll or maintain enrollment status, premium rates, or the issuance, renewal, or replacement of a policy or certificate;

(4) The issuer notifies the secretary in writing that the issuer is conducting activities pursuant to the exception provided for under this subsection, including a description of the activities conducted; and

(5) The issuer complies with such other conditions as the secretary may by regulation require for activities conducted under this subsection.

(g) An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase genetic information for underwriting purposes.

(h) An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase genetic information with respect to any individual prior to such individual's enrollment under the policy in connection with such enrollment.

(i) If an issuer of a Medicare supplement policy or certificate obtains genetic information incidental to the requesting, requiring, or purchasing of other information concerning any individual, such request, requirement, or purchase shall not be considered a violation of subsection (h) if such request, requirement, or purchase is not in violation of subsection (g).

(j) For the purpose of this section only:

(1) "Issuer of a Medicare supplement policy or certificate" includes third-party administrator, or other person acting for or on behalf of such issuer;

(2) "Family member" means, with respect to an individual, any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of such individual;

(3) "Genetic information" means, with respect to any individual, information about such individual's genetic tests, the genetic tests of family members of such individual, and the manifestation of a disease or disorder in family member of such individual. Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or family member of such individual. Any reference to genetic information concerning an individual or family member of an individual who is a pregnant woman, includes genetic information of any fetus carried by such pregnant woman, or with respect to an individual or family member utilizing reproductive technology, includes genetic information of any embryo legally held by an individual or family member. The term "genetic information" does not include information about the sex or age of any individual;

(4) "Genetic services" means a genetic test, genetic counseling, including obtaining, interpreting, or assessing genetic information, or genetic education;

(5) "Genetic test" means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detect genotypes, mutations, or chromosomal changes. The term "genetic test" does not mean an analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal charges; or an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise if the field of medicine involved; and

(6) "Underwriting purposes" means:

a. Rules for, or determination of, eligibility, including enrollment and continued eligibility, for benefits under the policy;

b. The computation of premium or contribution amounts under the policy;

c. The application of any preexisting condition exclusion under the policy; and

d. Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.

History

#9559, eff 10-13-09 ss by #12370, eff 10-13-17 (from Ins 1905.25)

N.H. Code Admin. R. Ann. Ins 1905.27 Waiver or Suspension of Rules {#sec-ins-1905.27 omnilex-key=us-nh-regs-official--agency-ins--Ins 1905.27}

(1) Applying the rule provision would result in a form that is inaccurate, would cause confusion, or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to or inconsistent with the form of policy;

(3) There are specific circumstances unique to the form such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

Appendix A.

MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR_________________

TYPE1__________________________________________________________ SMSBP2__________________________________________________ For the State of______________________________ Company Name__________________________ NAIC Group Code___________________________ NAIC Company Code_____________________ Address____________________________________ Person Completing Exhibit_________________ Title_______________________________________ Telephone Number________________________

Line

(a)

Earned Premium ³

(b)

Incurred Claims ⁴

Current Year's Experience

a. Total (all policy years)

b. Current year's issues ⁵

c. Net (for reporting purposes = 1a–1b

Past Years' Experience (all policy years)

Total Experience

(Net Current Year + Past Year)

Refunds Last Year (Excluding Interest)

Previous Since Inception (Excluding Interest)

Refunds Since Inception (Excluding Interest)

Benchmark Ratio Since Inception ( see worksheet for Ratio 1 )

Experienced Ratio Since Inception ( Ratio 2 )

Total Actual Incurred Claims (line 3, col. b)

Total Earned Prem. (line 3, col. a)–Refunds Since Inception (line 6)

Life Years Exposed Since Inception

If the Experienced Ratio is less than the Benchmark Ratio, and there are more than 500 life years exposure, then proceed to calculation of refund.

Tolerance Permitted (obtained from credibility table)

Medicare Supplement Credibility Table

Life Years Exposed

Since Inception

Tolerance

10,000 +

0.0%

5,000 -9,999

5.0%

2,500 -4,999

7.5%

1,000 -2,499

10.0%

500

15.0%

If less than 500, no credibility.

1 Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

2 "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans.

3 Includes Modal Loadings and Fees Charged

4 Excludes Active Life Reserves

5 This is to be used as "Issue Year Earned Premium" for Year 1 of next year's "Worksheet for Calculation of Benchmark Ratios"

MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR________________________________________________

TYPE1 ___________________________________________________________________________________________________________________

SMSBP2_________________________________________________________________________________________________________________

For the State of__________________________________________________________________

Company Name ________________________________________________________________

NAIC Group Code_______________________________________________________________

NAIC Company Code_____________________________________________________________

Address________________________________________________________________________

Person Completing Exhibit_________________________________________________________

Title___________________________________________________________________________

Telephone Number_______________________________________________________________

Adjustment to Incurred Claims for Credibility

Ratio 3 = Ratio 2 + Tolerance

If Ratio 3 is more than Benchmark Ratio (Ratio 1), a refund or credit to premium is not required.

If Ratio 3 is less than the Benchmark Ratio, then proceed.

Adjusted Incurred Claims

[Total Earned Premiums (line 3, col. a)–Refunds Since Inception (line 6)] x Ratio 3 (line 11)

Refund

Total Earned Premiums (line 3, col. a)–Refunds Since Inception (line 6)

–[Adjusted Incurred Claims (line 12)/Benchmark Ratio (Ratio 1)]

If the amount on line 13 is less than .005 times the annualized premium in force as of December 31 of the reporting year, then no refund is made. Otherwise, the amount on line 13 is to be refunded or credited, and a description of the refund or credit against premiums to be used must be attached to this form.

I certify that the above information and calculations are true and accurate to the best of my knowledge and belief.

_______________________________________ Signature

________________________________________ Name - Please Type

________________________________________ Title - Please Type

________________________________________ Date

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES FOR CALENDAR YEAR____________________

TYPE1_______________________________________________

SMSBP2_____________________________________________

For the State of________________________________________

Company Name_______________________________________

NAIC Group Code_____________________________________

NAIC Company Code__________________________________

Address_____________________________________________

Person Completing Exhibit______________________________

Title________________________________________________

Telephone Number____________________________________

(a)³

(b)⁴

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(o)⁵

Earned

Cumulative

Policy Year

Year

Premium

Factor

(b)x(c)

Loss Ratio

(d)x(e)

Factor

(b)x(g)

Loss Ratio

(h)x(i)

Loss Ratio

2.770

0.507

0.000

0.46

4.175

0.567

0.000

0.63

4.175

0.567

1.194

0.759

0.75

4.175

0.567

2.245

0.771

0.77

4.175

0.567

3.170

0.782

0.80

4.175

0.567

3.998

0.792

0.82

4.175

0.567

4.754

0.802

0.84

4.175

0.567

5.445

0.811

0.87

4.175

0.567

6.075

0.818

0.88

4.175

0.567

6.650

0.824

0.88

4.175

0.567

7.176

0.828

0.88

4.175

0.567

7.655

0.831

0.88

4.175

0.567

8.093

0.834

0.89

4.175

0.567

8.493

0.837

0.89

15+⁶

4.175

0.567

8.684

0.838

0.89

Total:

(k):

(l):

(m):

(n):

Benchmark Ratio Since Inception: (l + n)/(k + m): __________

1 Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

2 "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans

3 Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)

4 For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

5 These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.

6 To include the earned premium for all years prior to as well as the 15th year prior to the current year.

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES FOR CALENDAR YEAR____________________

TYPE1____________________________________________________________

SMSBP2__________________________________________________________

For the State of_____________________________________________________

Company Name____________________________________________________

NAIC Group Code__________________________________________________

NAIC Company Code_______________________________________________

Address__________________________________________________________

Person Completing Exhibit___________________________________________

Title_____________________________________________________________

Telephone Number_________________________________________________

(a)³

(b)⁴

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(o)⁵

Earned

Cumulative

Policy Year

Year

Premium

Factor

(b)x(c)

Loss Ratio

(d)x(e)

Factor

(b)x(g)

Loss Ratio

(h)x(i)

Loss Ratio

2.770

0.442

0.000

0.40

4.175

0.493

0.000

0.55

4.175

0.493

1.194

0.659

0.65

4.175

0.493

2.245

0.669

0.67

4.175

0.493

3.170

0.678

0.69

4.175

0.493

3.998

0.686

0.71

4.175

0.493

4.754

0.695

0.73

4.175

0.493

5.445

0.702

0.75

4.175

0.493

6.075

0.708

0.76

4.175

0.493

6.650

0.713

0.76

4.175

0.493

7.176

0.717

0.76

4.175

0.493

7.655

0.720

0.77

4.175

0.493

8.093

0.723

0.77

4.175

0.493

8.493

0.725

0.77

15+⁶

4.175

0.493

8.684

0.725

0.77

Total:

(k):

(l):

(m):

(n):

Benchmark Ratio Since Inception: (l + n)/(k + m): _______________

1 Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

2 "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans

3 Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)

4 For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

6 To include the earned premium for all years prior to as well as the 15th year prior to the current year.

Appendix B.

FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

Company Name: ________________________________________________

Address: ________________________________________________

Phone Number: ________________________________________________

Due March 1, annually

The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.

Policy and Date of

Certificate # Issuance

___________________________________ Signature

___________________________________ Name and Title (please type)

___________________________________ Date

Appendix C.

DISCLOSURE STATEMENTS

Instructions for Use of the Disclosure Statements for Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare

Section 1882 (d) of the federal Social Security Act [42 U.S.C. 1395ss] prohibits the sale of a health insurance policy (the term policy includes certificate) to Medicare beneficiaries that duplicates Medicare benefits unless it will pay benefits without regard to a beneficiary's other health coverage and it includes the prescribed disclosure statement on or together with the application for the policy.
All types of health insurance policies that duplicate Medicare shall include one of the attached disclosure statements, according to the particular policy type involved, on the application or together with the application. The disclosure statement may not vary from the attached statements in terms of language or format (type size, type proportional spacing, bold character, line spacing, and usage of boxes around text).
State and federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare supplement policy except as a replacement policy.
Property/casualty and life insurance policies are not considered health insurance.
Disability income policies are not considered to provide benefits that duplicate Medicare.
Long-term care insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits that duplicate Medicare.
The federal law does not preempt state laws that are more stringent than the federal requirements.
The federal law does not preempt existing state form filing requirements.
Section 1882 of the federal Social Security Act was amended in Subsection (d)(3)(A) to allow for alternative disclosure statements. The disclosure statements already in Appendix C remain. Carriers may use either disclosure statement with the requisite insurance product. However, carriers should use either the original disclosure statements or the alternative disclosure statements and not use both simultaneously.

[Original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]

Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits

This is not Medicare Supplement Insurance

This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when it pays:

 hospital or medical expenses up to the maximum stated in the policy

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Original disclosure statement for policies that provide benefits for specified limited services.]

Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits

This is not Medicare Supplement Insurance

This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when:

 any of the services covered by the policy are also covered by Medicare

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Original disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]

Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits

This is not Medicare Supplement Insurance

This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when it pays:

 hospital or medical expenses up to the maximum stated in the policy

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]

Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits

This is not Medicare Supplement Insurance

This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]

Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits

This is not Medicare Supplement Insurance

This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when:

 any expenses or services covered by the policy are also covered by Medicare

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 hospice

 other approved items and services

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Original disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]

Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits

This is not Medicare Supplement Insurance

This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when:

 any expenses or services covered by the policy are also covered by Medicare; or

 it pays the fixed dollar amount stated in the policy and Medicare covers the same event

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice care

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items & services

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Original disclosure statement for other health insurance policies not specifically identified in the preceding statements.]

Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits

This is not Medicare Supplement Insurance

This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when it pays:

 the benefits stated in the policy and coverage for the same event is provided by Medicare

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]

Important Notice to Persons on Medicare This Is Not Medicare Supplement Insurance

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Alternative disclosure statement for policies that provide benefits for specified limited services.]

Important Notice to Persons on Medicare This Is Not Medicare Supplement Insurance

Some health care services paid for by Medicare may also trigger the payment of benefits under this policy.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Alternative disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]

Important Notice to Persons on Medicare This Is Not Medicare Supplement Insurance

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. Medicare generally pays for most or all of these expenses.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]

Important Notice to Persons on Medicare This Is Not Medicare Supplement Insurance

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]

Important Notice to Persons on Medicare This Is Not Medicare Supplement Insurance

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]

Important Notice to Persons on Medicare This Is Not Medicare Supplement Insurance

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice care

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items & services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

[Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]

Important Notice to Persons on Medicare This Is Not Medicare Supplement Insurance

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

 hospitalization

 physician services

 hospice

 [outpatient prescription drugs if you are enrolled in Medicare Part D]

 other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

BEFORE YOU BUY THIS INSURANCE

Ö Check the coverage in all health insurance policies you already have.

Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].

History

#12370, eff 10-13-17

Part Ins 1907 Nondiscrimination in Health Insurance Coverage in the Group Market

N.H. Code Admin. R. Ann. Ins 1907.01 Purpose and Scope {#sec-ins-1907.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1907.01}

(a) The purpose of this chapter is to incorporate the requirements set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and federal regulations that prohibit carriers providing health insurance coverage under a health benefit plan in the group market from discriminating against individual participants or beneficiaries in these plans with respect to plan eligibility and in setting premium and contribution rates based on any health factor of the participants or beneficiaries.

(b) This chapter shall apply to any carrier that provides coverage under a health benefit plan in the group market.

History

#8607, eff 4-17-06, EXPIRED: 4-17-14

N.H. Code Admin. R. Ann. Ins 1907.02 Definitions {#sec-ins-1907.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1907.02}

As used in this chapter:

(a) "Affiliation period" means a period of time that shall expire before health insurance coverage provided by a carrier becomes effective, and during which the carrier is not required to provide benefits.

(b) "Beneficiary" has the meaning stated in Section 3(8) of the Employee Retirement Income Security Act of 1974 (ERISA).

(c) "Carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services. For the purposes of this chapter, carrier includes a sickness and accident insurance company, a nonprofit hospital and health service corporation, a health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation.

(d) "Commissioner" means the insurance commissioner of this state.

(e) "Creditable coverage" means:

(1) With respect to an individual, health benefits or coverage provided under any of the following:

a. A group health plan;

b. A health benefit plan;

c. Part A or Part B of Title XVIII of the Social Security Act (Medicare);

d. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928 (the program for distribution of pediatric vaccines);

e. Chapter 55 of Title 10, United States Code (medical and dental care for members and certain former members of the uniformed services and for their dependents). For purposes of Chapter 55 of Title 10, U.S.C., "uniformed services" means the armed forces and the Commissioned Corps of the National Oceanic and Atmospheric Administration and of the Public Health Service);

f. A medical care program of the Indian Health Service or of a tribal organization;

g. A state health benefits risk pool;

h. A health plan offered under Chapter 89 of Title 5, United States Code (Federal Employees Health Benefits Program (FEHBP));

i. A public health plan, which for purposes of this chapter, means a plan established or maintained by a state, county, or other political subdivision of a state that provides health insurance coverage to individuals enrolled in the plan; or

j. A health benefit plan under Section 5 (e) of the Peace Corps Act (22 U.S.C. 2504 (e)).

(2) A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a group health plan, if, after such period and before the enrollment date, the individual experiences a significant break in coverage.

(f) "Dependent" means a spouse, an unmarried child under the age of 19, an unmarried child who is a full-time student under the age of 25 and who is financially dependent upon the participant, and an unmarried child of any age who is medically certified as disabled and dependent upon the participant.

(g) "Enrollment date" means the first day of coverage or, if there is a waiting period, the first day of the waiting period, whichever is earlier.

(h) "Genetic information" means:

(1) Information about genes, gene products and inherited characteristics that may derive from the individual or a family member;

(2) Information regarding an individual's carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct analysis of genes or chromosomes.

(i) "Group health plan" means:

(1) An employee welfare benefit plan, as defined in Section 3(1) of ERISA, to the extent that the plan provides medical care and including items and services paid for as medical care to employees or their dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.

(2) For the purposes of this chapter:

a. Any plan, fund or program that would not be, but for PHSA Section 2721(e), as added by Pub. L. No. 104-191, an employee welfare benefit plan and that is established or maintained by a partnership, to the extent that the plan, fund or program provides medical care, including items and services paid for as medical care, to present or former partners in the partnership, or to their dependents, as defined under the terms of the plan, fund or program, directly or through insurance, reimbursement or otherwise, shall be treated, subject to subparagraph b. of this paragraph, as an employee welfare benefit plan that is a group health plan;

b. In the case of a group health plan, the term "employer" also includes the partnership in relation to any partner; and

c. In the case of a group health plan, the term "participant," as defined in subsection (g) below, also includes an individual who is, or may become, eligible to receive a benefit under the plan, or the individual's beneficiary who is, or may become, eligible to receive a benefit under the plan, if:

In connection with a group health plan maintained by a partnership, the individual is a partner in relation to the partnership; or
In connection with a group health plan maintained by a self-employed individual, under which, one or more employees are participants, the individual is the self-employed individual.

(j) "Health benefit plan" means:

(1) A policy, contract, certificate or agreement offered or issued by a carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

(2) Short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as otherwise specifically exempted in this definition.

(k) "Health benefit plan" shall not include:

(1) One or more, or any combination of, the following:

a. Coverage only for accident, or disability income insurance, or any combination thereof;

b. Liability insurance, including general liability insurance and automobile liability insurance;

c. Coverage issued as a supplement to liability insurance;

d. Workers' compensation or similar insurance;

e. Automobile medical payment insurance;

f. Credit-only insurance;

g. Coverage for on-site medical clinics; and

h. Other similar insurance coverage, specified in federal regulations issued pursuant to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits.

(2) The following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:

a. Limited scope dental or vision benefits;

b. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or

c. Other similar, limited benefits specified in federal regulations issued pursuant to Pub. L. No. 104-191.

(3) The following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under a group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under a group health plan maintained by the same plan sponsor:

a. Coverage only for a specified disease or illness; or

b. Hospital indemnity or other fixed indemnity insurance.

(4) The following if offered as a separate policy, certificate or contract of insurance:

a. Medicare supplemental health insurance as defined in Section 1882(g)(1) of the Social Security Act;

b. Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; or

c. Similar supplemental coverage provided to coverage under a group health plan.

(l) "Health care services" means services for the diagnosis, prevention, treatment, cure or relief of a medical condition, illness, injury or disease.

(m) "Health maintenance organization" means a person that undertakes to provide or arrange for the delivery of health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments or deductibles or both.

(n) "Health factor" means:

(1) In relation to an individual, any of the following health status-related factors:

a. Health status;

b. Medical condition, including both physical and mental illnesses, as defined in subsection (p) below;

c. Claims experience;

d. Receipt of health care;

e. Medical history;

f. Genetic information;

g. Evidence of insurability, including:

Conditions arising out of acts of domestic violence; or
Participation in activities, such as motorcycling, snowmobiling, all-terrain vehicle riding, horseback riding, skiing, and other similar activities; or

h. Disability.

(2) For purposes of this subsection, "health factor" does not include the decision whether to elect health insurance coverage, including the time chosen to enroll, such as under special enrollment or late enrollment.

(o) "Medical care" means amounts paid for:

(1) The diagnosis, care, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;

(2) Transportation primarily for and essential to medical care referred to in subparagraph (1); and

(3) Insurance covering medical care referred to in subparagraphs (1) and (2).

(p) "Medical condition" means:

(1) Any condition, whether physical or mental, including any condition resulting from illness, injury, accident, pregnancy or congenital malformation;

(2) For the purposes of subparagraph (1), genetic information is not a condition.

(q) "Participant" has the meaning stated in Section 3(7) of ERISA.

(r) "Preexisting condition" means a condition, 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 enrollment date of the coverage.

(s) "Preexisting condition" shall not mean:

(1) A condition for which medical advice, diagnosis, care or treatment was recommended or received for the first time while the covered person held creditable coverage and that was a covered benefit under the health benefit plan, provided that the prior creditable coverage was continuous to a date not more than 90 days prior to the enrollment date of the new coverage; or

(2) Genetic information which shall not be treated as a condition under paragraph (r) for which a preexisting condition exclusion may be imposed in the absence of a diagnosis of the condition related to the information.

(t) "Significant break in coverage" means a period of 90 consecutive days during all of which the individual does not have any creditable coverage, except that neither a waiting period nor an affiliation period is taken into account in determining a significant break in coverage.

(u) "Waiting period" means, with respect to a health benefit plan and an individual, who is a potential enrollee in the plan, the period that shall pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan. For purposes of calculating periods of creditable coverage pursuant to (e)(2) above, a waiting period shall not be considered a gap in coverage.

History

#8607, eff 4-17-06, EXPIRED: 4-17-14

N.H. Code Admin. R. Ann. Ins 1907.03 Prohibited Discrimination in Rules for Eligibility {#sec-ins-1907.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1907.03}

(a) A carrier subject to this chapter shall not establish a rule for eligibility, including continued eligibility, of an individual to enroll for benefits under the plan that discriminates based on any health factor that relates to the individual or dependent of the individual.

(b) For purposes of this section, rules of eligibility includes rules relating to:

(1) Enrollment;

(2) The effective date of coverage;

(3) Waiting or affiliation periods;

(4) Late and special enrollment;

(5) Eligibility for benefit packages, including rules for individuals to change their selection among benefit packages;

(6) Benefits, including rules relating to covered benefits, benefit restrictions, and cost-sharing mechanisms, such as coinsurance, copayments and deductibles as described in Ins 1907.05 (a) and (b) of this chapter;

(7) Continued eligibility; and

(8) Terminating coverage, including disenrollment, of an individual under the plan.

(1) Establishing more favorable rules of eligibility for individuals with an adverse health factor, such as disability, than for individuals without the adverse health factor; or

(2) Subject to state law, charging a higher premium or contribution with respect to an individual with an adverse health factor if the individual would not be eligible for coverage, but for the adverse health factor.

History

#8607, eff 4-17-06, EXPIRED: 4-17-14

N.H. Code Admin. R. Ann. Ins 1907.04 Prohibited Discrimination in Premium and Contribution Rates {#sec-ins-1907.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1907.04}

(a) A carrier subject to this chapter shall:

(1) Not require an individual, as a condition of enrollment or continued enrollment under the plan, to pay a premium or contribution rate that is greater than the premium or contribution rate for a similarly situated individual enrolled in the plan based on any health factor that relates to the individual or a dependent of the individual.

(2) Take into account, in determining an individual's premium or contribution rate, discounts, rebates, payments-in-kind and any other premium differential mechanisms.

(b) Nothing in this section restricts the aggregate amount that a carrier subject to this chapter may charge an employer for coverage under a plan. However, a carrier subject to this chapter shall not quote or charge an employer or an individual participant or beneficiary a different premium than that quoted or charged an individual in a group of similarly situated individuals based on a health factor unless permitted under Ins 1907.03 (c) or (d) below.

(d) Notwithstanding (a) and (b) above, a carrier subject to this chapter may establish a premium or contribution differential based on whether an individual has complied with the requirements of a bona fide wellness program.

(e) Nothing in this section prohibits a carrier subject to this chapter from charging an individual a premium or contribution rate that is less than the premium or contribution rate for similarly situated individuals if the lower charge is based on an adverse health factor of the individual, such as a disability.

History

#8607, eff 4-17-06, EXPIRED: 4-17-14

N.H. Code Admin. R. Ann. Ins 1907.05 Application of Ins 1907.03 to Plan Benefits; Preexisting Condition Exclusions; Similarly Situated Individuals {#sec-ins-1907.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1907.05}

(a) Subject to (b) and (c) below, Ins 1907.03 does not require a carrier subject to this chapter to provide coverage for any particular benefit to any group of similarly situated individuals.

(1) A carrier subject to this chapter shall make the benefits provided under a plan available uniformly to all similarly situated individuals, as those groups are determined under (c) below.

a. For any restriction on a benefit or benefits provided under a plan, a carrier subject to this chapter:

Shall apply the restriction uniformly to all similarly situated individuals; and
Shall not direct the restriction, as determined based on all of the relevant facts and circumstances, at individual participants or beneficiaries based on any health factor of the participants or beneficiaries.

b. A carrier subject to this chapter may impose annual, lifetime or other limits on benefits and may require a deductible, copayment, coinsurance or other cost-sharing requirement in order to obtain a benefit under the plan if the limit or cost-sharing requirement:

Applies uniformly to all similarly situated individuals; and
Is not directed at individual participants or beneficiaries based on any health factor of the participants or beneficiaries.

c. For purposes of (a), a plan amendment applicable to all individuals in one or more groups of similarly situated individuals under the plan and made effective no earlier than the first day of the first plan year after the amendment is adopted is not considered to be directed at any individual participants or beneficiaries.

(2) If a carrier subject to this chapter generally provides benefits for a type of injury, the plan or carrier shall not deny an individual participant or beneficiary benefits otherwise provided under the plan for treatment of the injury if the injury results from an act of domestic violence or a medical condition.

(3) A carrier subject to this chapter with a cost-sharing mechanism, such as a deductible, copayment or coinsurance, that requires a higher payment from an individual, based on a health factor of that individual or dependent of that individual, than for a similarly situated individual under the plan, does not violate this section if the payment differential is based on whether the individual has complied with the requirements of a bona fide wellness program.

(b) Ins 1907.03 does not prohibit a carrier subject to this chapter from imposing a preexisting condition exclusion period if:

(1) The preexisting exclusion period:

a. Complies with the requirements for imposing a preexisting condition exclusion period established by federal regulation;

b. Is applied uniformly to all similarly situated individuals, as those groups are determine under (d) below; and

c. Is not directed at individual participants or beneficiaries based on any health factor of the participants or beneficiaries.

(2) For purposes of this subsection, a plan amendment relating to a preexisting condition exclusion that is applicable to all individuals in one or more groups of similarly situated individuals under the plan and made effective no earlier than the first day of the first plan year after the amendment is adopted is not considered to be directed at any individual participants or beneficiaries.

(c) This subsection applies only within a group of individuals who are treated as similarly situated individuals, so that:

(1) Subject to (4) below of this subsection, Ins 1907.03 does not prohibit a carrier subject to this chapter from treating participants as 2 or more distinct groups of similarly situated individuals if the distinction made between or among groups of participants is based on a bona fide employment-based classification that is consistent with the employer's usual business practice.

a. Whether an employment-based classification is bona fide shall be determined based on all of the relevant facts and circumstances.

b. For purposes of 1. a. above, relevant facts and circumstances include whether the employer uses the classification for purposes independent of qualification for health coverage, such classifications may include:

Full-time versus part-time status;
Geographic location;
Membership in a collective bargaining unit;
Date of hire;
Length of service;
Current employee versus former employee status; and
Occupation.

c. A classification based on a health factor shall not be determined to be a bona fide employment-based classification for purposes of this subjection unless the requirements of Ins 1907.03 (c) and Ins 1907.04 (e) are satisfied.

(2) Subject to subparagraph (4) of this subsection, Ins 1907.03 does not prohibit a carrier subject to this chapter from treating beneficiaries as 2 or more distinct groups of similarly situated individuals if the distinction is made between or among the groups of beneficiaries is based on any of the following factors:

a. A bona fide employment-based classification of the participant through whom the beneficiary is receiving coverage;

b. Relationship to the participant (e.g., as a spouse or as a dependent child);

c. Marital status;

d. With respect to a child of the participant, age or student status; or

e. Any other factor, if the factor is not a health factor.

(3) Subparagraph (1) above shall not be construed to prevent a carrier subject to this chapter from providing more favorable treatment of individuals under the plan with adverse health factors in accordance with Ins 1907.03 (c) and Ins 1907.04 (e).

(4) Notwithstanding subparagraphs (1) and (2) of this subsection, unless permitted under Ins 1907.03 (c) and Ins 1907.04 (e), if the creation or modification of an employment or coverage classification is directed at individual participants or beneficiaries based on a health factor of the participants or beneficiaries, the classification is not permitted under this subsection.

History

#8607, eff 4-17-06, EXPIRED: 4-17-14

N.H. Code Admin. R. Ann. Ins 1907.06 Application of Ins 1907.03 and Ins 1907.04 to Nonconfinement and Actively-at-Work Provisions {#sec-ins-1907.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1907.06}

(a) Except to the extent permitted under (b)(2) or (c) below, in accordance with Ins 1907.03 and Ins 1907.04, a carrier subject to this chapter shall not establish a rule of eligibility or set an individual's premium or contribution rate based on:

(1) Whether the individual is confined in a hospital or other health care institution; or

(2) The individual's ability to engage in normal life activities.

(b) In accordance with Ins 1907.03 and Ins 1907.04:

(1) A carrier subject to this chapter shall not establish a rule for eligibility or set an individual's premium or contribution rate based on whether the individual is actively-at-work, including whether an individual is continuously employed, unless absence from work due to any health factor is treated, for purposes of the plan, as being actively-at-work.

(2) Notwithstanding subparagraph (1) above, a carrier subject to this chapter may establish a rule for eligibility that requires an individual to begin work for the employer sponsoring the plan before coverage under the plan becomes effective if the rule for eligibility applies regardless of the reasons for the absence.

(c) Notwithstanding paragraphs (a) and (b) above, a carrier subject to this chapter may establish a rule of eligibility or set an individual's premium or contribution rate with respect to similarly situated individuals, as those groups are determined under Ins 1907.05 (d).

History

#8607, eff 4-17-06, EXPIRED: 4-17-14

N.H. Code Admin. R. Ann. Ins 1907.07 Enforcement {#sec-ins-1907.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 1907.07}

(a) The commissioner shall conduct a reasonable investigation based on a complaint received by the commissioner and issue a prompt determination as to whether a violation of this chapter may have occurred.

(b) If the commissioner finds from the investigation that a violation of this chapter may have occurred, the commissioner shall promptly begin an adjudicatory proceeding.

(c) The commissioner may address a violation of this chapter through means appropriate to the nature and extent of the violation, which may include suspension or revocation of certificates of authority or licenses, imposition of civil penalties, issuance of cease and desist orders, injunctive relief, a requirement for restitution, referral to prosecutorial authorities or any combination of these.

(d) The powers and duties set forth in this section are in addition to all other authority of the commissioner.

History

#8607, eff 4-17-06, EXPIRED: 4-17-14

Part Ins 1908 Coverage for Individuals Under the Age of 19

N.H. Code Admin. R. Ann. Ins 1908.01 Purpose {#sec-ins-1908.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 1908.01}

The purpose of this part is to authorize the New Hampshire Individual Health Plan Benefit Association, an existing entity established pursuant to RSA 404-G, to operate a new mechanism for risk adjustment and subsidization to assist health carriers who have issued individual health insurance policies on or after September 23, 2010 to children under the age of 19, as required by federal law.

History

#10023, eff 11-14-11

N.H. Code Admin. R. Ann. Ins 1908.02 Scope and Applicability {#sec-ins-1908.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 1908.02}

The requirements of this part shall apply to writers of individual health insurance that are subject to the association's plan of operation under RSA 404-G:5.

History

#10023, eff 11-14-11

N.H. Code Admin. R. Ann. Ins 1908.03 Definitions {#sec-ins-1908.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 1908.03}

The definitions in RSA 404-G:2 shall be applicable to this part, except insofar as a defined term is clarified below:

(a) "Association" means the New Hampshire Individual Health Plan Benefit Association, established under RSA 404-G:4.

(b) "Board" means the association's board of directors.

(c) "Carrier" means any entity licensed to provide health insurance in this state, including an insurance company, a group hospital or medical service corporation, a fraternal benefit society, a health maintenance organization, an organized delivery system, or any other entity providing health insurance subject to state insurance regulation.

(d) "Child-only policies" means individual health insurance policies issued to persons under 19 years of age.

History

#10023, eff 11-14-11

N.H. Code Admin. R. Ann. Ins 1908.04 Risk Adjustment and Subsidization {#sec-ins-1908.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 1908.04}

(a) Risks shall be shared as follows:

(1) Sharing shall be implemented through a risk adjustment and subsidization mechanism whereby all carriers will subsidize losses of certain carriers issuing individual health insurance policies to persons under 19 years old;

(2) Only individual policies with an age rating factor equal to or lower than the lowest applicable age factor for ages 19 and over, and issued directly to persons under 19 years old, shall be eligible for subsidy. For example, persons under 19 years old provided coverage under a family policy issued in the individual market shall not be eligible for subsidy.

(3) Only individual policies issued with the maximum allowable health status factor shall be eligible for subsidy; and

(4) Only policies issued on or after September 23, 2010, the date on which carriers were required under federal law to issue individual policies to persons under 19 years old, shall be eligible for subsidy.

(b) The subsidy eligibility calculation shall be performed as follows:

(1) Except as provided in Ins 1908.06, subsidy calculation shall be for experience incurred during a calendar year;

(2) For purposes of the subsidy calculation, the following additional definitions shall apply:

a. "Subsidizable incurred claims" means claims incurred on subsidy eligible policies during the experience period and paid through the reporting date;

b. "Subsidizable gross earned premium" means earned premium accrued during the experience period from subsidy eligible policies; and

c. "Experience period net premium" means subsidizable earned premium times 0.90 less the smaller of:

0.06 times subsidizable incurred claims; or
0.09 times subsidizable gross earned premium;

(3) The subsidy shall be based on the amount by which subsidizable incurred claims (SIC) exceed the experience period net premium (EPNP);

(4) The subsidy shall be calculated by adding the following:

a. 97 percent of SIC above 100 percent of EPNP up to 140 percent of EPNP;

b. 93 percent of SIC above 140 percent of EPNP up to 170 percent of EPNP;

c. 85 percent of SIC above 170 percent of EPNP up to 190 percent of EPNP; and

d. 75 percent of SIC above 190 percent of EPNP;

(5) Carriers eligible for risk sharing as described in (a) above shall be eligible for a subsidy based upon experience of the prior calendar year provided that such carrier was actively marketing individual health insurance child-only policies during the experience period.

(1) On or before July 1 of each year, each eligible carrier wishing to apply for a subsidy with respect to the prior year's experience shall make application to the association, including in the application all data required under Ins 1908.04(b) and a calculation of the anticipated amount of the subsidy; and

(2) A carrier that has made application, while an eligible carrier pursuant to (1) above, for a subsidy with respect to the prior calendar year's experience, may submit a corrective application for a corrective subsidy determination and payment based upon additional experience for that calendar year. Such corrective application may be submitted only once, shall be filed not later than 12 months after the July 1 date for initial application, and shall be completed and contain data with respect to its experience in this market during the current calendar year. A carrier shall not need to be an eligible carrier at the time of such corrective application or at the time of receipt of any corrective subsidy payment.

(3) Any errors in the subsidy application shall be reported to the board immediately upon discovery.

History

#10023, eff 11-14-11

N.H. Code Admin. R. Ann. Ins 1908.05 Assessment and Disbursement Plans {#sec-ins-1908.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 1908.05}

(a) Each year, the board shall specify its assessment and disbursement plans for eligible subsidies under this part. The assessment and disbursement plans shall each be considered amendments to the association's plan of operations pursuant to RSA 404-G:5 and shall conform to all applicable requirements of RSA 404-G.

(b) The board's assessment plan shall apply to all association members and shall be calculated to provide sufficient revenue to cover actuarial projections of anticipated subsidies, calculated in accordance with this part.

(1) Add available funds remaining from the prior year to anticipated current year assessments, investment income and experience period subsidies;

(2) Subtract anticipated expenses, including windup expenses; and

(3) From the remaining funds, calculate subsidies in accordance with Ins 1908.04(b) for eligible carriers, including prior unfunded experience period subsidies, based on the applications and experience data submitted by carriers.

(d) The board shall notify subsidy eligible carriers of the disbursement plan no later than November 1 of each year.

(e) The board shall collect assessments in accordance with its assessment plan and make payments in accordance with its disbursement plan.

History

#10023, eff 11-14-11

N.H. Code Admin. R. Ann. Ins 1908.06 Initial Subsidy Period {#sec-ins-1908.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 1908.06}

(a) The initial subsidy period shall be for claims incurred during the experience period from September 23, 2010 through December 31, 2011 for individual health insurance child-only policies that meet the requirements of Ins 1908.04.

(b) Applications for the initial subsidy period shall be due July 1, 2012.

(c) Payment of initial subsidies shall be made in the second year in the event sufficient funds are not available in the first year of the subsidy.

APPENDIX 1

RULE

STATUTE

Ins 1901.01

RSA 400-A:15, I; 415-A:2, I

Ins 1901.02

RSA 400-A:15, I; 415-A:2, I

Ins 1901.03

RSA 400-A:15, I; 415-A:2,I (n); 415:6; 415:18

Ins 1901.04

RSA 400-A:15, I; 402:8; 417:4, IX; 402:39-42; 76-83; 415-A:2; 415-A:5; 415:2; 415:3; 420-G:6, III; 415:6; 415:18

Ins 1901.05

RSA 400-A:15, I; 415-A:2, I; 415-A:3; 415:6; 415:18

Ins 1901.06

RSA 400-A:15, I; 415:5; 415:6; 415:18

Ins 1901.07

RSA 400-A:15, I; 415-A:2; 415:6; 415:18

Ins 1901.08

RSA 400-A:15, I; 415:20

Ins 1901.09

RSA 400-A:15-c

Ins 1902.01

RSA 415:5, I.

Ins 1902.02

RSA 415:1; RSA 415-F:2

Ins 1902.03

RSA 400-A:15, I.; RSA 415-F:1

Ins 1902.04

RSA 400-A:15, I.; RSA 415-F:1

Ins 1902.05

RSA 415:15, I.; RSA 415-F:3

Ins 1902.06

RSA 400-A:15, I.; RSA 415-F:3

Ins 1902.07

RSA 415:15, I.; RSA 415-F:5

Ins 1902.08

RSA 400-A:15, I.; 415-F:3

Ins 1902.09

RSA 400-A:15, I.; RSA 415-F:4

Ins 1902.10

RSA 400-A:15, I.

Ins 1902.11

RSA 400-A:15, I.

Ins 1902.12

RSA 415:15, I.

Ins 1902.13

RSA 400-A:15, I.

Ins 1902.14

RSA 400-A:15, I.

Ins 1902.15

RSA 400-A:15, .I

Ins 1903.01

RSA 415:5 I

Ins 1903.02

RSA 415:1

Ins 1903.03

RSA 400-A:15 I

Ins 1903.04

RSA 400-A:15 I

Ins 1903.05

RSA 400-A:15 I

Ins 1903.06

RSA 400-A:15 I

Ins 1904.01

RSA 400-A:15, I; 415-A:1; 415-A:2

Ins 1904.02

RSA 400-A:15, I; 415-A:1; 415-A:2, I (c)

Ins 1904.03

RSA 400-A:15, I; 415-A:2, I (n)

Ins 1904.04

RSA 400-A:15, I; 415-A:2

Ins 1904.05

RSA 400-A:15, I; 415-A:2, I (c)

Ins 1904.06

RSA 400-A:15, I; 415-A:2

Ins 1904.07

RSA 400-A:15, I; 415-A:2

Ins 1904.08

RSA 400-A:15, I; 415-A:2

Ins 1904.09

RSA 400-A:15, I; 415-A:2

Ins 1904.10

RSA 400-A:15, I

Ins 1904.11

RSA 400-A:15, I

Ins 1905.02

RSA 415-F:2

Ins 1905.03

RSA 415-F:3, III

Ins 1905.04

RSA 415-F:3, III

Ins 1905.05

RSA 415-F:3, III

Ins 1905.06

RSA 415-F:3, III, IV, V

Ins 1905.07

RSA 415-F:3, III, IV, V

Ins 1905.08

RSA 415-F:3, III, IV, V

Ins 1905.09

RSA 415-F:3, III, IV, V

Ins 1905.10

RSA 415-F:3, III, IV, V

Ins 1905.11

RSA 415-F:3, III, IV, V

Ins 1905.12

RSA 415-F:3, III, V

Ins 1905.13

RSA 415-F:3, III, IV

Ins 1905.14

RSA 415-F:3, III, IV, V

Ins 1905.15

RSA 415-F:3, III, IV

Ins 1905.16

RSA 415-F:3, V; RSA 415-F:4

Ins 1905.17

RSA 415-F:3, III, IV, V

Ins 1905.18

RSA 415-F:3, IV

Ins 1905.19

RSA 415-F:3, III, IV, V; RSA 415-F:6

Ins 1905.20

RSA 415-F:3, III, IV

Ins 1905.21

RSA 415-F:3, IV; RSA 415-F:7

Ins 1905.22

RSA 415-F:5 IV, V

Ins 1905.23

RSA 415-F:3 IV; RSA 415-F:5 V

Ins 1905.24

RSA 415-F:3 III

Ins 1905.25

RSA 415-F:3 III, V

Ins 1905.22

RSA 415-F:3, IV; RSA 415-F:7

Ins 1905.23

RSA 415-F:5, IV, V

Ins 1905.24

RSA 415-F:3, IV

Ins 1905.25

RSA 415-F:3, III, IV, V

Ins 1905.26

RSA 415-F:3, III, V

Ins 1905.27

RSA 400-A:15, I

Appendix A

RSA 400-A:15, I

Appendix B

RSA 400-A:15, I

Appendix C

RSA 400-A:15, I

Ins 1906.05

RSA 415-A:2 I (f)

Ins 1906.06

RSA 415:18-a

Ins 1907.01

RSA 400-A:15, I

Ins 1907.02

RSA 415-A:2

Ins 1907.03

RSA 415-A:2 I (b)

Ins 1907.04

RSA 415-A:2, II

Ins 1907.05

RSA 415-A:2, I (e)

Ins 1907.06

RSA 415-A:2 I (b) & II

Ins 1907.07

RSA 400-A:15, III

Ins 1908.01

RSA 400-A:15, I.; 404-G:1

Ins 1908.02

RSA 400-A:15, I.; 404-G:1

Ins 1908.03

RSA 400-A:15, I.; 404-G:2

Ins 1908.04

RSA 400-A:15, I.; 404-G:5

Ins 1908.05

RSA 400-A:15, I.; 404-G:5

Ins 1908.06

RSA 400-A:15, I.; 404-G:5

APPENDIX 2

Rule

Title

Obtain at:

Ins 1905.16(c)(5)

The NAIC Medicare Supplement Insurance Compliance Manual, March 25, 2010; published by the NAIC

Available for no cost on-line at:

http://www.naic.org/documents/prod_serv

_supplementary_med_lm.pdf

History

#10023, eff 11-14-11

Chapter Ins 2000 Medical Utilization Review Entities

Part Ins 2001 Licensure of Medical Utilization Review Entities

N.H. Code Admin. R. Ann. Ins 2001.01 Purpose {#sec-ins-2001.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.01}

The purpose of this chapter is to implement RSA 420-E wherein the general court has provided for the licensure of medical utilization review entities, oversight by the state of the procedures used by such entities, and a requirement that such entities adhere to prescribed minimum standards.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.02 Scope of Rule {#sec-ins-2001.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.02}

(a) This chapter shall apply to any medical utilization review entity, as defined under Ins 2001.03(b)(8), that performs medical utilization review services with respect to beneficiaries whose insurance policies or certificates or other evidence of health care expense coverage were delivered or issued for delivery in New Hampshire.

(b) This chapter shall not apply to any organization exempt under RSA 420-E:2, I or any person, partnership, or corporation if:

(1) Its medical utilization review activities are performed solely for research purposes and are not used in any manner to determine commensurability of pending claims or eligibility of covered persons for benefits or continuation thereof; or

(2) Its medical utilization review activities are performed solely pursuant to any program of the United States government and are preempted under federal law, including but not limited to:

a. Title XVIII of the United States Social Security Act;

b. The Civilian Health and Medical Program of the United States (CHAMPUS), 10 U.S.C. 1072(4), Medicare; or

c. Title XIX of the United States Social Security Act, Medicaid.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.03 Definitions {#sec-ins-2001.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.03}

(a) For the purposes of this part, the definitions appearing under RSA 420-E:1 shall apply whenever any word or phrase defined under RSA 420-E:1 is used in this part.

(b) With respect to the following words or phrases used in this part, but which are not defined under RSA 420-E:1, the following definitions shall apply:

(1) "Beneficiary" means any person or his or her covered dependent who is receiving or is proposed to receive a health care service covered under a health care benefit plan for which utilization review is to be conducted;

(2) "Business days" means all days other than weekends and legal holidays;

(3) "Confidential medical information" means medical information that is not intended to be disclosed to third persons other than those present to further the interest of the beneficiary in a consultation, examination, or interview, or persons, including members of the beneficiary's family, who are participating in the diagnosis and treatment of the beneficiary under the direction of a physician, psychotherapist, or other licensed health care provider;

(4) "Emergency" means a medical case involving a critical, life-threatening condition requiring medical or surgical care which, if not received immediately, would result in risk to life;

(5) "Emergency notification requirement" means the duty imposed upon a beneficiary by the beneficiary's health care benefit plan to notify a medical utilization review entity in the event of the beneficiary's receipt of emergency medical treatment;

(6) "Exempt organization" means an insurer, nonprofit service organization, health maintenance organization, preferred provider organization, or an employee of an exempt organization;

(7) "Health care benefit plan" means a contract or other agreement by which an insurer, a nonprofit service organization, a health maintenance organization, a third party administrator, or an employer arranges for or is the payor for health care services;

(8) "Medical utilization review entity" means any person, partnership, or corporation that provides utilization review services. The term includes “utilization review entity”;

(9) "Medical utilization review services" means those services that are performed in the conduct of utilization review as defined under RSA 420-E:1, IV. The term includes “utilization review services”;

(10) "National committee for quality assurance (NCQA)" means the independent, nonprofit organization based in Washington, D.C. whose primary purpose is to assess and report on the quality of managed care plans, including health maintenance organizations;

(11) "Reasonable explanation" means that sufficient information is provided to the beneficiary to enable the beneficiary to effectively exercise the right of appeal;

(12) "Utilization review accreditation commission (URAC)" means the voluntary, nonprofit organization based in Washington, D.C. that provides a centralized review and accreditation process.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.04 Licensure Procedure {#sec-ins-2001.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.04}

(a) No utilization review entity, other than an exempt organization, shall perform utilization review services unless the entity has received a license from the commissioner.

(b) To obtain a medical utilization review license, the utilization review entity shall make application to the commissioner by completing and submitting an application form prescribed by the commissioner for this purpose under Ins 2001.07. This application shall be accompanied by the appropriate application fee pursuant to Ins 2001.09.

(c) Utilization review entities applying for a license shall provide complete answers to all questions appearing on the application form. If the space provided on the application form is not sufficient to provide the applicant the space needed for a complete answer, the applicant shall provide such additional information as is necessary to provide a complete answer on additional sheets of paper which shall be attached to the application form.

(d) Each medical utilization review entity that has an application pending shall keep its application and any accompanying information or supporting material current. Any amendments or other changes to any of the documents that are part of or which accompany a pending application shall be filed within 30 days. Failure to comply with this requirement on the part of a medical utilization review entity shall be considered a violation of this part.

(e) Any applicant whose application is rejected shall be entitled to appeal the denial in accordance with the provisions of RSA 541, RSA 541-A, and Ins 200, and shall be so notified.

(f) Licenses issued pursuant to this part shall expire at the end of business on the March 31st following the date of issue. Such licenses shall be renewable pursuant to Ins 2001.05.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9621-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.05 Procedures of Licensure Renewal {#sec-ins-2001.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.05}

(a) In order to renew a medical utilization review license, the utilization review entity shall make application for renewal to the commissioner by completing and submitting an application form prescribed by the commissioner for this purpose under Ins 2001.07. The renewal application shall be accompanied by the appropriate fee pursuant to Ins 2001.09.

(b) Renewal applications received shall be reviewed and approved or rejected by the commissioner.

(c) Any applicant whose renewal application is rejected shall be entitled to appeal the denial in accordance with the provisions of RSA 541, RSA 541-A and Ins 200, and shall be so notified.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9621-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.06 Privileged Information {#sec-ins-2001.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.06}

No information required to obtain a utilization review license shall be withheld by an applicant on the grounds that it is proprietary or otherwise confidential. Any information deemed confidential by the applicant may be submitted under separate cover, accompanied by a statement of the scope of the privilege claimed by the applicant and the basis for the claim of privilege. The applicant shall have the opportunity to request a hearing if the commissioner denies such a claim in whole or in part.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.07 Forms Required {#sec-ins-2001.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.07}

(a) The applicant for a medical utilization review license or for the renewal of such license shall provide the following on Form INS-MURL-APP-1 Application for License as a Medical Utilization Review Facility:

(1) The exact name of the utilization review entity for which application is made;

(2) The applicant's Federal I.D. number or Social Security number;

(3) A statement as to whether the application is for a new license or for renewal of a license;

(4) The applicant's current street address and mailing address, if different;

(5) The name and address of the parent company if the applicant is a subsidiary;

(6) The name and address of the medical director;

(7) Verification that the medical director is licensed under RSA 329;

(8) A statement as to whether the applicant is a partnership, corporation, or association, or other type of organization such that:

a. If the applicant is a corporation, it shall indicate the state of incorporation and list all states in which the corporation does business; and

b. If the applicant represents a type of organization other than a partnership, corporation, or association, it shall specify its type of organization;

(9) A list of the principal proprietors, partners, directors, officers, and administrators and any others responsible for the operation, management, and control of the applicant;

(10) A biographical sketch of all principal proprietors, partners, directors, officers, and administrators listed which shall include, at a minimum, the person's current business and home address, current position(s), education, and previous experience;

(11) A statement showing the number of the applicant's employees in New Hampshire and the estimated number of employees nationally;

(12) If operations are conducted at more than one location, whether in or outside of New Hampshire, a list of all locations, the range of activities at each location, and the number of employees at each location;

(13) A description of the types of medical utilization review programs offered by the applicant, including but not limited to:

a. Second opinion program;

b. Hospital preadmission review;

c. Preinpatient service eligibility certification; and

d. Concurrent review to determine appropriate length of a hospital stay;

(14) A description of the process by which the applicant performs each of the medical utilization review services listed pursuant to the requirement of Ins 2001.07(a)(13) and shall specify:

a. The steps followed by the applicant's personnel in the performance of each type of review program; and

b. The categories of health care personnel that perform medical utilization review for the applicant and whether those persons are licensed in this or any other state;

(15) A description of the process used by the applicant to address beneficiary and provider complaints, requests for redeterminations, and appeals;

(16) A copy of all materials to be used by the applicant to inform beneficiaries of the requirements of the utilization review plans and the rights and responsibilities of the beneficiaries under the plan;

(17) A statement of whether the applicant's utilization review program has been certified by either the Utilization Review Accreditation Commissioner (URAC) or the National Committee for Quality Assurance (NCQA);

(18) A statement of the telephone number or numbers, including any toll-free numbers and fax numbers, at which beneficiaries and providers may reach representatives of the applicant including:

a. The number of lines maintained;

b. The hours and days of the week during which representatives of the applicant may be contacted; and

c. Any hours or days of the week during which calls are unanswered or are answered solely by recordings or answering services which do not provide access to representatives during the call;

(19) A statement by the applicant describing the procedures established for preserving the confidentiality of medical information used in the utilization review process, including a signed acknowledgment that the applicant shall sign stating that, "The undersigned also acknowledges that all applicable state and federal laws to protect the confidentiality of medical information will be followed."; and

(20) The signature of the applicant, or an officer of the firm if the applicant is a firm, certifying the following statement: "I have read the foregoing application and attachments and state that the answers supplied therein are true and correct to the best of my knowledge and belief. Further, by submitting this application to the insurance department, the applicant acknowledges that it has read and will comply with the performance standards set forth in RSA 420-E and any applicable rules."

(b) If the purpose of the application is to renew a license, the applicant shall, in the course of providing the information required by Ins 2001.07(a)(4) through (20), explain any changes from the most recent previous application on file with the department.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-B, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.08 Change in Name {#sec-ins-2001.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.08}

Should any medical utilization review entity that is licensed by the commissioner pursuant to this part propose to undergo a change in name, the licensee shall, by letter to the commissioner, request that its license or registration be transferred to the licensee's or the organization's new name. The commissioner shall approve such a name change, except in any case where the new name is either the same as or closely resembles the name of any other licensee or registered exempt organization or in any case where the new name is misleading or deceptive.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.09 Fees {#sec-ins-2001.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.09}

(a) The application fee that shall accompany the application for a medical utilization review license submitted pursuant to Ins 2001.04(b) shall be $500.00.

(b) The annual renewal fee that shall accompany an application for the renewal of a medical utilization review license submitted pursuant to Ins 2001.05(a) shall be $100.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.10 Standards Relative to Time Periods for Notification of Determinations {#sec-ins-2001.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.10}

(a) No claim for benefits shall be denied or payment reduced on the basis of an adverse medical utilization review determination except in accordance with RSA 420-E:4.

(b) All hospital preadmission review programs shall include specific provisions concerning immediate hospitalization of a beneficiary for whom the treating physician determines the admission to be an emergency, including subsequent documentation of medical necessity.

(c) Preadmission inpatient service eligibility programs shall include, but not be limited to, a review of the medical necessity for admission to a skilled nursing facility, intermediate care facility, or other long term care facility as defined in the applicable health insurance contract, policy, certificate, or other evidence of coverage.

(d) When engaged in review to determine the appropriate length of an inpatient hospital stay, no medical utilization review entity shall reduce or recommend a reduction of benefits otherwise payable, based on a determination that a hospital stay is medically unnecessary or inappropriate, unless sufficient notice is given so that the beneficiary is allowed an expedited review.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.11 Manner and Intent of Notification {#sec-ins-2001.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.11}

The manner and intent of notifications of claim benefit determinations shall be in accordance with the requirements of RSA 420-E:4.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.12 Standards for Telephone Accessibility {#sec-ins-2001.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.12}

(a) A medical utilization review entity shall maintain the number of telephone lines reasonably necessary to service the volume of calls which it may be expected to receive from beneficiaries and health care providers. The medical utilization review entity shall ensure that an adequate number of representatives respond to calls at least 7 days a week during the utilization review entity’s normal working hours.

(b) Medical utilization review entities may use computerized telephone routing systems and may use systems for the receipt of information for which replies are not required. Time periods during which calls are answered solely by these systems or by answering services shall not qualify toward meeting the requirements of Ins 2001.12(a).

(c) A medical utilization review entity shall provide access to its review staff by a toll free or collect phone line, at a minimum, from 9:00 a.m. to 4:00 p.m. of each standard business day, in the provider's local time zone.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.13 Reconsideration Procedures {#sec-ins-2001.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.13}

A medical utilization review entity shall establish an appeal process for addressing beneficiary and provider complaints and requests for reconsiderations. No license shall be issued pursuant to Ins 2001.04 unless and until a medical utilization review entity has established an appeals process providing assurances to beneficiaries and providers that their complaints and requests for reconsiderations shall be fairly and objectively considered in accordance with RSA 420-E:4.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.14 Confidentiality {#sec-ins-2001.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.14}

(a) Each utilization review entity shall have written procedures for assuring that patient-specific information obtained during the process of utilization review shall be:

(1) Kept confidential in accordance with applicable laws and rules;

(2) Used solely for the purposes of utilization review, quality management, discharge planning, and case management;

(3) Shared only with the claims administrator and other such persons who have authority to receive such information; and

(4) Limited to the information necessary for the claims administrator to adjudicate the claim.

(b) All data which provides sufficient information to allow identification of an individual patient, enrollee, or claimant shall be considered confidential medical information.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.15 Scope of Review {#sec-ins-2001.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.15}

When conducting routine prospective, concurrent, and retrospective utilization review, a medical utilization review entity shall be entitled to collect and review only the information necessary to certify the admission, procedure or treatment, length of stay, or frequency and duration of services.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.16 Reviewers {#sec-ins-2001.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.16}

(a) Medical utilization review entity personnel or exempt organization personnel who are not licensed health care providers shall not communicate with a beneficiary or provider except for the purpose of collecting and recording demographic data. Demographic data shall include information to identify the patient, enrollee, and attending physician or other provider. Demographic data shall not include any information related to the health or medical condition of the patient.

(b) All communications on the part of a medical utilization review entity or exempt organization with either a beneficiary or provider, other than communications carried out for the purpose of collecting and recording demographic data, shall be conducted by personnel who are licensed health care providers.

(c) The medical director of the medical utilization review entity shall be a New Hampshire licensed physician under RSA 329.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.17 Other Provisions {#sec-ins-2001.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.17}

(a) A prerequisite for the licensing of a medical utilization review entity shall be accreditation of the utilization review services performed by the utilization review entity from the URAC or the NCQA.

(b) A licensed medical utilization review entity shall allow any licensed facility rendering service, physician, or responsible beneficiary representative, including a family member, to assist in fulfilling any certification or other managed care requirement.

(c) Any written procedures maintained in order to comply with the standards of the URAC or the NCQA by a licensed medical utilization review entity shall be made available to the insurance department upon the department's written request.

(d) No claim for benefits shall be denied nor shall any payment be reduced on the basis of an adverse medical utilization review determination unless the beneficiary is given notice of the right to appeal. The notice shall contain an explanation of the appeals process that shall be sufficient to enable the beneficiary to effectively exercise the right of appeal.

(e) A denial or reduction of benefits based on the failure of a provider to supply the medical utilization review entity with complete information shall describe in detail the information required but not received by the medical utilization review entity.

History

#5931, eff 12-5-94, EXPIRED: 12-5-00
#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.18 Compliance {#sec-ins-2001.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.18}

Any violations of these rules by a medical utilization review entity shall be subject to such denial, suspension, or revocation of license or administrative fine not to exceed $1,000 per violation, as may be applicable under RSA 420-E:8.

History

#7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18

N.H. Code Admin. R. Ann. Ins 2001.19 Waiver of Rules {#sec-ins-2001.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 2001.19}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule

provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX A

Rule

Specific State Statute the Rule Implements

Ins 2001.01

RSA 400-A:15, I; RSA 420-E:7

Ins 2001.02

RSA 400-A:15, I; RSA 420-E:2; RSA 420-E:7

Ins 2001.03

RSA 400-A:15, I; RSA 420-E:1; RSA 420-E:7

Ins 2001.04

RSA 400-A:15, I; RSA 420-E:2; RSA 420-E:7, I, V & XI

Ins 2001.05

RSA 400-A:15, I; RSA 420-E:7, I, VI, IX, & XII

Ins 2001.06

RSA 400-A:15, I; RSA 420-E:3; RSA 420-E:7, V & VIII

Ins 2001.07

RSA 400-A:15, I; RSA 420-E:7, I, VI, IX, & XII

Ins 2001.08

RSA 400-A:15, I; RSA 420-E:7, V, VI, & XII

Ins 2001.09

RSA 400-A:15, I; RSA 420-E:2; RSA 420-E:7, II

Ins 2001.10

RSA 400-A:15, I; RSA 420-E:4, IV & V; RSA 420-E:7, III

Ins 2001.11

RSA 400-A:15, I; RSA 420-E:4, IV & V; RSA 420-E:7, III

Ins 2001.12

RSA 400-A:15, I; RSA 420-E:4, I; RSA 420-E:7, IV

Ins 2001.13

RSA 400-A:15, I; RSA 420-E:4, V; RSA 420-E:7, XII

Ins 2001.14

RSA 400-A:15, I; RSA 420-E:7, VIII

Ins 2001.15

RSA 400-A:15, I; RSA 420-E:7, IX

Ins 2001.16

RSA 400-A:15, I; RSA 420-E:2-a; RSA 420-E:4, II; RSA 420-E:7, X

Ins 2001.17

RSA 400-A:15, I; RSA 420-E:3, II; RSA 420-E:4, III; RSA 420-E:7, XII

Ins 2001.18

RSA 400-A:15; RSA 420-E:8

Ins 2001.19

RSA 400-A:15; RSA 541-A:22, IV

APPENDIX B

Form INS-MURL-APP-1

Received _________________________

Approved ________________________

License No. ______________________

Issued ___________________________

STATE OF NEW HAMPSHIRE

INSURANCE DEPARTMENT

APPLICATION FOR LICENSE AS A MEDICAL UTILIZATION REVIEW ENTITY

Application is hereby made on behalf of the medical utilization review entity herein named for a license authorizing it to transact business and to otherwise perform as a medical utilization review entity in New Hampshire.

The EXACT name of the medical utilization review entity is:________________________________

(If the name is not in English, state it and give an exact literal translation.)

The medical utilization review entity’s Federal ID number or Social Security number is:

This application is for (check one):

___________ A new license.

___________ Renewal of an existing license.

The applicant’s current street address is: _________________________________________________

The applicant’s current mailing address is: _______________________________________________

The name and address of the parent company, if the applicant is a subsidiary: ____________________

The name and address of the medical director: ____________________________________________

Verification that the medical director is licensed under RSA 329: _____________________________

The applicant is a (check one):

____________ Sole Proprietorship

____________ Partnership

____________ Corporation

____________ Other (please specify)

a. If the applicant is a corporation, please specify the State of incorporation: ______________________________________________________________________________

b. List all states in which the corporation does business:

List the principal proprietors, partners, directors, officers and administrators. Also, include any others responsible for the operation, management and control of the applicant. Attach a separate sheet of paper, if necessary.

Name(s) Title(s)_______________________________________

Attach separate sheets of paper giving biographical sketches of all persons listed under question 7. Include, at least, the person’s current business and home address, current position(s), education and previous experience.
The applicant has __________ employees in New Hampshire and __________employees nationally.
Locations. List all locations from which operations are conducted whether in or outside of New Hampshire. Show the range of activities and the number of employees at each location. Attach a separate sheet if necessary.

Location (City and State) Activities No. of Employees

Describe the types of medical utilization review programs offered by the applicant, including but not limited to:

a. Second opinion program;

b. Hospital preadmission review;

c. Pre-inpatient service eligibility certification and

d. Concurrent hospital review to determine appropriate length of stay.

IT IS REQUESTED THAT THE APPLICANT PROVIDE THE INFORMATION REQUESTED BY ITEM 11 ON SEPARATE SHEETS OF PAPER ATTACHED TO THE APPLICATION FORM.

Describe the process by which the applicant proposes to perform each of the utilization review services listed under (11) above. Specify (1) The steps followed by the applicant’s personnel as they perform each type of review program; and (2) the categories of health care personnel that perform medical utilization review for the applicant, and whether those persons are licensed in this or any other state.

IT IS REQUESTED THAT THE APPLICANT PROVIDE THE INFORMATION REQUESTED BY ITEM 11 ON SEPARATE SHEETS OF PAPER ATTACHED TO THE APPLICATION FORM.

On separate sheets of paper attached to the application form, describe the process that the applicant will use to address beneficiary and provider complaints, requests for redeterminations and appeals.
The applicant is requested to enclose with the application copies of all materials used by the applicant to inform beneficiaries of the requirements of the utilization review plan and the rights and responsibilities of beneficiaries under the plan.
Has the applicant’s utilization review program been certified by the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA)? Please check one.

Yes______ No______

Note: The applicant is requested to attach a copy of the accreditation certificate received from URAC or the NCQA.

List the telephone number(s), including toll-free numbers and fax numbers, at which beneficiaries and providers may reach representatives of the applicant. For each number listed indicate the number of lines maintained and the hours and days of the week during which the number is available.

Phone Number Number of Lines Days and Hours Available

16.a. Indicate the hours or days of the week during which calls are unanswered or answered solely by the recordings or answering services that do not provide access to representatives during the call.

The applicant is requested to attach separate sheets of paper describing the procedures established by the applicant for preserving the confidentiality of medical information used in the utilization review process.
I have read the foregoing application and attachments and state that the answers supplied therein are true and correct to the best of my knowledge and belief. The undersigned also acknowledges that all applicable state and federal laws to protect the confidentiality of medical information will be followed. Further, by submitting this application to the Insurance Department, the applicant acknowledges that it has read and will comply with the performance standards set forth in RSA 420-E and any applicable rules.

Signed on behalf of the applicant by:

Name (Typed) ________________________________________________________

Title: ________________________________________________________________

Date: ________________________________________________________________

History

#12545, eff 6-11-18

Chapter Ins 2200 Health Maintenance Organizations

Part Ins 2201 Licensing and Regulation of Health Maintenance Organizations

N.H. Code Admin. R. Ann. Ins 2201.01 Purpose {#sec-ins-2201.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.01}

The purpose of this rule is to delineate a system for regulation of health maintenance organizations that is fair and efficient, and promotes their continued solvency.

History

#9335, eff 12-5-08; ss by #11194, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2201.02 Applicability and Scope {#sec-ins-2201.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.02}

(a) No health maintenance organization shall, without being licensed in accordance with this part:

(1) Provide or arrange for health care services to enrolled participants in exchange primarily for a prepaid per capita or aggregate fixed sum; or

(2) Commence operations, except as provided in Ins 2201.04(g), with operations deemed to commence on the date on which any contracts for health services are available to members or on which evidences of coverage are issued.

(b) This part shall apply to any health maintenance organization regardless of whether services are to be delivered through physicians or other health professionals:

(1) Who are employees of the health maintenance organization;

(2) Who are organized on a group practice basis;

(3) Who are organized on an individual practice basis; or

(4) Under any other arrangements.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #5944, eff 1-1-95, EXPIRED: 1-1-03
#9335, eff 12-5-08; ss by #11194, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2201.03 Definitions {#sec-ins-2201.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.03}

(a) For the purposes of this part, the definitions appearing in RSA 420-B:1 shall apply.

(b) With respect to the following words or phrases used in this part, not defined in RSA 420-B:1, the following definitions shall apply:

(1) "Active recipient of mental health services" means an insured, subscriber, or member of a replacing carrier's health insurance benefit plan who received mental health services from a mental health provider while covered by a prior carrier's benefit plan provided such services were for a purpose other than monitoring medications and were received at least as often as:

a. In the case of outpatient services:

For 2 separate days during the 30 day period immediately prior to the effective date of the replacing carrier's plan;
For 3 separate days during the 90 day period immediately prior to the effective date of the replacing carrier's plan; or
For 5 separate days within the 12 month period immediately preceding the effective date of the replacing carrier's plan; and

b. In the case of inpatient services, one inpatient confinement during the 12 month period immediately prior to the effective date of the replacing carrier's plan;

(2) "Complaints" means the grievances of persons concerning the services of the health maintenance organization;

(3) "Controlling interest" means the possession, either directly or indirectly, of the power of a person or persons to direct or cause the direction of the management and policies of the health maintenance organization, whether through the ownership of voting stock, or by contract, other than commercial contract for goods or management services, or through official position or positions of, or corporate office or offices held by, the person or persons, or otherwise, and includes a presumed controlling interest;

(4) "Mental health provider" means any professional or institution listed under RSA 415:18-a, IV; and

(5) "Presumed controlling interest" means the existence of a controlling interest when any person, directly or indirectly, owns, controls, holds, with the present power to vote more than 5 percent of the voting stock of the health maintenance organization, or holds proxies representing more than 5 percent of the voting stock of any other person or persons.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#9335, eff 12-5-08; ss by #11194, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2201.04 Certificate of Authority {#sec-ins-2201.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.04}

(a) Any health maintenance organization seeking to do insurance business in this state shall complete and submit an original copy of the National Association of Insurance Commissioners (NAIC) Uniform Certificate of Authority Application (UCAA) as a health maintenance organization.

(b) The UCAA includes 3 applications, http://www.naic.org/industry_ucaa_corp_amend.html, available as noted in Appendix B:

(1) The Primary Application - UCAA Form 2P, revised 08/18/14, for use by newly formed companies seeking a Certificate of Authority in their domicile state and by companies wishing to re-domesticate to a uniform state;

(2) The Expansion Application - UCAA Form 2E, revised 08/18/14, for use by companies in good standing in their state of domicile that wish to expand their business

into a uniform state; and

(3) The Corporate Amendments Application - UCAA Form 2C, revised 12/19/14, for use by an existing company for requesting amendments to its certificate of authority.

(c) The UCAA application shall be complete, provided, however, that where a form mentions perjury, perjury shall mean any applicable penalty found in RSA 641, falsification in official matters, including RSA 641:3, unsworn falsification.

(d) The UCAA application shall also include all required information and attachments, and shall include the following state specific information and requirements:

(1) If the applicant is not domiciled in this state, a power of attorney duly executed and appointing the commissioner and his successors in office, and duly authorized deputies, as true and lawful attorney for the applicant for service of process in this state pursuant to RSA 420-B:4;

(2) Payment by check or other draft of required application fees as set forth in RSA 400-A:29;

(3) Basic organizational documents, articles of incorporation, and all amendments thereto;

(4) Copies of all by-laws, rules, and regulations of the applicant;

(5) Copies of the organizational chart of the applicant, including the titles, names, and salaries, if any, of officers and key management personnel dealing in marketing, administration, enrollment, grievance procedures, quality assurance, contract negotiations, and financial matters;

(6) A list of members of the board of directors, or similar policymaking body of the applicant, with the name, principal occupation, and employer of each;

(7) A description of the applicant's proposed system for handling complaints that shall include procedures for the registration of complaints and procedures for the resolution of complaints;

(8) Financial reports for the prior 3 fiscal years, with the qualification that financial reports submitted by insurance companies or hospital, medical, or health service corporations applying for a certificate of authority to operate a health maintenance organization as a subsidiary or affiliate pursuant to RSA 420-B:19 shall be restricted in subject matter to the finances of such subsidiary or affiliate;

(9) Financial statements projecting the results of the applicant's operations for the next 3 years from the date of application, on a quarterly basis for years one and 2 and annually for year 3, including the following:

a. Balance sheet;

b. Statement of income from all sources, and expenses;

c. Cash flow;

d. Present and anticipated capital expenditures;

e. Repayment schedules for existing or anticipated loans or alternative financing arrangements;

f. Statement indicating when the applicant estimates that income from enrollments and other operations will equal expenses; and

g. Detailed statements underlying assumptions used and the basis thereof;

(10) A detailed statement of the health maintenance organization's plan to establish and maintain reserves or other funds necessary to cover any risks projected and not otherwise assumed by another entity, carrier, or reinsurer;

(11) A detailed statement of current and projected reserve-establishment calculations, as well as amounts, purpose and uses of the reserves, and assumptions and bases therefor, including, but not limited to, identification of reserves set aside to meet uncovered reinsurance items;

(12) Copies of all reinsurance, conversion, or other arrangements with other insurers, health providers, medical service corporations, hospital service corporations, health service corporations, governmental agencies or organizations, or other health maintenance organizations that provide payment schedules for contracted-for health care services, or made directly to provide services, in the event the health maintenance organization is unable or ceases to provide contracted-for health services for any reason;

(13) A copy of the applicant's official notification of status as a federally qualified health maintenance organization, if it is so designated;

(14) A statement of insurance or funded self-insurance for:

a. Protection against loss of property and liability of the applicant;

b. Workers' compensation to protect against claims arising from work-related injuries of the applicant's employees; and

c. Medical malpractice liability insurance for the applicant and its providers;

(15) A listing of shareholders or other equity holders, or members with holdings of 5 percent or more of capital shares, partnership interest, or other evidence of equity holdings, listed by name, address, number and percentage of shares or other interest held, and any other affiliations with the applicant;

(16) A listing of the applicant's legal, accounting, and actuarial representatives by name and address;

(17) A statement that fidelity bond coverage exists for all officers and employees entrusted with the handling of funds for the applicant;

(18) A statement of enrollment practices and procedures;

(19) An enrollment projection of members per month for the next 3 years from the date of application, on a quarterly basis for years one and 2, and annually for year 3, including:

a. The current total enrollment of the applicant;

b. The current categories of membership of the applicant:

Private;
Group;
Non-group;
Medicaid;
Medicare;
Federal employees;
State employees; and

c. A detailed statement of assumptions used, and the basis therefor;

(20) A description of the geographical area to be served, including:

a. Present population figures for each city or town within the current area; and

b. Projections of future population trends for each city and town within the current area for the next 5 years from the date of application; and

(21) A statement certifying to the commissioner that the health maintenance organization is in compliance with all federal laws and regulations pertaining to health maintenance organizations.

(e) The application documents shall be compiled in the order in which they are required.

(f) The applicant shall state the reasons for the absences of any items required, but not included in the application.

(g) In the event that the commissioner finds the application incomplete, the commissioner shall provide the applicant written notice specifying the additional documents or information required under this part.

(h) The applicant shall have 30 days from receipt of the notice in which to file the additional material required by (d) above or the application shall be deemed rejected.

(i) Prior to the issuance of a certificate of authority to operate a health maintenance organization, an applicant may:

(1) Engage in such activities as are necessary to the gathering of information for applications for certification as a federally qualified health maintenance organization, and for certification pursuant to RSA 420-B and these parts;

(2) Make contact with potential enrolled participants, employers, or both for the purposes of determining the feasibility of establishing a health maintenance organization in a given area, and for the purpose of generally acquainting the potential enrolled participants, employers, or both with the general benefits of the applicant's proposed program; and

(3) Engage in the establishment of physical facilities for the operation of the health maintenance organization.

(j) In no event, shall an applicant make a commitment to render services or initiate a contract between the applicant and enrolled participants, employers, or both until a certificate of authority has been issued by the department.

(k) The applicant company may continue to operate pursuant to Ins 2201.04(i), above, until such time as its application shall be denied.

(l) Before issuing a certificate of authority to an applicant, the commissioner shall be satisfied, by examination and evidence that the applicant has complied, and will continue to comply with the requirements of RSA 420-B and this part.

(m) The commissioner shall act upon an application for a certificate of authority within 90 days after the filing of a completed application.

(n) The commissioner shall notify the applicant, in writing, of the approval of the application or its denial, and if the application is denied, the reasons therefor.

(o) If the applicant wishes a hearing before the commissioner concerning the denial of the certificate of authority, it may make an application for such hearing pursuant to RSA 400-A:17 and the hearing shall be conducted in accordance with the provisions of RSA 400-A and Ins 200.

(p) Each certificate of authority issued under this part shall be renewed pursuant to RSA 420-B:5-a unless revoked or suspended by the commissioner, provided that the health maintenance organization commences operations within one year after the date on which the certificate of authority was issued.

(q) Failure to commence operations within the period in (p) above shall invalidate the certificate of authority and a new application shall be submitted before another certificate of authority will be issued.

(r) Grounds for revocation or suspension of certificate of authority shall include:

(1) An unsound financial condition;

(2) Business policies or methods are unsound or improper;

(3) Management conditions that render the further transaction of business hazardous to the public or to its members;

(4) The committing of acts prohibited by RSA 420-B:12; and

(5) Officers or agents that have refused to submit to an examination as provided for in RSA 420-B:10.

(s) Any denial or approval of the application shall be public, however, all documents and workpapers submitted or used in the course of analysis by the department of the financial condition of the applicant shall be confidential in accordance with RSA 400-A:37 and not subject to disclosure under RSA 91-A. Any other information submitted as part of the UCAA application by the health maintenance organization that is confidential commercial information, proprietary information, information protected as a trade secret, information that is confidential by law, or information that, if disclosed, would constitute an invasion of privacy shall be marked by the health maintenance organization as confidential and shall not be subject to disclosure under RSA 91-A.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#9335, eff 12-5-08; ss by #11194, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2201.05 Evidences {#sec-ins-2201.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.05}

of Coverage and Advertising. All evidences of coverage and advertising shall be made in accordance with Ins 400, Ins 2600, and Ins 3100.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#9335, eff 12-5-08; ss by #11194, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2201.06 Periodic and Special Reporting {#sec-ins-2201.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.06}

(a) The health maintenance organization shall provide concurrent notice to the commissioner of any of the following events or occurrences:

(1) Plans to purchase, lease, construct, renovate, operate, or maintain medical facilities;

(2) Any loans made with an annual aggregate from one creditor exceeding one percent of the health maintenance organization's liabilities, including:

a. The amount of the loan(s);

b. The term(s) of repayment;

c. Security given, if any; and

d. Any guarantees or sureties provided;

(3) Any contracts entered into with an insurance company or health service corporation, excluding contracts for fringe benefits for organization employees; and

(4) Any grants to be received from public or private sources exceeding on an annual basis from any one source one percent of the health maintenance organization's assets.

(b) The health maintenance organization shall file a report of all changes in controlling interest within 30 days of their occurrence.

(c) Each health maintenance organization shall, within 5 business days after the occurrence, inform the commissioner of any extraordinary loss or claim that has the potential to render it incapable of meeting its obligations as they become due.

(d) The health maintenance organization shall maintain and provide to the department upon request, the following information:

(1) Plans to purchase, lease, construct, renovate, operate, or maintain medical facilities;

(2) Any loans made with an annual aggregate from one creditor exceeding one percent of the health maintenance organization's liabilities, including:

a. The amount of the loan(s);

b. The term(s) of repayment;

c. Security given, if any; and

d. Any guarantees or sureties provided;

(3) Any contracts entered into with an insurance company or health service corporation, excluding contracts for fringe benefits for organization employees;

(4) Any grants to be received from public or private sources exceeding on an annual aggregate basis from any one source one percent of the health maintenance organization's assets; and

(5) Membership changes in group and non-group categories.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#9335, eff 12-5-08; ss by #11194, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2201.07 Annual Reports {#sec-ins-2201.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.07}

(a) Every health maintenance organization shall annually file with the commissioner and with the commissioner of the department of health and human services, within 120 days after the close of its fiscal year, 2 copies of a report, verified by an official of the organization, showing the health maintenance organization's financial condition on the last day of the preceding fiscal year.

(b) Each health maintenance organization shall complete and submit the following materials to the commissioner as documentation of its annual report:

(1) A financial statement, using the form of the National Association of Insurance Commissioners (NAIC) Annual Statement Blank available at http://www.naic.org/ industry_financial_filing.htm and as noted in Appendix B, accompanied by a statement certified by an independent public accountant;

(2) Any changes, occurring during the preceding fiscal year, in information that had been submitted with the health maintenance organization's application for a certificate of authority;

(3) Details of services provided by the health maintenance organization on a fee-for-service or charitable basis;

(4) A listing of all complaints received by the health maintenance organization from members during the period of the preceding fiscal year, with a description of the complaint, and how it was resolved;

(5) A statement of all investments made by the health maintenance organization, as provided in the NAIC Annual Statement Blank; and

(6) A statement certifying to the commissioner that the health maintenance organization is in compliance with federal laws and regulations pertaining to health maintenance organizations.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#9335, eff 12-5-08; ss by #11194, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2201.08 Licensing of Producers {#sec-ins-2201.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.08}

All producers of health maintenance organizations shall be licensed pursuant to RSA 402-J.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#9335, eff 12-5-08; ss by #11194, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2201.09 Continuity of Benefits {#sec-ins-2201.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2201.09}

(a) The transition, under the employment-related group health insurance plan, from a traditional indemnity or nonprofit health service corporation mode of coverage to a health maintenance organization shall:

(1) Be effected in every case without application of waiting periods or exclusions or limitations based on health status as conditions of enrollment or transfer; and

(2) Provide all basic health services, as defined in section 1302(1) of the Health Maintenance Organization Act of 1973 (42USC§ 300e-1(1)) as amended, that exist under the applicable traditional indemnity or nonprofit health service corporation mode of coverage from which transfer is made.

(b) Whenever there is a replacement of a carrier's benefit plan by the benefit plan of another carrier, the insureds, subscribers, or members who were active recipients of mental health services under the prior carrier's plan shall be entitled to continue to receive mental health services from the same mental health provider who provided the services received while the insured, subscriber, or member was an active recipient of mental health services under the prior carrier's plan.

(1) Continue for one year following the effective date of the new carrier's benefit plan;

(2) Override any provisions in the replacing carrier's plan requiring the insured, subscriber or member to receive mental health services from mental health providers who have contracted with the replacing carrier to be part of the replacing carrier's provider network;

(3) Override any provisions in the replacing carrier's plan that reduce or eliminate benefits for mental health services whenever such services are received from a mental health provider who has not contracted to be part of the replacing carrier's network;

(4) Be provided to any insured, subscriber or member who, during an open enrollment period, changed from a benefit plan sponsored by the employer to another benefit plan sponsored by the same employer;

(5) Be subject to any provisions of the replacing carrier's plan requiring mental health services to be medically necessary, as defined in the replacing carrier's plan;

(6) Be subject to any provisions of the replacing carrier's plan requiring mental health services to be preauthorized by the replacing carrier or its utilization review agent;

(7) Be subject to the provision of proof of receipt of prior services while the prior carrier's plan was in effect as follows:

a. The insured, subscriber, or member shall be responsible for providing such proof in the form of:

An explanation of benefits form from the prior carrier;
A letter from the provider who provided the services attesting to the fact that services were provided together with the dates such services were rendered; or
Any other documentation which the replacing carrier determines to be acceptable as proof; and

(8) Be subject to verification that the provider of services under the prior carrier is protected by a malpractice policy with coverage of at least $1,000,000 per single incident and at least $3,000,000 in the aggregate.

(d) While the entitlement provided pursuant to (b) above is in effect, benefits shall be paid by the replacing carrier as if the insured, subscriber, or member were receiving mental health services from a mental health provider who has contracted with the replacing carrier.

(e) The replacing carrier shall not be required to make direct benefit payments to a non-network provider nor shall the liability of the replacing carrier exceed what its liability would have been if the mental health services had been received from a contracting mental health provider who is reimbursed on a fee-for-service basis.

APPENDIX A: State Statute Implemented

Rule

Statute

Ins 2201.01

RSA 400-A:15, I; 420-B:2

Ins 2201.02

RSA 400-A:15, I; 420-B:2

Ins 2201.03

RSA 400-A:15, I; 420-B:1; 420-B:2; 420-B:8-b

Ins 2201.04

RSA 400-A:15, I; 420-B:2; 420-B:3, 420-B:4, 420-B:5; 420-B:5-a; 420-B:5-b; 420-B:6

Ins 2201.05

RSA 400-A:15, I; 420-B:12; 420-B:20; 406-A; 417

Ins 2201.06

RSA 400-A:15, I; 420-B:12, 420-B:20

Ins 2201.07

RSA 400-A:15, I; 420-B:9; 420-B:12; 420-B:20

Ins 2201.08

RSA 400-A:15, I; 402-J; 420-B:18

Ins 2201.09

RSA 400-A:15, I; 415:2, I(b); 417:4, I; 420-B:7, X; 420-B:8-b; 420-B:8-c; 420-B:8-d; 420-B:8-i; 420-B:8-n; 420-B:12; 420-B:20

APPENDIX B: Incorporation by Reference Information

Rule

Title

Obtain:

Ins 2201.04(a)(1)

UCAA Primary Application, Form 2P, Revised 08/18/14

Online: http://www.naic.org/documents/industry_ucaa_form02P.doc

No cost to download this form

Ins 2201.04(a)(2)

UCAA Expansion Application, Form 2E, Revised 08/18/14

Online: http://www.naic.org/documents/industry_ucaa_form02E.doc

No cost to download this form

Ins 2201.04(a)(3)

UCAA Corporate Amendments Application, Form 2C, Revised 12/19/14

Online: http://www.naic.org/documents/industry_ucaa_form02C.doc

No cost to download this form

Ins 2201.07(b)(1)

NAIC Annual Financial Statement Blank

2008 version, available for filing under current year

Online:

http://www.naic.org/industry_financial_filing.htm

No cost for this form

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
#9335, eff 12-5-08; ss by #11194, eff 12-5-16 (from Ins 2201.10)

Chapter Ins 2300 Third Party Administrators

Part Ins 2301 Regulation of Third Party Administrators

N.H. Code Admin. R. Ann. Ins 2301.01 Purpose {#sec-ins-2301.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.01}

The purpose of this part is to provide for the regulation and licensing of third party administrators and to set forth rules and procedural requirements which the commissioner deems necessary to carry out the provisions of RSA 402-H.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.02 Definitions {#sec-ins-2301.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.02}

(a) “Administrator" means “third party administrator (TPA)" as defined in RSA 402-H:1, I.

(b) "Affiliate" means “affiliate” as defined in RSA 402-H:1, II. The term includes “affiliated”.

(d) "Control" means "control" as defined in RSA 401-B:1, III.

(e) "Employee Retirement Security Act of 1974" means "ERISA", Pub.L. 93-406, 88 Stat. 829, effective September 2, 1974.

(f) "Insurer" means "insurer" as defined in RSA 402-H:1, VII.

(g) "Person" means an individual or business entity.

(h) "Underwrites" means “underwrites” as defined in RSA 402-H:1, XIII. The term includes underwriting.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.03 Application Forms {#sec-ins-2301.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.03}

(a) An administrator shall not operate as an administrator in this state without a certificate of authority or exemption from the department. Administrators wishing to do business in this state shall complete an application, an exemption registration, which shall be filed annually on a form provided by the department pursuant to requirements in RSA 402-H:11 and attached hereto as Appendix 1, Form TPA-1. Persons or entities that are specifically excepted by RSA 402-H:1, I shall complete an exception from licensing form, which shall be filed annually on a form provided by the department pursuant to the requirements of RSA 402-H:1, I(a) through (m) and attached hereto as Appendix 2, Form TPA-2.

(b) The application shall be completed and signed by an officer or authorized representative of the administrator. The complete application shall be filed at the department. The application shall be accompanied by the filing fee required in RSA 400-A:29, I(a).

(c) For any pooled risk management program operated pursuant to RSA 5-B, a completed copy of the RSA 5-B:4 informational filing may be submitted as an exemption registration.

(d) An application or exemption registration shall not be deemed to be filed until all of the information necessary to properly process the application or exemption has been received by the commissioner.

(e) An application by a corporation, association, partnership or benefit society shall be accompanied by a current certificate of good standing as a business corporation in this state.

(f) An administrator shall notify the commissioner in writing of any change in the information required to be filed under these rules including, but not limited to, a change of address or name, no later than 30 days after the change.

(g) Where any form used for compliance with this rule mentions perjury, perjury shall mean any applicable penalty found in RSA 641, falsification in official matters, including RSA 641:3, unsworn falsification.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00; amd by #7506, eff 6-25-01; paras. (a)-(c)(14), (c)(16)a. - (24), (d)(1)-(9), & (f)-(h) EXPIRED: 8-1-08; paras. (c)(15), (16) intro., (25), (d)(10), & (e) EXPIRED: 6-25-09
#9510, eff 7-10-09; ss by #12228, eff 7-10-17; ss by #13070, eff 7-22-20

N.H. Code Admin. R. Ann. Ins 2301.04 Disclosure of Information {#sec-ins-2301.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.04}

(a) Each applicant for a certificate of authority as an administrator shall indicate on the application whether the applicant has:

(1) Ever been denied a license or certificate of authority as an insurance agent, broker, or administrator;

(2) Been licensed or authorized as an insurance agent, broker, or administrator;

(3) Had a license or certificate of authority as an insurance agent, broker, or administrator suspended or revoked or has been denied the renewal of such license; and

(4) Had any contract as an agent or administrator for an insurer cancelled for cause and, if so, the facts concerning that action.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.05 Surety Bond {#sec-ins-2301.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.05}

(a) An administrator that administers benefit plans for an insurer that is not licensed in New Hampshire, a multiple employer welfare arrangement, or a church plan shall include a surety bond in a minimum amount of $100,000 or 10 percent of the administrator's average daily client account balance during the preceding calendar year, but not more than $1,000,000.

(b) If an administrator cannot obtain a bond, then another security, including, but not limited to, cash or negotiable securities in an amount equal to the amount of the required surety bond shall be set aside in one or more trusteed bank accounts in the State of New Hampshire under trust terms that require the commissioner’s signature for any account activity, except the accumulation of interest or other funds into the account, and allow the commissioner, by order, to disburse the trust funds for the satisfaction of policyholder or customer claims.

(1) Unconditional;

(2) Be issued by a bank or insurer licensed to do business in New Hampshire; and

(3) Be payable to the commissioner to ensure the financial protection of the administrator’s customers, subject to the dollar limitation of the surety bond.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00; amd by #7506, eff 6-25-01; EXPIRED: 8-1-08 except for para. (c)(3)
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.06 Audited Financial Statement {#sec-ins-2301.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.06}

(a) Each renewal of a certificate of authority shall be accompanied by the applicant's current audited financial statement.

(b) The financial statement shall reflect a positive net worth in order to be acceptable as proof of the applicant's financial responsibility.

(c) The department, in determining an applicant's ability to pay his obligations when due, shall request reports of the applicant's credit and present financial condition.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.07 Written Agreement Necessary {#sec-ins-2301.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.07}

(a) An administrator shall not act on behalf of an insurer without a written agreement with an insurer or other person for whom the services are performed.

(b) Pursuant to RSA 402-H:2, the agreement shall be retained by the administrator and the insurer for the period of the contract and for 5 years beyond the contract's termination.

(1) The names and addresses of the parties to the contract;

(2) An enumeration of the responsibilities and contractual obligations of the parties to the agreement;

(3) Provisions for contract termination by either of the parties to the agreement and provisions for the fulfillment of any lawful obligations with respect to policies affected by the written agreement;

(4) The lines, classes, or types of insurance to be administered;

(5) The underwriting or other standards to be used and administered;

(6) The financial arrangement for the transfer of funds between the insurer and the administrator in the conduct of business as stipulated in the contract; and

(7) Other special provisions deemed necessary by the parties to the contract.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.08 Fiduciary Obligation {#sec-ins-2301.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.08}

(a) Any money received by a TPA as premium or return premium on or under any policy of insurance or application therefor shall be received by the TPA in its fiduciary capacity.

(b) Any TPA who appropriates to its own use, or with intent to appropriate to its own use, takes, secretes, withholds, lends, invests, or otherwise disposes of, or uses or applies any such premium or return premium received by it, contrary to the instructions or without the consent of the insurer for or on account of which the same was received by it, shall be deemed to have violated this part, irrespective of whether the TPA has or claims to have any commission or other interest in such premium or return premium.

(c) A TPA shall hold premiums and return premiums as a trustee, and not as the owner of the beneficial title to the funds. A TPA shall treat all premiums and return premiums as trust funds and segregate them from the TPA’s own funds.

(d) The TPA shall keep an accurate record of all fiduciary funds in accordance with Ins 2301.13. The TPA shall not treat insurance premiums or return premiums as personal assets. The TPA's financial statement shall clearly show those funds which are held in trust accounts for the benefit of insurers and the liability section of the TPA's statement shall reflect the balances due companies from such trust accounts. A TPA shall not use fiduciary funds as collateral for a personal or business loan.

(e) In order to meet its fiduciary obligations, a TPA shall set up a trust account in a bank or financial institution and maintain all fiduciary funds in such bank or financial institution until actually remitted to the insurer or person entitled thereto. The remittance of premiums shall be governed by the terms of the individual contracts or agreements between the TPA and insurer.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.09 Establishment of Premium Trust Account {#sec-ins-2301.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.09}

(a) Each TPA that collects premium or return premiums shall establish a premium trust account for New Hampshire business.

(b) If the account is interest bearing, the requirements of Ins 2301.11 shall be observed.

(c) Fiduciary funds on New Hampshire business shall at all times be maintained in the premium trust account separate from any other account or depository. Such account shall be in an amount at least equal to the premiums and return premiums, net of commission, received by the TPA and unpaid to the persons entitled thereto or, at such persons' direction or pursuant to written contract, for the account of such persons.

(d) The TPA's New Hampshire premium trust account signature card shall contain the following notation: "This is an insurance premium trust account maintained under the provisions of Chapter Ins 2300, Part Ins 2301."

(e) Checks drawn on the premium trust account shall bear the notation "Premium Trust Account."

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.10 Commingling of Funds Prohibited {#sec-ins-2301.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.10}

(a) Under no circumstances shall a TPA place fiduciary funds in a personal or business operating account. The TPA may retain commission income or other funds in its premium trust account in order to advance premiums, establish reserves for paying return commissions or for such contingencies as might arise in the business of receiving and transmitting premiums or return premium funds.

(b) The TPA may retain a portion of his or her unearned commissions in the premium trust account in order to avoid being short in the event of a policy cancellation. When a policy is cancelled and the return premium is received by the TPA by means of a credit or otherwise, those funds shall be placed in the premium trust account until remitted to the insured entitled thereto.

(c) Cash premium payments shall not be deposited into the TPA's personal account in order to draw a personal check in the amount of net premium payment to the insurer. The use of personal checks to transmit fiduciary funds shall be prohibited in any situation that results in commingling the fiduciary funds with the TPA's personal funds.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.11 Interest-Bearing Accounts {#sec-ins-2301.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.11}

A TPA shall only utilize interest-bearing accounts that require no advance notice for the withdrawal of funds, and the TPA shall arrange all such interest-bearing accounts so that funds therein contained shall be immediately available during normal business hours.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.12 Return Premiums {#sec-ins-2301.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.12}

The TPA shall retain the return premium in the trust account until remittance to the client is made. Remittance to the client shall occur no later than 45 days from the date the return premium is determined. If the return premium cannot be delivered to the insured entitled thereto, the funds shall be returned to the insurer. The insurer shall report the funds escheated to the state of New Hampshire, in accordance with applicable statutes.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.13 Recordkeeping Requirements {#sec-ins-2301.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.13}

(a) The following records relative to the premium trust account shall be maintained at all times by the TPA:

(1) Periodic statements of account supplied by the bank for all premium trust accounts maintained pursuant to this part;

(2) Records of all deposits made into each premium trust account;

(3) Cancelled checks drawn on, or records of withdrawal of funds from, such premium trust accounts; and

(4) An accounts receivable listing or similar record.

(b) All records described above shall be kept in the principal office of the TPA.

(c) All records shall be maintained in an orderly manner so that the information therein is readily available and shall be open to inspection or examination by the commissioner at all times. The commissioner shall require a TPA to furnish the department any information maintained or required to be maintained.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.14 Periodic Audit {#sec-ins-2301.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.14}

(a) The commissioner shall examine an administrator pursuant to RSA 402-H:4, II on a regularly scheduled basis or pursuant to RSA 402-H:13 when an evaluation of any submission to the department by the administrator, insurer, policyholder or publication indicates potential financial or operational irregularities contrary to statute or rule. The cost of the audit shall be paid by the administrator pursuant to RSA 402-H:13. Audits shall include, but not be limited to financial condition, premium collection, claims processing and marketing practices.

(b) Any one or more of the following factors present shall require an additional amount of security:

(1) A material reduction in liquid assets or retained earnings, or liquid assets below the level that would be called for in a surety bond;

(2) A deteriorating financial condition, as evidenced through an audit by the commissioner or any other insurance commissioner; and

(3) Any other relevant considerations jeopardizing insurers and insureds, including a pattern of complaints by consumers, material litigation, revocation or cancellation of surety bonds or errors and omissions insurance coverage, missing, incomplete, or inaccurate financial and transaction records.

(c) The administrator shall have continuing access to all books and records in order to fulfill its contractual obligations.

(d) All books and records maintained by the administrator as part of that contractual obligation shall:

(1) Be owned by the insurer or the administrator;

(2) Conform to the standards of insurance record keeping required of insurers subject to filing an annual audited financial statement pursuant to RSA 400-A:36;

(3) Be retained for 5 years from the date of their creation; and

(4) Be subject to examination by the commissioner or the insurer for which the records are kept.

(e) Upon termination of an agreement between the administrator and person contracting for the services pursuant to the termination provisions in the agreement, the records may be transferred to a new administrator in lieu of the required 5 year retention. If such a transfer occurs, the new administrator shall acknowledge in writing that he/she has received the records and shall be responsible for them.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.15 Responsibilities of the Insurer {#sec-ins-2301.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.15}

(a) The insurer shall be responsible for determining benefits, premium rates, underwriting criteria, and claims payment procedures applicable to the coverage and for securing reinsurance.

(b) The standards pertaining to (a) above shall be provided in writing by the insurer to the administrator.

(c) If the administrator has any responsibility for the development or formulation of the items in (a) above, they shall be set forth in the written agreement between the administrator and the person contracting for the services.

(d) The insurer shall conduct semiannual reviews of the operations of the administrator if the administrator administers benefits for more than 100 certificate holders on behalf of the insurer. One such review shall consist of an on-site audit by the insurer.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.16 Approval of Advertising {#sec-ins-2301.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.16}

(a) All advertising conducted by the TPA on behalf of the insurer shall be approved in writing by the insurer in advance of its use.

(b) Advertisements of insurance shall comply with the provisions of Ins 2600.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.17 Grounds for Denial, Non-renewal, Suspension, or Revocation of Certificate; Penalty {#sec-ins-2301.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.17}

(a) An administrator shall be subject to the provisions of RSA 402-H:14 and RSA 402-H:16 for the following reasons:

(1) Failure to comply with any provisions of these rules or of RSA 402-H;

(2) Failure to comply with any lawful order of the commissioner;

(3) Committing an unfair or deceptive act or practice as described in RSA 417;

(4) Deterioration of financial condition adversely affecting the certificate holder's ability to operate as an administrator;

(5) Filing an application or any necessary forms with the department which contain fraudulent information or omissions;

(6) Misappropriation, conversion, illegal withholding, or refusal to pay over, upon proper demand, any monies that belong to a person otherwise entitled to them and that have been entrusted to the administrator in his/her fiduciary capacity;

(7) Evidence that an owner, principal, officer, partner, manager, director, stockholder, trustee, employee of the administrator, or the administrator itself has:

a. Had an insurance license or an application for an insurance license in any state denied, suspended, or revoked;

b. Been the subject of a fine, penalty, order, withdrawal, or informal settlement with any state insurance department; or

c. Pled guilty or no contest to any felony or misdemeanor; or

(8) At any time fails to meet any qualification for which the issuance of the certificate could have been refused had such failure then existed and been known to the Department.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00; ss by #7506, eff 6-25-01, EXPIRED: 6-25-09
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.18 Inquiry by Commissioner {#sec-ins-2301.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.18}

(a) The commissioner shall address any inquiries to the administrator concerning its TPA business. The administrator shall reply in writing to any inquiry made by the commissioner pursuant to Ins 1001.01(c).

(b) An administrator shall keep all complaints on file for a period of 5 years. Complaint information shall be made available to the department by the administrator upon the commissioner's request.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.19 Hearing and Appeal {#sec-ins-2301.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.19}

Prior to denying an application or a renewal application or suspending or revoking a certificate issued under this part, a certificate holder shall be provided with written notice of the commissioner's allegations and provided an opportunity for a hearing as provided in RSA 400-A and Ins 200.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.20 Violations and Penalties {#sec-ins-2301.20 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.20}

(a) Non-compliance with Ins 2301.03 through Ins 2301.16 shall be a violation under RSA 402-H. The department shall specify which sections, including specific subsections if any, of RSA 402-H are allegedly violated in any enforcement action brought under this section.

(b) In addition to any other penalties provided by the laws of this state for violating a rule, an administrator or individual who violates a requirement of the administrative rules sections cited in (a) above shall, after notice and hearing in accordance with the procedures set forth in Ins 200, be subject to suspension, revocation, or administrative penalty pursuant to RSA 402-H:16.

History

#5787, eff 2-14-94; ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00; amd by #7506, eff 6-25-01 (paras. (c) & (d) deleted); EXPIRED: 8-1-08
#9510, eff 7-10-09; ss by #12228, eff 7-10-17

N.H. Code Admin. R. Ann. Ins 2301.21 Waiver or Suspension of Rules {#sec-ins-2301.21 omnilex-key=us-nh-regs-official--agency-ins--Ins 2301.21}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance

with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX 1

Form TPA-1 Application Certification

I. APPLICATION

CERTIFICATION

THIRD PARTY ADMINISTRATOR

R.S.A. 402-H

ADMINISTRATOR NAME:

TRADE NAME (if any):

DOMICILE:

ADDRESS:

CONTACT NAME:

CONTACT TITLE: PHONE:

CONTACT ADDRESS:

Note: The Department shall address all correspondence regarding this application to the named contact person. The named contact person may be an employee of the company or a contracted individual.

FEES

Application Examination (RSA 400-A:29 I.(a)) $1,000.00

Annual Report Filing Fee (RSA 400-A:29 III.) $100.00

(Due March 1st of each year following licensure)

Annual Renewal (RSA 400:29 I.(c)) $100.00

(Due June 14th each year following licensure)

All checks shall be made payable to: New Hampshire Insurance Department

All application, annual reporting, and annual renewal fees shall be filed with the respective

documents.

SECTION 1 MANAGEMENT

1.) OFFICIAL LIST OF ALL INDIVIDUALS responsible for the conduct of affairs of the administrator. The list shall give the name, position occupied, address and the professional qualifications of each of these individuals. It shall also be sworn to as a true and complete list by the secretary of the administrator. The list shall include:

·Board of Directors

·Board of Trustees

·Executive Committee/Governing Board/Committee

·Principal Officers

·Shareholders (10% or more) Others exercising control/influence

·Any other individual who exercises control or influence over the affairs of the administrator

SECTION 2 FINANCIAL

1.) STATUTORY DEPOSIT as indicated below. Please note that no bonding shall be required by the commissioner of any administrator whose business is restricted solely to benefit plans which are either fully insured by an authorized insurer or which are bona fide employee benefit plans established by an employer or any employee organization, or both, for which the insurance laws of this state are preempted pursuant to the Employee Retirement Income Security Act of 1974.

· A safekeeping or trust receipt from a New Hampshire bank indicating that a minimum of

$100,000.00 has been placed with that bank and pledged to the commissioner of insurance of the State of New Hampshire, or

· A surety bond issued for a minimum of $100,000.00 by a surety company licensed to do business in the State of New Hampshire.

2.) THE PHYSICAL ADDRESS WHERE THE BOOKS AND RECORDS MAINTAINED BY THE ADMINISTRATOR ARE LOCATED:

3.) THE FOLLOWING DOCUMENTS SHALL BE INCLUDED WITH THE APPLICATION:

·Federal Tax Returns (last 3 years)

·Audited Financial Statement (2 most recent years)

SECTION 3 DOCUMENTARY

1.) CERTIFIED COPIES OF ALL BASIC ORGANIZATIONAL DOCUMENTS, including Articles of Incorporation, Articles of Association, partnership agreements, trade name certificate, trust agreement, shareholder agreement, recent certificate of good standing for state of domicile and for the State of New Hampshire, and all amendments thereto. These items shall be certified by the proper domiciliary state official.

2.) COPY OF THE BY-LAWS of the applicant certified as a true and correct copy of the secretary of the company.

3.) BUSINESS PLAN STATEMENT. Attach a separate sheet outlining the Administrator's Business Plan, including staffing levels proposed for New Hampshire and nationwide.

4.) SUMMARY of INSURANCE POLICIES. Attach copies of binder pages from insurance carriers for Administrator's:

"Errors & Omissions" Insurance (carrier/limits/policy period)

"Directors & Officers" Insurance (carrier/limits/policy period)

Any other pertinent coverages (carrier/limits/policy period)

5.) If the applicant shall be managing the solicitation of new or renewal business or shall be directly soliciting insurance contracts or otherwise acting as an agent, furnish the name and New Hampshire agent license number(s) of the individual (s) who shall be performing these duties and indicate if they are contract workers or employees. Please be aware that these individuals shall need a current appointment with the insurer (s) for which they shall be soliciting.

Name License # Employment Status

6.) If the applicant is currently contracted with any insurer as a third party administrator include a copy of each contract and a "Notice of Contract" shall be completed for each contract and submitted to this Office. (form attached, reproduce as needed)

7.) The license or authority of the administrator in any state, district or country has at no time been revoked, suspended or cancelled, nor has it been refused admission to any state, district or country, except as stated below. (state in full detail any exception)

NOTARIZATION

STATE of

COUNTY of

BEFORE ME, the undersigned authority, personally appeared __________________________________ who, being duly sworn, stated that all information contained in the attached application for licensure is, to the best of his knowledge, true, complete and correct.

(Witness Signature) (Authorized Representative - Signature)

(Printed Name) (Printed Name)

Sworn to and subscribed before me this ________ day of

in the year _________

Notary Public Signature

(Printed Name)

II. BIOGRAPHICAL AFFIDAVIT

BIOGRAPHICAL AFFIDAVIT

(Print or Type)

Full Name and Address of Company (Do Not Use Group Names)

In connection with the above-named company, I herewith make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.) IF ANSWER IS "NO" OR "NONE", SO STATE.

Affiant's Full Name (Initials Not Acceptable):
a. Have you ever had your name changed?

b. Other names used at any time.

Affiant's Social Security Number.
Date and Place of Birth.
Affiant's Business Address.

Business Telephone.

List your residences for the last ten (10) years starting with your current address, giving:

Date Address City and State

Education: Dates, Names, Locations and Degrees.

College:

Graduate Studies:

Other:

List memberships in Professional Societies and Associations.
Present or Proposed Position with the Applicant Company.
List complete employment record (up to and including present jobs, positions, directorates or officerships) for the past twenty (20) years, giving:

DATES EMPLOYER AND ADDRESS TITLE

Present employer may be contacted. YES NO

Former employer may be contacted. YES NO

a. Have you ever been in a position which required a fidelity bond? If any claims were made on the bond, give details.

b. Have you ever been denied an individual or position schedule fidelity bond, or have a bond cancelled or revoked? If yes, give details.

List any professional, occupational, and vocational licenses issued by any public or governmental licensing agency or regulatory authority which you presently hold or have held in the past (state date license issued, issuer of license, date terminated, reasons for termination).
During the last ten (10) years, have you ever been refused a professional, occupational, or vocational license by any public or governmental licensing agency or regulatory authority, or has any such license held by you ever been suspended or revoked? If yes, give details.
List any insurers in which you control directly or indirectly or own legally or beneficially 10% or more of the outstanding stock (in voting power). If any of the stock is pledged or hypothecated in any way give details.
Will you or members of your immediate family subscribe to or own, beneficially or of record, shares of stock of the applicant insurance company or its affiliates? If any of the shares or stock are pledged or hypothecated in any way, give details.
Have you ever been adjudged a bankrupt?
a. Have you ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended or been pardoned for conviction of or pleaded guilty or nolo contendere to any information or indictment charging any felony, or charging a misdemeanor involving embezzlement, theft, larceny, or mail fraud, or charging violation of any corporate securities statute or any insurance law, or have you been subject of any disciplinary proceedings of any federal or state regulatory agency?

If yes, give details.

b. Has any company been so charged, allegedly as a result of any action or conduct on your part? ______ If yes, give details.

Have you ever been an officer, director, trustee, investment committee member, key employee, or controlling stockholder of any insurer which, while you occupied any such position or capacity with respect to it, became insolvent or was placed under supervision or in receivership, rehabilitation, liquidation or conservatorship?
Has the certificate of authority or license to do business of any insurance company of which you were an officer or director or key management person ever been suspended or revoked while you occupied such position?

If yes, give details.

Dated and signed this day of at

_____________________________________ I hereby certify under penalty of perjury that I am acting on behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.

(Signature of Affiant)

State of

County of

Personally appeared before me the above named ___________________________________________________ personally known to me, who, being duly sworn, deposes and says that he executed the above instrument and that the statements and answers contained therein are true and correct to the best of my knowledge and belief.

Subscribed and sworn to before me this day of 20

(Notary Public)

My Commission Expires

SEAL

III. NOTICE of CONTRACT

BETWEEN THIRD PARTY ADMINISTRATOR

AND INSURER OR OTHER PERSON

ADMINISTRATOR NAME:

TRADE NAME (if used):

ADDRESS:

NAME of INSURER:

ADDRESS:

CONTACT NAME:

CONTACT TITLE: PHONE:

CONTACT ADDRESS:

Under the terms of the attached contract, the administrator shall be responsible for: (check those which apply)

______ Solicitation of Coverage ______ Underwriting

______ Collection Charges/Premium ______ Claims Adjustment

______ General Management Services ______ Distribution Ad Materials

______ Claims Payment ______ Other (explain)

Effective Date of Contract:

Physical location of books and records maintained by the administrator in regard to this agreement:

Also include the following items:

 A copy of the contract between the administrator and insurer or other person.

 A copy of the notification which shall be sent to policyholders informing them of this arrangement.

 Copies of all advertisement and marketing materials to be distributed by the administrator.

 Level of reinsurance provided for the benefit of insureds under this contract, include carrier name.

 Actual or estimated annual losses paid for a 3 year period.

(Signature of Administrator Representative) (Signature of Insurer Representative)

(Printed Name) (Printed Name)

IV, REQUEST for an EXEMPTION of LICENSURE

as a THIRD PARTY ADMINISTRATOR

in New Hampshire

An administrator is not required to hold a license as an administrator in this state under certain conditions set forth in RSA 402-H:11-b. An exemption shall be requested by completing this form and page one of the licensing application and submitting it to this Department. No fee is charged for the registration of an exempted administrator. The Department shall notify the applicant if the request for an exemption is approved. This exemption shall be renewed no later than June 14th of every year subsequent to the initial application.

ADMINISTRATOR NAME:

The above named administrator hereby requests an exemption from licensure because we meet the following requirement (s): (check those which apply)

_____ An association administering a pooled risk management program operated pursuant to RSA 5-B.

_____ A association conducting business that is exempt from taxation under the Internal Revenue Code, Section 115.

NOTARIZATION

STATE of

COUNTY of

BEFORE ME, the undersigned authority, personally appeared _____________________________________ who being duly sworn, stated that all information contained in the attached application for exemption of licensure is, to the best of his knowledge, true, complete and correct.

(Witness Signature) (Authorized Representative Signature)

(Printed Name) (Printed Name)

Sworn to and subscribed before me this __________ day of _______in the year ____________

(Notary Public Signature)

(Notary Public Printed Name)

APPENDIX 2

Form TPA-2 Authorization of Exception

I. REQUEST for an EXCEPTION from LICENSURE

as a THIRD PARTY ADMINISTRATOR

in New Hampshire

Certain persons or entities are not required to hold a license as an administrator in this state under certain conditions set forth in RSA 402-H:1, I (a) through (m). An exception shall be requested by completing this form and page one of the licensing application and submitting it to this Department. No fee is charged for the registration of an excepted person or entity. The Department shall notify the applicant if the request for an exception is approved. This exception shall be renewed no later than June 14th of every year subsequent to the initial application.

EXCEPTED PERSON OR ENTITY NAME:

The above named excepted person or entity hereby requests an exception from licensure because we meet the following requirement (s): (check those which apply)

_____ An employer, or a wholly owned direct or indirect subsidiary of an employer, on behalf of

its employees or the employees of one or more subsidiaries or affiliated corporations of such

employer.

_____ A union on behalf of its members.

_____ An insurer which is authorized to transact insurance in this state pursuant to RSA 401, or a

subsidiary or affiliated corporation of such insurer, with respect to a policy lawfully issued and

delivered in and pursuant to the laws of this state.

_____ An insurance producer licensed to sell life or health insurance or annuities or workers'

compensation insurance in this state, acting on behalf of an authorized insurer.

_____ A creditor on behalf of its debtors with respect to insurance covering a debt between the

creditor and its debtors.

_____ A trust and its trustees, agents and employees acting pursuant to such trust established in

conformity with 29 U.S.C. section 186.

_____ A trust exempt from taxation under Section 501(a) of the Internal Revenue Code, its

trustees and employees acting pursuant to such trust, or custodian and the custodian's agents or

employees acting pursuant to a custodian account which meets the requirements of Section 401(f)

of the Internal Revenue Code.

_____ A credit union or a financial institution which is subject to supervision or examination by

federal or state banking authorities, or a mortgage lender, to the extent it collects and remits

premiums to licensed insurance producers or authorized insurers in connection with loan payments.

_____ A credit card issuing company which advances for and collects insurance premiums or

charges from its credit card holders who have authorized collection.

_____ A person who adjusts or settles claims in the normal course of that person's practice or

employment as an attorney at law and who does not collect charges or premiums in connection

with life, annuity, or health coverage or workers' compensation insurance.

_____ An adjuster licensed by this state whose activities are limited to adjustment of claims.

_____ A person subject to regulation under RSA 281-A:5-d or under a self-funded governmental

plan that is exempt from the provisions of the Employee Retirement Income Security Act (ERISA)

pursuant to 29 U.S.C. Section 1003(b)(1). To qualify, the TPA shall administer exclusively

(100%) self-funded governmental plans only. The applicant shall attach a list of plans it is

administering. See RSA 402-H:1 I.

_____ A person licensed as a managing general agent in this state, pursuant to RSA 402-E, whose

activities are limited exclusively to the scope of activities conveyed under such license.

_____ An administrator who is affiliated with an insurer and who only performs the contractual

duties, between the administrator and the insurer, of an administrator for the direct and assumed

insurance business of the affiliated insurer. The insurer is responsible for the acts of the

administrator and is responsible for providing all of the administrator's books and records to the

insurance commissioner, upon request from the insurance commissioner. For purposes of this

subparagraph, "insurer" means a licensed insurance company, prepaid hospital or medical care

plan, or a health maintenance organization.

_____ An administrator is not required to hold a certificate of authority as an administrator in this

state if all of the following conditions are met:

(1) The administrator has its principal place of business in another state.

(2) The administrator is not soliciting business as an administrator in this state.

(3) The administrator's New Hampshire business includes in total fewer than 100 certificate holders.

NOTARIZATION

STATE of

COUNTY of

BEFORE ME, the undersigned authority, personally appeared _____________________________________ who being duly sworn, stated that all information contained in the attached application for exception of licensure is, to the best of his knowledge, true, complete and correct.

(Witness Signature) (Authorized Representative Signature)

(Printed Name) (Printed Name)

Sworn to and subscribed before me this __________ day of _______in the year ____________

(Notary Public Signature)

(Notary Public Printed Name)

APPENDIX 3

Form TPA-3 NEW HAMPSHIRE THIRD PARTY ADMINISTRATOR BOND

BOND NO. ________

KNOW ALL MEN BY THESE PRESENTS:

That we, ______________________________________________________________, as Principal, and

_____________________________________________________________________as Surety, are held and firmly bound unto, _____________________________________________ Commissioner of Insurance for the State of New Hampshire and his successors in office, for the use and benefit of the State of New Hampshire and the citizens thereof, in the sum of _______________________________________________ dollars, lawful money of the United States, for the payment of which well and truly to be made, we hereby bind ourselves, our successors and assigns, jointly, severally and firmly by these presents.

WHEREAS the said Principal has applied to the Commissioner of Insurance of the State of New Hampshire to be licensed as a Third Party Administrator in the State of New Hampshire as prescribed in New Hampshire Revised Statutes Annotated RSA 402-H and as required by Regulations Ins 2300 of the New Hampshire Insurance Department to give bond unto the Commissioner of Insurance for the State of New Hampshire to guarantee the payment of all claims or other legal obligations which the Principal fails to pay, up to the amount of this bond, which arise from the operations of the Principal in the State of New Hampshire.

NOW, THEREFORE, this bond shall continue in full force and effect until terminated in the following manner. This bond may be cancelled by the Insurance Commissioner for the State of New Hampshire by written notice from the Insurance Commissioner to the Surety hereon, which notice shall specify the date of termination of the bond.

Cancellation by the Surety Company shall not be effective until 90 days following receipt of written notice to the Insurance Commissioner and Principal.

IN WITNESS WHEREOF, the parties herein have caused this bond to be executed this _______

day of , 20 .

(Witness) (Principal)

By:

(Witness) By:

APPENDIX A

Rule

Statute

Ins 2301.01

RSA 402-H

Ins 2301.02

RSA 402-H:2

Ins 2301.03

RSA 400-A:15, I; RSA 402-H:11

Ins 2301.04

RSA 402-H:9, 10

Ins 2301.05

RSA 402-H:11, VIII

Ins 2301.06

RSA 402-H:11,12

Ins 2301.07

RSA 402-H:11

Ins 2301.08

RSA 402-H:7,9

Ins 2301.09

RSA 402-H:7

Ins 2301.10

RSA 402-H:7

Ins 2301.11

RSA 402-H:7

Ins 2301.12

RSA 402-H:7

Ins 2301.13

RSA 402-H:4

Ins 2301.14

RSA 402-H:13

Ins 2301.15

RSA 402-H:6

Ins 2301.16

RSA 402-H:5

Ins 2301.17

RSA 402-H:14

Ins 2301.18

RSA 402-H:15

Ins 2301.19

RSA 402-H:15

Ins 2301.20

RSA 402-H:16

Ins 2301.21

RSA 402-H:16

Appendix 1

RSA 400-A:15, I; RSA 402-H:11

Appendix 2

RSA 400-A:15, I, RSA 402-H:1, I

Appendix 3

RSA 400-A:15, I

History

#12228, eff 7-10-17

Chapter Ins 2400 Actuarial Opinion and Memorandum

Part Ins 2401 Guidelines and Standards

N.H. Code Admin. R. Ann. Ins 2401.01 Purpose {#sec-ins-2401.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2401.01}

(a) The purpose of this part is to prescribe:

(1) Requirements for statements of actuarial opinion that are to be submitted in accordance with RSA 410, and for memoranda in support thereof;

(2) Rules applicable to the appointment of an appointed actuary; and

(3) Guidance as to the meaning of “adequacy of reserves.”

History

#6635, eff 11-24-97; ss by #8484, eff 11-24-05; ss by #9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2401.02 Applicability and Scope {#sec-ins-2401.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2401.02}

(a) This part shall apply to all life insurance companies and fraternal benefit societies doing business in this state and to all life insurance companies and fraternal benefit societies that are authorized to reinsure life insurance, annuities, or accident and health insurance business in this state. This part shall be applied in a manner that allows the appointed actuary to utilize his or her professional judgment in performing the asset analysis and developing the actuarial opinion and supporting memoranda, consistent with relevant actuarial standards of practice. However, the commissioner shall have the authority to specify specific methods of actuarial analysis and actuarial assumptions when, in the commissioner’s judgment, these specifications are necessary for an acceptable opinion to be rendered relative to the adequacy of reserves and related items.

(b) This part shall be applicable to all annual statements filed with the office of the commissioner after the effective date of this part.

(c) A statement of opinion on the adequacy of the reserves and related actuarial items based on an asset adequacy analysis in accordance with Ins 2401.05 and a memorandum in support thereof pursuant to Ins 2401.06 shall be required each year.

History

#6635, eff 11-24-97; ss by #8484, eff 11-24-05; ss by #9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2401.03 Definitions {#sec-ins-2401.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2401.03}

(a) “Actuarial opinion” means the opinion of an appointed actuary regarding the adequacy of the reserves and related actuarial items based on an asset adequacy analysis in accordance with Ins 2401.05 and with applicable actuarial standards of practice.

(b) “Actuarial standards board” means the board established by the American Academy of Actuaries to develop and promulgate standards of actuarial practice.

(c) “Annual statement” means that statement required by RSA 400-A:36 to be filed by the company with the office of the commissioner annually.

(d) “Appointed actuary” means an individual who is appointed or retained in accordance with the requirements set forth in Ins 2401.04(c) to provide the actuarial opinion and supporting memorandum as required by RSA 410.

(e) “Asset adequacy analysis” means an analysis that meets the standards and other requirements referred to in Ins 2401.04(d).

(f) “Commissioner” means the insurance commissioner of this state.

(g) “Company” means a life insurance company, fraternal benefit society, or reinsurer subject to the provisions of this part.

(h) “NAIC” means the National Association of Insurance Commissioners.

(i) “Qualified actuary” means an individual who meets the requirements set forth in Ins 2401.04(b).

History

#6635, eff 11-24-97; ss by #8484, eff 11-24-05; ss by #9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2401.04 General Requirements {#sec-ins-2401.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2401.04}

(a) Submission of Statement of Actuarial Opinion:

(1) There is to be included on or attached to Page 1 of the annual statement for each year, beginning with the year in which this part becomes effective, the statement of an appointed actuary, entitled “Statement of Actuarial Opinion,” setting forth an opinion relating to reserves and related actuarial items held in support of policies and contracts, in accordance with Ins 2401.05; and

(2) Upon written request by the company, the commissioner may grant an extension of the date for submission of the statement of actuarial opinion.

(b) Qualified Actuary. A qualified actuary is an individual who:

(1) Is a member in good standing of the American Academy of Actuaries;

(2) Is qualified to sign statements of actuarial opinion for life and health insurance company annual statements in accordance with the American Academy of Actuaries qualification standards for actuaries signing such statements;

(3) Is familiar with the valuation requirements applicable to life and health insurance companies;

(4) Has not been found by the commissioner, following appropriate notice and hearing, or if so found has subsequently been reinstated as a qualified actuary, to have:

a. Violated any provision of, or any obligation imposed by, Title XXXVII or other law in the course of his or her dealings as a qualified actuary;

b. Been found guilty of fraudulent or dishonest practices;

c. Demonstrated his or her incompetency, lack of cooperation, or untrustworthiness to act as a qualified actuary;

d. Submitted to the commissioner during the past 5 years, pursuant to this part, an actuarial opinion or memorandum that the commissioner rejected because it did not meet the provisions of this part including standards set by the actuarial standards board; or

e. Resigned or been removed as an actuary within the past 5 years as a result of acts or omissions indicated in any adverse report on examination or as a result of failure to adhere to generally acceptable actuarial standards; and

(5) Has not failed to notify the commissioner of any action taken by any commissioner of any other state similar to that under Ins 2401.04(b)(4).

(c) Appointed Actuary. An appointed actuary is a qualified actuary who is appointed or retained to prepare the Statement of Actuarial Opinion required by this part, either directly by or by the authority of the board of directors through an executive officer of the company other than the qualified actuary. The company shall give the commissioner timely written notice of the name, title, and, in the case of a consulting actuary, the name of the firm, and manner of appointment or retention of each person appointed or retained by the company as an appointed actuary and shall state in the notice that the person meets the requirements set forth in Ins 2401.04(b). Once notice is furnished, no further notice is required with respect to this person, provided that the company shall give the commissioner timely written notice in the event the actuary ceases to be appointed or retained as an appointed actuary or to meet the requirements set forth in Ins 2401.04(b). If any person appointed or retained as an appointed actuary replaces a previously appointed actuary, the notice shall so state and give the reasons for replacement.

(d) Standards for Asset Adequacy Analysis. The asset adequacy analysis required by this part shall:

(1) Conform to the standards of practice as promulgated from time to time by the actuarial standards board and on any additional standards under this part, which standards are to form the basis of the statement of actuarial opinion in accordance with this part; and

(2) Be based on methods of analysis as are deemed appropriate for such purposes by the actuarial standards board.

(e) Liabilities to be covered:

(1) Under authority of RSA 410, the statement of actuarial opinion shall apply to all in force business on the statement date, whether directly issued or assumed, regardless of when or where issued, e.g., reserves of Exhibits 8, 9 and 10, and claim liabilities in Exhibit 11, Part 1 and equivalent items in the separate account statement or statements;

(2) If the appointed actuary determines as the result of asset adequacy analysis that a reserve should be held in addition to the aggregate reserve held by the company and calculated in accordance with methods set forth in RSA 410, the company shall establish the additional reserve; and

(3) Additional reserves established under (2) above and deemed not necessary in subsequent years may be released. Any amounts released shall be disclosed in the actuarial opinion for the applicable year. The release of such reserves would not be deemed an adoption of a lower standard of valuation.

History

#6635, eff 11-24-97; ss by #8484, eff 11-24-05; ss by #9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2401.05 Statement of Actuarial Opinion Based on an Asset Adequacy Analysis {#sec-ins-2401.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2401.05}

(a) General Description. The statement of actuarial opinion submitted in accordance with this section shall consist of:

(1) A paragraph identifying the appointed actuary and his or her qualifications;

(2) A scope paragraph identifying the subjects on which an opinion is to be expressed and describing the scope of the appointed actuary’s work, including a tabulation delineating the reserves and related actuarial items that have been analyzed for asset adequacy and the method of analysis and identifying the reserves and related actuarial items covered by the opinion that have not been so analyzed;

(3) A reliance paragraph describing those areas, if any, where the appointed actuary has deferred to other experts in developing data, procedures, or assumptions, e.g., anticipated cash flows from currently owned assets, including variation in cash flows according to economic scenarios, supported by a statement of each such expert in the form prescribed by Ins 2401.05(e);

(4) An opinion paragraph expressing the appointed actuary’s opinion with respect to the adequacy of the supporting assets to mature the liabilities; and

(5) One or more additional paragraphs will be needed in individual company cases as follows:

a. If the appointed actuary considers it necessary to state a qualification of his or her opinion;

b. If the appointed actuary must disclose an inconsistency in the method of analysis or basis of asset allocation used at the prior opinion date with that used for this opinion;

c. If the appointed actuary must disclose whether additional reserves as of the prior opinion date are released as of this opinion date, and the extent of the release; and

d. If the appointed actuary chooses to add a paragraph briefly describing the assumptions that form the basis for the actuarial opinion.

(b) Recommended Language. The following paragraphs are to be included in the statement of actuarial opinion in accordance with this section. Language is that which in typical circumstances shall be included in a statement of actuarial opinion. The language may be modified as needed to meet the circumstances of a particular case, but the appointed actuary should use language that clearly expresses his or her professional judgment. However, in any event the opinion shall retain all pertinent aspects of the language provided in this section:

(1) The opening paragraph shall generally indicate the appointed actuary’s relationship to the company and his or her qualifications to sign the opinion. For a company actuary, the opening paragraph of the actuarial opinion shall include a statement such as:

“I, [name], am, [title] of [insurance company name] and a member of the American Academy of Actuaries. I was appointed by, or by the authority of, the board of directors of said insurer to render this opinion as stated in the letter to the commissioner dated [insert date]. I meet the Academy qualification standards for rendering the opinion and am familiar with the valuation requirements applicable to life and health insurance companies.”

For a consulting actuary, the opening paragraph shall include a statement such as:

“I, [name], a member of the American Academy of Actuaries, am associated with the firm of [name of consulting firm]. I have been appointed by, or by the authority of, the board of directors of [name of company] to render this opinion as stated in the letter to the commissioner dated [insert date]. I meet the Academy qualification standards for rendering the opinion and am familiar with the valuation requirements applicable to life and health insurance companies.”;

(2) The scope paragraph shall include a statement such as:

“I have examined the actuarial assumptions and actuarial methods used in determining reserves and related actuarial items listed below, as shown in the annual statement of the company, as prepared for filing with state regulatory officials, as of December 31, [ ]. Tabulated below are those reserves and related actuarial items which have been subjected to asset adequacy analysis.”

Asset Adequacy Tested Amounts – Reserves and Liabilities

Statement Item

Formula Reserves

(1)

Additional

Actuarial

Reserves (a)(2)

Analysis

Method

(b)

Other

Amount

(3)

Total Amount (1)+(2)+(3)

(4)

Exhibit 8

A Life Insurance

B Annuities

C Supplementary Contracts Involving Life Contingencies

D Accidental Death Benefit

E Disability – Active

F Disability – Disabled

G Miscellaneous

Total (Exhibit 8, Item 1, Page 3)

Exhibit 9

A Active Life Reserve

B Claim Reserve

Total (Exhibit 9, Item 2, Page 3)

Exhibit 10

Premiums and Other Deposit Funds

(Column 5, Line 14)

Guaranteed Interest Contracts

(Column 2, Line 14)

Other

(Column 6, Line 14)

Supplemental Contracts and Annuities Certain

(Column 3, Line 14)

Dividend Accumulations or Refunds

(Column 4, Line 14)

Total Exhibit 10

(Column 1, Line 14)

Exhibit 11 Part 1

1 Life (Page 3, Line 4.1)

2 Health (Page 3, Line 4.2)

Total Exhibit 11, Part 1

Separate Accounts

(Page 3 of the Annual Statement of the Separate Accounts, Lines 1, 2, 3.1, 3.2, 3.3)

TOTAL RESERVES

IMR (General Account, Page Line )

(Separate Accounts, Page Line )

Net Deferred and Uncollected Premium

Notes:

(a) The additional actuarial reserves are the reserves established under Ins 2401.05 (e)(2).

(b) The appointed actuary should indicate the method of analysis, determined in accordance with the standards for asset adequacy analysis referred to in Ins 2401.04(d) of this part, by means of symbols that should be defined in footnotes to the table.

(3) If the appointed actuary has relied on other experts to develop certain portions of the analysis, the reliance paragraph shall include a statement such as:

"I have relied on [name], [title] for [e.g., “anticipated cash flows from currently owned assets, including variations in cash flows according to economic scenarios” or “certain critical aspects of the analysis performed in conjunction with forming my opinion”], as certified in the attached statement. I have reviewed the information relied upon for reasonableness.”

A statement of reliance on other experts shall be accompanied by a statement by each of the experts in the form prescribed by Ins 2401.05(e);

(4) If the appointed actuary has examined the underlying asset and liability records, the reliance paragraph shall include a statement such as:

“My examination included such review of the actuarial assumptions and actuarial methods and of the underlying basic asset and liability records and such tests of the actuarial calculations as I considered necessary. I also reconciled the underlying basic asset and liability records to [exhibits and schedules listed as applicable] of the company’s current annual statement.”

(5) If the appointed actuary has not examined the underlying records, but has relied upon data [e.g., listings and summaries of policies in force or asset records] prepared by the company, the reliance paragraph shall include a statement such as:

“In forming my opinion on [specify types of reserves] I relied upon data prepared by [name and title of company officer certifying in force records or other data] as certified in the attached statements. I evaluated that data for reasonableness and consistency. I also reconciled that data to [exhibits and schedules to be listed as applicable] of the company’s current annual statement. In other respects, my examination included review of the actuarial assumptions and actuarial methods used and tests of the calculations I considered necessary.”

The section shall be accompanied by a statement by each person relied upon in the form prescribed by Ins 2401.05(e); and

(6) The opinion paragraph shall include a statement such as:

“In my opinion the reserves and related actuarial values concerning the statement items identified above:

a. Are computed in accordance with presently accepted actuarial standards consistently applied and are fairly stated, in accordance with sound actuarial principles;

b. Are based on actuarial assumptions that produce reserves at least as great as those called for in any contract provision as to reserve basis and method, and are in accordance with all other contract provisions;

c. Meet the requirements of the insurance laws and rules of the state of [state of domicile] and are at least as great as the minimum aggregate amounts required by the state in which this statement is filed.

d. Are computed on the basis of assumptions consistent with those used in computing the corresponding items in the annual statement of the preceding year-end [with any exceptions as noted below]; and

e. Include provision for all actuarial reserves and related statement items which ought to be established.

The reserves and related items, when considered in light of the assets held by the company with respect to such reserves and related actuarial items including, but not limited to, the investment earnings on the assets, and the considerations anticipated to be received and retained under the policies and contracts, make adequate provision, according to presently accepted actuarial standards of practice, for the anticipated cash flows required by the contractual obligations and related expenses of the company.

The actuarial methods, considerations and analyses used in forming my opinion conform to the appropriate standards of practice as promulgated by the Actuarial Standards Board, which standards form the basis of this statement of opinion.

This opinion is updated annually as required by statute. To the best of my knowledge, there have been no material changes from the applicable date of the annual statement to the date of the rendering of this opinion which should be considered in reviewing this opinion; or

The following material changes which occurred between the date of the statement for which this opinion is applicable and the date of this opinion should be considered in reviewing this opinion: (Describe the change or changes.)

The impact of unanticipated events subsequent to the date of this opinion is beyond the scope of this opinion. The analysis of asset adequacy portion of this opinion should be viewed recognizing that the company’s future experience may not follow all the assumptions used in the analysis.

Signature of Appointed Actuary

Address of Appointed Actuary

Telephone Number of Appointed Actuary

Date”

(c) Assumption for New Issues. The adoption for new issues or new claims or other new liabilities of an actuarial assumption that differs from a corresponding assumption used for prior new issues or new claims or other new liabilities is not a change in actuarial assumptions within the meaning of Ins 2401.05.

(d) Adverse Opinions. If the appointed actuary is unable to form an opinion, he or she shall refuse to issue a statement of actuarial opinion. If the appointed actuary’s opinion is adverse or qualified, then he or she shall issue an adverse or qualified actuarial opinion explicitly stating the reason for the opinion. This statement shall follow the scope paragraph and precede the opinion paragraph.

(e) Reliance on Information Furnished by Other Persons. If the appointed actuary relies on the certification of others on matters concerning the accuracy or completeness of any data underlying the actuarial opinion, or the appropriateness of any other information used by the appointed actuary in forming the actuarial opinion, the actuarial opinion should so indicate the persons the actuary is relying upon and a precise identification of the items subject to reliance. In addition, the persons on whom the appointed actuary relies shall provide a certification that precisely identifies the items on which the person is providing information and a statement as to the accuracy, completeness, or reasonableness, as applicable, of the items. This certification shall include the signature, title, company, address, and telephone number of the person rendering the certification, as well as the date on which it is signed.

(f) Alternate Option:

(1) RSA 410 gives the commissioner broad authority to accept the valuation of a foreign insurer when that valuation meets the requirements applicable to a company domiciled in this state in the aggregate. As an alternative to the requirements of Ins 2401.05(b)(6)c., the commissioner may make one or more of the following additional approaches available to the opining actuary:

a. A statement that the reserves “meet the requirements of the insurance laws and rules of the State of [state of domicile] and the formal written standards and conditions of this state for filing an opinion based on the law of the state of domicile.” If the commissioner chooses to allow this alternative, a formal written list of standards and conditions shall be made available. If a company chooses to use this alternative, the standards and conditions in effect on July 1 of a calendar year shall apply to statements for that calendar year, and they shall remain in effect until they are revised or revoked. If no list is available, this alternative is not available;

b. A statement that the reserves “meet the requirements of the insurance laws and rules of the State of [state of domicile] and I have verified that the company’s request to file an opinion based on the law of the state of domicile has been approved and that any conditions required by the commissioner for approval of that request have been met.” If the commissioner chooses to allow this alternative, a formal written statement of such allowance shall be issued no later than March 31 of the year it is first effective. It shall remain valid until rescinded or modified by the commissioner. The rescission or modifications shall be issued no later than March 31 of the year they are first effective. Subsequent to that statement being issued, if a company chooses to use this alternative, the company shall file a request to do so, along with justification for its use, no later than April 30 of the year of the opinion to be filed. The request shall be deemed approved on October 1 of that year if the commissioner has not denied the request by that date;

c. A statement that the reserves “meet the requirements of the insurance laws and rules of the State of [state of domicile] and I have submitted the required comparison as specified by this state.”

If the commissioner chooses to allow this alternative, a formal written list of products, to be added to the table in b. below, for which the required comparison shall be provided, will be published. If a company chooses to use this alternative, the list in effect on July 1 of a calendar year shall apply to statements for that calendar year, and it shall remain in effect until it is revised or revoked. If no list is available, this alternative is not available;
If a company desires to use this alternative, the appointed actuary shall provide a comparison of the gross nationwide reserves held to the gross nationwide reserves that would be held under NAIC codification standards. Gross nationwide reserves are the total reserves calculated for the total company in force business directly sold and assumed, indifferent to the state in which the risk resides, without reduction for reinsurance ceded. The information provided shall be at least:

(1)

Product Type

(2)

Death Benefit or Account Value

(3)

Reserves Held

(4)

Codification Reserves

(5)

Codification Standard

The information listed shall include all products identified by either the state of filing or any other states subscribing to this alternative;
If there is no codification standard for the type of product or risk in force or if the codification standard does not directly address the type of product or risk in force, the appointed actuary shall provide detailed disclosure of the specific method and assumptions used in determining the reserves held; and
The comparison provided by the company is to be kept confidential to the same extent and under the same conditions as the actuarial memorandum; and

(2) Notwithstanding the above, the commissioner may reject an opinion based on the laws and rules of the state of domicile and require an opinion based on the laws of this state. If a company is unable to provide the opinion within 60 days of the request or such other period of time determined by the commissioner after consultation with the company, the commissioner may contract an independent actuary at the company’s expense to prepare and file the opinion.

History

#6635, eff 11-24-97; ss by #8484, eff 11-24-05; ss by #9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2401.06 Description of Actuarial Memorandum Including an Asset Adequacy Analysis and Regulatory Asset {#sec-ins-2401.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2401.06}

Adequacy Issues Summary.

(a) General;

(1) In accordance with RSA 410, the appointed actuary shall prepare a memorandum to the company describing the analysis done in support of his or her opinion regarding the reserves. The memorandum shall be made available for examination by the commissioner upon his or her request but shall be returned to the company after such examination and shall not be considered a record of the insurance department or subject to automatic filing with the commissioner;

(2) In preparing the memorandum, the appointed actuary may rely on, and include as a part of his or her own memorandum, memoranda prepared and signed by other actuaries who are qualified within the meaning of Ins 2401.04(b), with respect to the areas covered in such memoranda, and so state in their memoranda;

(3) If the commissioner requests a memorandum and no such memorandum exists or if the commissioner finds that the analysis described in the memorandum fails to meet the standards of the Actuarial Standards Board or the standards and requirements of this part, the commissioner shall designate a qualified actuary to review the opinion and prepare such supporting memorandum as is required for review. The reasonable and necessary expense of the independent review shall be paid by the company but shall be directed and controlled by the commissioner;

(4) The reviewing actuary shall have the same status as an examiner for purposes of obtaining data from the company, and the work papers and documentation of the reviewing actuary shall be retained by the commissioner; provided, however, that any information provided by the company to the reviewing actuary and included in the work papers shall be considered as material provided by the company to the commissioner and shall be kept confidential to the same extent as is prescribed by law with respect to other material provided by the company to the commissioner pursuant to RSA 410. The reviewing actuary shall not be an employee of a consulting firm involved with the preparation of any prior memorandum or opinion for the insurer pursuant to this part for any one of the current year or the preceding 3 years; and

(5) In accordance with RSA 410, the appointed actuary shall prepare a regulatory asset adequacy issues summary, the contents of which are specified in Ins 2401.06(c). The regulatory asset adequacy issues summary shall be submitted no later than March 15 of the year following the year for which a statement of actuarial opinion based on asset adequacy is required. The regulatory asset adequacy issues summary is to be kept confidential to the same extent and under the same conditions as the actuarial memorandum;

(b) Details of the Memorandum Section Documenting Asset Adequacy Analysis:

When an actuarial opinion is provided, the memorandum shall demonstrate that the analysis has been done in accordance with the standards for asset adequacy referred to in Ins 2401.04(d) and any additional standards under this part. It shall specify:

(1) For reserves:

a. Product descriptions including market description, underwriting, and other aspects of a risk profile and the specific risks the appointed actuary deems significant;

b. Source of liability in force;

c. Reserve method and basis;

d. Investment reserves;

e. Reinsurance arrangements;

f. Identification of any explicit or implied guarantees made by this general account in support of benefits provided through a separate account or under a separate account policy or contract and the methods used by the appointed actuary to provide for the guarantees in the asset adequacy analysis; and

g. Documentation of assumptions to test reserves for the following:

Lapse rates, both base and excess;
Interest crediting rate strategy;
Mortality;
Policyholder dividend strategy;
Competitor or market interest rate;
Annuitization rates;
Commissions and expenses; and
Morbidity;

The documentation of the assumptions shall be such that an actuary reviewing the actuarial memorandum could form a conclusion as to the reasonableness of the assumptions;

(2) For assets:

a. Portfolio descriptions, including a risk profile disclosing the quality, distribution, and types of assets;

b. Investment and disinvestment assumptions;

c. Source of asset data;

d. Asset valuation bases; and

e. Documentation of assumptions made for:

Default costs;
Bond call function;
Mortgage prepayment function;
Determining market value for assets sold due to disinvestment strategy; and
Determining yield on assets acquired through the investment strategy;

The documentation of the assumption shall be such that an actuary reviewing the actuarial memorandum could form a conclusion as to the reasonableness of the assumptions;

(3) For the analysis basis:

a. Methodology;

b. Rationale for inclusion or exclusion of different blocks of business and how pertinent risks were analyzed;

c. Rationale for degree of rigor in analyzing different blocks of business; include in the rationale the level of “materiality” that was used in determining how rigorously to analyze different blocks of business;

d. Criteria for determining asset adequacy; include in the criteria the precise basis for determining if assets are adequate to cover reserves under “moderately adverse conditions” or other conditions as specified in relevant actuarial standards of practice; and

e. Whether the impact of federal income taxes was considered and the method of treating reinsurance in the asset adequacy analysis;

(4) Summary of material changes in methods, procedures, or assumptions from prior year’s asset adequacy analysis;

(5) Summary of results; and

(6) Conclusions.

(1) The regulatory asset adequacy issues summary shall include:

a. Descriptions of the scenarios tested, including whether those scenarios are stochastic or deterministic, and the sensitivity testing done relative to those scenarios. If negative ending surplus results under certain tests in the aggregate, the actuary should describe those tests and the amount of additional reserve as of the valuation date which, if held, would eliminate the negative aggregate surplus values. Ending surplus values shall be determined by either extending the projection period until the in force and associated assets and liabilities at the end of the projection period are immaterial or by adjusting the surplus amount at the end of the projection period by an amount that appropriately estimates the value that can reasonably be expected to arise from the assets and liabilities remaining in force;

b. The extent to which the appointed actuary uses assumptions in the asset adequacy analysis that are materially different than the assumptions used in the previous asset adequacy analysis;

c. The amount of reserves and the identity of the product lines that had been subjected to asset adequacy analysis in the prior opinion but were not subject to analysis for the current opinion;

d. Comments on any interim results that may be of significant concern to the appointed actuary. For example, the impact of the insufficiency of assets to support the payment of benefits and expenses and the establishment of statutory reserves during one or more interim periods;

e. The methods used by the actuary to recognize the impact of reinsurance on the company’s cash flows, including both assets and liabilities, under each of the scenarios tested; and

f. Whether the actuary has been satisfied that all options, whether explicit or embedded, in any asset or liability, including but not limited to those affecting cash flows embedded in fixed income securities, and equity-like features in any investments have been appropriately considered in the asset adequacy analysis; and

(2) The regulatory asset adequacy issues summary shall contain the name of the company for which the regulatory asset adequacy issues summary is being supplied and shall be signed and dated by the appointed actuary rendering the actuarial opinion.

(d) Conformity to Standards of Practice. The memorandum shall include a statement:

"Actuarial methods, considerations, and analysis used in the preparation of this memorandum conform to the appropriate Standards of Practice as promulgated by the Actuarial Standards Board, which standards form the basis for this memorandum."

(e) Use of Assets Supporting the Interest Maintenance Reserve and the Asset Valuation Reserve.

An appropriate allocation of assets in the amount of the interest maintenance reserve (IMR), whether positive or negative, shall be used in any asset adequacy analysis. Analysis of risks regarding asset default may include an appropriate allocation of assets supporting the asset valuation reserve (AVR); these AVR assets may not be applied for any other risks with respect to reserve adequacy. Analysis of these and other risks may include assets supporting other mandatory or voluntary reserves available to the extent not used for risk analysis and reserve support.

The amount of the assets used for the AVR shall be disclosed in the table of reserves and liabilities of the opinion and in the memorandum. The method used for selecting particular assets or allocated portions of assets shall be disclosed in the memorandum.

(f) Documentation. The appointed actuary shall retain on file, for at least 7 years, sufficient documentation so that it will be possible to determine the procedures followed, the analyses performed, the bases for assumptions, and the results obtained.

History

#6635, eff 11-24-97; ss by #8484, eff 11-24-05; ss by #9892, eff 4-1-11; ss by #9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2401.07 Waiver of Rules {#sec-ins-2401.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2401.07}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

History

#12705, eff 4-1-19

Part Ins 2402 Property and Casualty Actuarial Opinion

N.H. Code Admin. R. Ann. Ins 2402.01 Purpose {#sec-ins-2402.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2402.01}

The purpose of this part is to prescribe requirements for statements of actuarial opinion that are to be submitted in accordance with RSA 400-A:36, and for memoranda in support thereof.

History

#9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2402.02 Applicability and Scope {#sec-ins-2402.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2402.02}

This part shall apply to every property and casualty insurance company doing business in this state, unless otherwise exempted by the domiciliary commissioner.

History

#9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2402.03 Statement of Actuarial Opinion {#sec-ins-2402.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2402.03}

Every property and casualty insurance company doing business in this state, unless otherwise exempted by the domiciliary commissioner, shall:

(a) Annually submit the opinion of an appointed actuary entitled "statement of actuarial opinion"; and

(b) File the opinion in accordance with the appropriate NAIC property and casualty annual statement instructions.

History

#9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2402.04 Actuarial Opinion Summary {#sec-ins-2402.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2402.04}

(a) Every property and casualty insurance company domiciled in this state that is required to submit a statement of actuarial opinion shall:

(1) Annually submit an actuarial opinion summary, written by the company's appointed actuary;

(2) File the opinion summary in accordance with the appropriate NAIC property and casualty annual statement instructions; and

(3) Consider the opinion summary as a document supporting the actuarial opinion required in Ins 2402.03.

(b) A company licensed but not domiciled in this state shall provide the actuarial opinion summary upon request.

History

#9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2402.05 Actuarial Report and Workpapers {#sec-ins-2402.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2402.05}

(a) An actuarial report and underlying workpapers as required by the appropriate NAIC property and casualty annual statement instructions shall be prepared to support each actuarial opinion.

(b) If the insurance company fails to provide a supporting actuarial report or workpapers at the request of the commissioner or the commissioner determines that the supporting actuarial report or workpapers provided by the insurance company is otherwise unacceptable to the commissioner, the commissioner may engage a qualified actuary at the expense of the company to review the opinion and the basis for the opinion and prepare the supporting actuarial report or workpapers.

(c) The appointed actuary shall not be liable for damages to any person, other than the insurance company and the commissioner, for any act, error, omission, decision, or conduct with respect to the actuary's opinion, except in cases of fraud or willful misconduct on the part of the appointed actuary.

History

#9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2402.06 Confidentiality {#sec-ins-2402.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2402.06}

(a) The statement of actuarial opinion shall be provided with the annual statement in accordance with the appropriate NAIC property and casualty annual statement instructions and shall be treated as a public document.

(b) Documents, materials or other information in the possession or control of the department that are considered an actuarial report, workpapers, or actuarial opinion summary provided in support of the opinion, and any other material provided by the company to the commissioner in connection with the actuarial report, workpapers, or actuarial opinion summary, shall be confidential by law and privileged, shall not be subject to RSA 91-A, shall not be subject to subpoena, and shall not be subject to discovery or admissible in evidence in any private civil action.

(c) The provisions of Ins 2402.06 shall not be construed to limit the commissioner's authority to release the documents to the actuarial board for counseling and discipline (ABCD) so long as the material is required for the purpose of professional disciplinary proceedings and that the ABCD establishes procedures satisfactory to the commissioner for preserving the confidentiality of the documents, nor shall this section be construed to limit the commissioner's authority to use the documents, materials, or other information in furtherance of any regulatory or legal action brought as part of the commissioner's official duties.

(d) Neither the commissioner nor any person who received documents, materials, or other information while acting under the authority of the commissioner shall be permitted or required to testify in any private civil action concerning any confidential documents, materials, or information subject to (b) and (c).

(e) In order to assist in the performance of the commissioner's duties, the commissioner:

(1) May share documents, materials, or other information, including the confidential and privileged documents, materials, or information subject to (b) and (c) above, with other state, federal, and international regulatory agencies, with the National Association of Insurance Commissioners and its affiliates and subsidiaries, and with state, federal, and international law enforcement authorities, provided that the recipient agrees to maintain the confidentiality and privileged status of the document, material, or other information and has the legal authority to maintain confidentiality;

(2) May receive documents, materials, or information, including otherwise confidential and privileged documents, materials, or information, from the National Association of Insurance Commissioners and its affiliates and subsidiaries, and from regulatory and law enforcement officials of other foreign or domestic jurisdictions, and shall maintain as confidential or privileged any document, material, or information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the document, material, or information; and

(3) May enter into agreements governing sharing and use of information consistent with (b), (c), and (e).

(f) No waiver of any applicable privilege or claim of confidentiality in the documents, materials, or information shall occur as a result of disclosure to the commissioner under this section or as a result of sharing as authorized in (e).

History

#9892, eff 4-1-11; ss by #12705, eff 4-1-19

N.H. Code Admin. R. Ann. Ins 2402.07 Waiver of Rules {#sec-ins-2402.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2402.07}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX

Rule

Specific State Statute Which the Rule Implements

Ins 2401.01

RSA 400-A:15 I; RSA 410

Ins 2401.029

RSA 400-A:15 I; RSA 410

Ins 2401.03

RSA 400-A:15 I; RSA 410:2

Ins 2401.04

RSA 400-A:15 I; RSA 410

Ins 2401.05

RSA 400-A:15 I; RSA 410

Ins 2401.06

RSA 400-A:15 I; RSA 410

Ins 2401.07

RSA 400-A:15 I; RSA 541-A:22, IV

Ins 2402.01

RSA 400-A:15 I; RSA 400-A:36

Ins 2402.02

RSA 400-A:15 I; RSA 400-A:36

Ins 2402.03

RSA 400-A:15 I; RSA 400-A:36

Ins 2402.04

RSA 400-A:15 I; RSA 400-A:36

Ins 2402.05

RSA 400-A:15 I; RSA 400-A:36

Ins 2402.06

RSA 400-A:15 I; RSA 400-A:36

Ins 2402.07

RSA 400-A:15 I; RSA 541-A:22, IV

History

#12705, eff 4-1-19

Chapter Ins 2600 Advertisements of Insurance

Part Ins 2601 Advertisements of Accident and Health Insurance

N.H. Code Admin. R. Ann. Ins 2601.01 Purpose {#sec-ins-2601.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.01}

The purpose of the advertisements of accident and health insurance part is to establish minimum criteria to assure proper and accurate description and to protect prospective purchasers with respect to the advertisement of accident and health insurance in the same manner as the rule governing advertisements of Medicare supplement insurance. This part assures the clear and truthful disclosure of the benefits, limitations and exclusions of policies sold as accident and health insurance by the establishment of standards of conduct in the advertising of accident and health insurance in a manner that prevents unfair, deceptive and misleading advertising and is conducive to accurate presentation and description to the insurance-buying public through the advertising media and material used by insurance agents and companies.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #6971, eff 4-1-99, EXPIRED: 4-1-07
#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.02 Applicability {#sec-ins-2601.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.02}

(a) This part shall apply to individual and group accident and health insurance (except Medicare supplement insurance or any other insurance that is covered by a separate state statute) "advertisement," as that term is defined in Ins 2601.03 (b), (g), (h) and (i) unless otherwise specified in this part, which the insurer knows or reasonably should know is intended for presentation, distribution or dissemination in this state when the presentation, distribution or dissemination is made either directly or indirectly by or on behalf of an insurer or producer, as those terms are defined in Title XXXVII.

(b) Every insurer shall establish and at all times maintain a system of control over the content, form and method of dissemination of all advertisements of its policies. All of the insurer's advertisements, regardless of by whom written, created, designed or presented, shall be the responsibility of the insurer whose policies are advertised.

(c) Advertising materials that are reproduced in quantity shall be identified by form numbers or other identifying means. The identification shall be sufficient to distinguish an advertisement from any other advertising materials, policies, applications or other materials used by the insurer.

History

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #6971, eff 4-1-99, EXPIRED: 4-1-07
#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.03 Definitions {#sec-ins-2601.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.03}

(a)(1) "Accident and health insurance policy" means a policy, plan, certificate, contract, agreement, statement of coverage, rider or endorsement that provides accident or health benefits or medical, surgical or hospital benefits, whether on an indemnity, reimbursements, service or prepaid basis, except when issued in connection with another kind of insurance other than life and except disability, waiver of premium and double indemnity benefits included in life insurance and annuity contracts. An accident and health insurance policy does not include a Medicare supplement policy, or any other type of accident and health insurance with advertising guidelines covered by a separate statute or rule.

(2) The language "except disability, waiver of premium and double indemnity benefits included in life insurance and annuity contracts" means it does not include disability, waiver of premium or double indemnity benefits included in life insurance, endowment or annuity contracts or contracts supplemental to the above contracts that contain only provisions that:

a. Provide additional benefits in case of death or dismemberment or loss of sight by accident; or

b. Operate to safeguard the contracts against lapse or to give a special surrender value, special benefit or an annuity in the event that the insured or annuitant shall become totally and permanently disabled as defined by the contract or supplemental contract.

(b)(1) "Advertisement" means:

a. Printed and published material, audio visual material, and descriptive literature of an insurer used in direct mail, newspapers, magazines, radio scripts, TV scripts, websites and other Internet displays or communications, other forms of electronic communications, billboards and similar displays;

b. Descriptive literature and sales aids of all kinds issued by a producer for presentation to members of the insurance-buying public, such as circulars, leaflets, booklets, depictions, illustrations, form letters and lead-generating devices of all kinds; and

c. Prepared sales talks, presentations and material for use by producers whether prepared by the insurer or the producer.

(2) The definition of "advertisement" includes advertising material included with a policy when the policy is delivered and material used in the solicitation of renewals and reinstatements.

(3) The definition of advertisement extends to the use of all media for communications to the general public, to the use of all media for communications to specific members of the general public, and to the use of all media for communications by producers.

(4) The definition of advertisement does not include:

a. Material used solely for the training and education of an insurer's employees and producers;

b. Material used in-house by insurers;

c. Communications within an insurer's own organization not intended for dissemination to the public;

d. Individual communications of a personal nature with current policyholders other than material urging the policyholders to increase or expand coverages;

e. Correspondence between a prospective group or blanket policyholder and an insurer in the course of negotiating a group or blanket contract;

f. Court-approved material ordered by a court to be disseminated to policyholders; or

g. A general announcement from a group or blanket policyholder to eligible individuals on an employment or membership list that a contract or program has been written or arranged; provided that the announcement clearly indicates that it is preliminary to the issuance of a booklet and that the announcement does not describe the specific benefits under the contract or program nor describe advantages as to the purchase of the contract or program. This does not prohibit a general endorsement of the program by the sponsor.

(c) "Certificate" means a statement of the coverage and provisions of a policy of group accident and sickness insurance, which has been delivered or issued for delivery in this state and includes riders, endorsements and enrollment forms, if attached.

(d) "Exception" means any provision in a policy whereby coverage for a specified hazard is entirely eliminated; it is a statement of a risk not assumed under the policy.

(e) "Insurer" means an individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyds, fraternal benefits society, health maintenance organization, hospital service corporation, medical service corporation, prepaid health plan and any other legal entity that is defined as an insurer under Title XXXVII, and is engaged in the advertisement of itself or an accident and health insurance policy.

(f) "Institutional advertisement" means an advertisement having as its sole purpose the promotion of the reader's, viewer's or listener's interest in the concept of accident and health insurance, or the promotion of the insurer as a seller of accident and health insurance.

(g) "Invitation to contract" means an advertisement that is neither an invitation to inquire nor an institutional advertisement.

(h) "Invitation to inquire" means:

(1) An advertisement having as its objective the creation of a desire to inquire further about accident and health insurance and that is limited to a brief description of the loss for which benefits are payable but may contain:

a. The dollar amount of benefits payable; and

b. The period of time during which benefits are payable.

(2) An invitation to inquire may not refer to cost.

(3) An invitation to inquire shall contain a provision in the following or substantially similar form:

"This policy has [exclusions] [limitations] [reduction of benefits] [terms under which the policy may be continued in force or discontinued]. For costs and complete details of the coverage, call [or write] your insurance producer or the company [whichever is applicable]."

(i) "Lead-generating device" means any communication directed to the public that, regardless of the form, content or stated purpose, is intended to result in the compilation or qualification of a list containing names and other personal information to be used to solicit residents of this State for the purchase of accident and health insurance.

(j) "Limitation" means a provision that restricts coverage under the policy other than an exception or a reduction.

(k) "Limited benefit health coverage" is health insurance that provides certain health related benefits, including income replacement coverage for certain health related events, that is not health coverage under RSA 420-G:2,IX.

(l) "Person" means a natural person, association, organization, partnership, trust, group, discretionary group, corporation or any other entity.

(m) "Prominently" or "conspicuously" means that the information to be disclosed prominently or conspicuously shall be presented in a manner that is noticeably set apart from other information or images in the advertisement.

(n) "Reduction" means a provision that reduces the amount of the benefit; a risk of loss is assumed but payment upon the occurrence of the loss is limited to some amount or period less than would be otherwise payable and the reduction has not been used.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.04 Method {#sec-ins-2601.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.04}

of Disclosure of Required Information.

(a) All information, exceptions, limitations, reductions and other restrictions required to be disclosed by this part shall be set out conspicuously and in close conjunction to the statements to which the information relates or under appropriate captions of such prominence that it shall not be minimized, rendered obscure or presented in an ambiguous fashion or intermingled with the context of the advertisements so as to be confusing or misleading. This part permits, but is not limited to, the use of either the following methods of disclosure:

(1) Disclosure in the description of the related benefits or in a paragraph set out in close conjunction with the description of the policy benefits; or

(2) Disclosure not in conjunction with the provisions describing policy benefits but under appropriate captions of such prominence that the information shall not be minimized, rendered obscure or otherwise made to appear unimportant. The phrase "under appropriate captions" means that the title shall be accurately descriptive of the captioned material. Appropriate captions include the following: "Exceptions," "Exclusions," "Conditions Not Covered," and "Exceptions and Reductions." The use of captions such as the following are prohibited because they do not provide adequate notice of the significance of the material: "Extent of Coverage," "Only these Exclusions," or "Minimum Limitations."

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.05 Form {#sec-ins-2601.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.05}

and Content of Advertisements.

(a) The format and content of an advertisement of an accident or health insurance policy shall be sufficiently complete and clear to avoid deception or the capacity or tendency to mislead or deceive. Format means the arrangement of the text and the captions.

(b) Distinctly different advertisements are required for publication in different media, such as newspapers or magazines of general circulation as compared to scholarly, technical or business journals and newspapers. Where an advertisement consists of more than one piece of material, each piece of material shall, independent of all other pieces of material, conform to the disclosure requirements of this part.

(c) Whether an advertisement has a capacity or tendency to mislead or deceive shall be determined by the commissioner from the overall impression that the advertisement may be reasonably expected to create within the segment of the public to which it is directed. Exceptions, reductions and limitations shall be in the same size and type as benefit features.

(d) Advertisements shall be truthful and not misleading in fact or in implication. Words or phrases, the meaning of which is clear only by implication or by familiarity with insurance terminology, shall not be used.

(e) An insurer shall clearly identify its accident and health insurance policy as an insurance policy. A policy trade name shall be followed by the words "insurance policy" or similar words clearly identifying the fact that an insurance policy or health benefits product (in the case of health maintenance organizations, prepaid health plans and other direct service organizations) is being offered.

(f) An insurer, producer or other person shall not solicit a resident of this state for the purchase of accident and health insurance in connection with or as the result of the use of advertisement by the person or any others persons, where the advertisement:

(1) Contains any misleading representations or misrepresentations, or is otherwise untrue, deceptive or misleading with regard to the information imparted, the status, character or representative capacity of the person or the true purpose of the advertisement; or

(2) Otherwise violates the provisions of this part.

(g) An insurer, producer or other person shall not solicit residents of this State for the purchase of accident and health insurance through the use of a true or fictitious name that is deceptive or misleading with regard to the status, character or proprietary or representative capacity of the person or the true purpose of the advertisement.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.06 Advertisements {#sec-ins-2601.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.06}

of Benefits Payable, Losses Covered or Premiums Payable.

(a) Covered benefits.

(1) The use of deceptive words, phrases or illustrations in advertisements of accident and health insurance is prohibited.

(2) An advertisement that fails to state clearly the type of insurance coverage being offered is prohibited.

(3) An advertisement shall not omit information or use words, phrases, statements, references or illustrations if the omission of information or use of words, phrases, statements, references or illustrations has the capacity, tendency or effect of misleading or deceiving purchases or prospective purchasers as to the nature or extent of any policy benefit payable, loss covered or premium payable. The fact that the policy offered is made available to a prospective insured for inspection prior to consummation of the sale or an offer is made to refund the premium if the purchaser is not satisfied, does not remedy misleading statements.

(4) An advertisement shall not contain or use words or phrases such as "all," "full," "complete," "comprehensive," "unlimited," "up to," "as high as," "this policy will help fill some of the gaps that Medicare and your present insurance leave out," "the policy will help to replace your income," (when used to express loss of time benefits), or similar words and phrases, in a manner that exaggerates a benefit beyond the terms of the policy.

(5) An advertisement of a hospital or other similar facility confinement benefit that makes reference to the benefit being paid directly to the policyholder is prohibited unless, in making the reference, the advertisement includes a statement that the benefits may be paid directly to the hospital or other health care facility if an assignment of benefits is made by the policyholder. An advertisement of medical and surgical expense benefits shall comply with this part in regard to the disclosure of assignments of benefits to providers of services. Phrases such as "you collect," "you get paid," "pays you," or other words or phrases of similar import may be used so long as the advertisement indicates that it is payable to the insured or someone designated by the insured.

(6) a. An advertisement for basic hospital expense coverage, basic medical-surgical expense coverage, basic hospital/medical-surgical expense coverage, hospital confinement indemnity coverage, accident only coverage, specified disease coverage, specified accident coverage or limited benefit health coverage or for coverage that covers only a certain type of loss is prohibited if:

The advertisement refers to a total benefit maximum limit payable under the policy in any headline, lead-in or caption without also in the same headline, lead-in or caption specifying the applicable daily limits and other internal limits;
The advertisement states a total benefit limit without stating the period benefit payment, if any, and the length of time the period benefit would be payable to reach the total benefit limit; or
The advertisement prominently displays a total benefit limit that would not, as a general rule, be payable under an average claim.

b. This paragraph does not apply to individual major medical expense coverage, individual basic medical expense coverage, or disability income insurance.

(7) Advertisements that emphasize total amounts payable under hospital, medical or surgical accident and health insurance coverage or other benefits in a policy, such as benefits for private duty nursing, are prohibited unless the actual amounts payable per day for the indemnity or benefits are stated.

(8) Advertisements that include examples of benefits payable under a policy shall not use examples in a way that implies that the maximum payable benefit payable under the policy will be paid, when less than maximum benefits are paid in an average claims.

(9) When a range of benefit levels is set forth in an advertisement, it shall be clear that the insured will receive only the benefit level written or printed in the policy selected and issued. Language that implies that the insured may select the benefit level at the time of filing claims is prohibited.

(10) Language in an advertisement that implies that the amount of benefits payable under a loss-of-time policy may be increased at the time of claim or disability according to the needs of the insured is prohibited.

(11) Advertisements for policies with premiums that are modest because of their limited coverage or limited amount of benefits shall not describe premiums as "low," "low cost," "budget" or use qualifying words of similar import. The use of words such as "only" and "just" in conjunction with statements of premium amounts when used to imply a bargain are prohibited.

(12) Advertisements that state or imply that premiums will not be changed in the future are prohibited unless the advertised policies expressly provide that the premiums will not be changed in the future.

(13) An advertisement for a policy that does not require the premium to accompany the application shall not overemphasize that fact and shall clearly indicate under what circumstances coverage will become effective.

(14) An advertisement that exaggerates the effects of statutorily mandated benefits or required policy provisions or that implies that the provisions are unique to the advertised policy is prohibited.

(15) An advertisement that implies that a common type of policy or a combination of common benefits is "new," "unique," "a bonus," "a breakthrough," or is otherwise unusual is prohibited. The addition of a novel method of premium payment to an otherwise common plan of insurance does not render it new.

(16) Language in an advertisement that states or implies that each member under a family contract is covered as to the maximum benefits advertised, where that is not the fact, is prohibited.

(17) An advertisement that contains statements such as "anyone can apply," or "anyone can join," other than with respect to a guaranteed issue policy for which administrative procedures exist to assure that the policy is issued within a reasonable period of time after the application is received by the insurer, is prohibited.

(18) An advertisement that states or implies immediate coverage of a policy is prohibited unless administrative procedures exist so that the policy is issued within 15 working days after the insurer receives the completed application.

(19) An advertisement that contains statements such as "here is all you do to apply," or "simply" or "merely" to refer to the act of applying for a policy that is not a guaranteed issue policy is prohibited unless it refers to the fact that the application is subject to acceptance or approval by the insurer.

(20) An advertisement of accident and health insurance sold by direct response shall not state or imply that because no insurance producer will call and no commissions will be paid to producers that it is a low cost plan, or use other similar words or phrases because the cost of advertising and servicing the policies is a substantial cost in the marketing by direct response.

(21) Applications, request forms for additional information and similar related materials are prohibited if they resemble paper currency, bonds, stock certificates, etc., or use any name, service mark, slogan, symbol or device in a manner that implies that the insurer or the policy advertised is connected with a government agency, such as the Social Security Administration or the Department of Health and Human Services.

(22) An advertisement that implies in any manner that the prospective insured may realize a profit from obtaining hospital, medical or surgical insurance coverage is prohibited.

(23) An advertisement that uses words such as "extra," "special" or "added" to describe a benefit in the policy is prohibited. No advertisement of a benefit for which payment is conditioned upon confinement in a hospital or similar facility shall use words or phrases such as "tax-free," "extra cash," "extra income," "extra pay," or substantially similar words or phrases because these words and phrases have the capacity, tendency or effect of misleading the public into believing that the policy advertised will, in some way, enable them to make a profit from being hospitalized.

(24) An advertisement of a hospital or other similar facility confinement benefit shall not advertise that the amount of the benefit is payable on a monthly or weekly basis when, in fact, the amount of the benefit payable is based upon a daily pro rata basis relating to the number of days of confinement unless the statements of the monthly or weekly benefit amounts are in juxtaposition with equally prominent statements of the benefit payable on a daily basis. The term "juxtaposition" means side by side or immediately above or below. When the policy contains a limit on the number of days of coverage provided, the limit shall appear in the advertisement.

(25) An advertisement of a policy covering only one disease or a list of specified diseases shall not imply coverage beyond the terms of the policy. Synonymous terms shall not be used to refer to any disease so as to imply broader coverage than is the fact.

(26) An advertisement that is an invitation to contract for a specified disease policy that provides lesser benefit amounts for a particular subtype of disease, shall clearly disclose the subtype and its benefits. This provision shall not apply to institutional advertisements.

(27) An advertisement of a specified disease policy providing expense benefits shall not use the term "actual" when the policy only pays up to a limited amount for expenses. Instead, the term "charges" or substantially similar language should be used that does not create the misleading impression that there is full coverage for expenses.

(28) An advertisement that describes any benefits that vary by age shall disclose that fact.

(29) An advertisement that uses a phrase such as "no age limit," if benefits or premiums vary by age or if age is an underwriting factor, shall disclose that fact.

(30) A television, radio, mail or newspaper advertisement or lead-generating device that is designed to produce leads either by use of a coupon, a request to write or to call the company or a subsequent advertisement prior to contact shall include information disclosing that a producer may contact the applicant.

(31) Advertisements, applications, requests for additional information and similar materials are prohibited if they state or imply that the recipient has been individually selected to be offered insurance or has had his or her eligibility for the insurance individually determined in advance when the advertisement is directed to all persons in a group or to all persons whose names appear on a mailing list.

(32) An advertisement, including invitations to inquire or invitations to contract, shall not employ devices that are designed to create undue fear or anxiety in the minds of those to whom they are directed. Examples of prohibited devices are:

a. The use of phrases such as "cancer kills somebody every two minutes" and "total number of accidents" without reference to the total population from which the statistics are drawn;

b. The exaggeration of the importance of diseases rarely or seldom found in the class of persons to whom the policy is offered;

c. The use of phrases such as "the finest kind of treatment," implying that the treatment would be unavailable without insurance;

d. The reproduction of newspaper articles, magazine articles, information from the Internet or other similar published material containing irrelevant facts and figures;

e. The use of images that unduly emphasize automobile accidents, disabled persons or persons confined in beds who are in obvious distress, persons receiving hospital or medical bills or persons being evicted from their homes due to their medical bills;

f. The use of phrases as "financial disaster," "financial distress," "financial shock," or another phrase implying that financial ruin is likely without insurance is only permissible in an advertisement for major medical expense coverage, individual basic medical expense coverage or disability income coverage, and only if the phrase does not dominate the advertisement;

g. The use of phrases or devices that unduly excite fear of dependence upon relatives or charity; and

h. The use of phrases or devices that imply that long sicknesses or hospital stays are common among the elderly.

(b) Exceptions, Reductions and Limitations.

(1) An advertisement shall not contain descriptions of policy limitations, exceptions or reductions, worded in a positive manner to imply that it is a benefit, such as describing a waiting period as a "benefit builder" or stating "even preexisting conditions are covered after two years." Words and phrases used in an advertisement to describe the policy limitations, exceptions and reductions shall fairly and accurately describe the negative features of the limitations, exceptions and reductions of the policy offered.

(2) An advertisement that is an invitation to contract shall disclose those exceptions, reductions and limitations affecting the basic provisions of the policy in the same size and type as benefit features.

(3) When a policy contains a waiting, elimination, probationary or similar time period between the effective date of the policy and the effective date of coverage under the policy or at a time period between the date a loss occurs and the date benefits begin to accrue for the loss, an advertisement that is subject to the requirements of the preceding paragraph shall prominently disclose the existence of the periods.

(4) An advertisement shall not use the words "only," "just," "merely," "minimum," "necessary" or similar words or phrases to describe the applicability of any exceptions, reductions, limitations or exclusions such as: "This policy is subject to the following minimum exceptions and reductions."

(5) An advertisement that is an invitation to contract that fails to disclose the amount of any deductible or the percentage of any coinsurance factor is prohibited.

(6) An advertisement for loss-of-time coverage that is an invitation to contract that sets forth a range of amounts of benefit levels is prohibited unless it also states that eligibility for the benefits is based upon condition of health, income or other economic conditions, or other underwriting standards of the insurer if that is the fact.

(7) An advertisement that refers to "hospitalization for injury or sickness" omitting the word "covered" when the policy excludes certain sicknesses or injuries, or that refers to "whenever you are hospitalized," "when you go to the hospital" or "while you are confined in the hospital" omitting the phrase "for covered injury or sickness," if the policy excludes certain injuries or sickness, is prohibited. Continued reference to "covered injury or sickness" is not necessary where this fact has been prominently disclosed in the advertisement and where the description of sicknesses or injuries not covered is prominently set forth.

(8) An advertisement that fails to disclose that the definition of "hospital" does not include certain facilities that provide institutional care such as a nursing home, convalescent home or extended care facility, when the facilities are excluded under the definition of hospital in the policy, is prohibited.

(9) An advertisement that fails to disclose any waiting or elimination periods for specific benefits is prohibited.

(10) An advertisement for a policy providing benefits for specified illnesses only, such as cancer, or for specified accidents only, such as automobile accidents, or other policies providing benefits that are limited in nature, shall clearly and conspicuously in prominent type state the limited nature of the policy. The statement shall be worded in language identical to or substantially similar to the following: "THIS IS A LIMITED POLICY," "THIS POLICY PROVIDES LIMITED BENEFITS," "THIS IS A CANCER ONLY POLICY," or "THIS IS AN AUTOMOBILE ACCIDENT ONLY POLICY."

(1) An advertisement that is an invitation to contract shall, in negative terms, disclose the extent to which any loss is not covered if the cause of the loss is traceable to a condition existing prior to the effective date of the policy. The use of the term "preexisting condition" without an appropriate definition or description shall not be used.

(2) When an accident and health insurance policy does not cover losses resulting from preexisting conditions, an advertisement of the policy shall not state or imply that the applicant's physical condition or medical history will not affect the issuance of the policy or payment of a claim under the policy. This part prohibits the use of the phrase "no medical examination required" and phrases of similar import, but does not prohibit explaining "automatic issue." If an insurer requires a medical examination for a specified policy, the advertisement if it is an invitation to contract shall disclose that a medical examination is required.

(3) When an advertisement contains an application form to be completed by the applicant and returned by mail, the application form shall contain a question or statement that reflects the preexisting condition provisions of the policy immediately preceding the blank space for the applicant's signature. For example, the application form shall contain a question or statement substantially as follows:

"Do you understand that this policy will not pay benefits during the first [insert number] [years, months] after the issue date for a disease or physical condition that you now have or have had in the past? YES"

Or substantially the following statement:

"I understand that the policy applied for will not pay benefits for any loss incurred during the first [insert number] [years, months] after the issue date on account of disease or physical condition that I now have or have had in the past."

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.07 Necessity {#sec-ins-2601.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.07}

for Disclosing Policy Provisions Relating to Renewability, Cancellability and Termination.

(a) An advertisement that is an invitation to contract shall disclose the provisions relating to renewability, cancellability and termination and any modification of benefits, losses covered, or premiums because of age or for other reasons, in a manner that shall not minimize or render obscure the qualifying conditions.

(b) Advertisements of cancellable accident and health insurance policies shall state that the contract is cancellable or renewable at the option of the company, as the case may be, in language substantially similar to the following: A policy that is renewable at the option of the insurance company shall be advertised in a manner similar to, "This policy is renewable at the option of the company," or "The company has the right to refuse renewal of this policy," or "Renewable at the option of the insurer," or "This policy can be cancelled by the company at any time."

(c) Advertisements of insurance policies that are guaranteed renewable, cancelable or renewable at the option of the company shall disclose that the insurer has the right to increase premium rates if the policy so provides.

(d) Qualifying conditions that constitute limitations on the permanent nature of the coverage shall be disclosed in advertisements of insurance policies that are guaranteed renewable, cancelable or renewable at the option of the company. Examples of qualifying conditions are:

(1) Age limits;

(2) Reservation of a right to increase premiums; and

(3) The establishment of aggregate limits.

a. Provisions for reduction of benefits at stated ages shall be set forth. For example, a policy may contain a provision that reduces benefits 50 percent after age 60 although it is renewable to age 65. Such a reduction shall be set forth. Also, a provision for the elimination of certain hazards at any specific ages or after the policy has been in force for a specified time shall be set forth.

b. An advertisement for a policy that provides for step-rated premium rates based upon the policy year or the insured's attained age shall disclose the rate increases and the times or ages at which the premiums increase.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.08 Standards {#sec-ins-2601.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.08}

for Marketing.

(a) An insurer, directly or through its producers, shall:

(1) Establish marketing procedures to assure that any comparison of policies by its producers will be fair and accurate;

(2) Establish marketing procedures assuring excessive insurance is not sold or issued, except this requirement does not apply to group major medical expense coverage and disability income coverage; and

(3) Establish auditable procedures for verifying compliance with this subsection.

(b) In addition to the practices prohibited in RSA 417, the following acts and practices are prohibited:

(1) Twisting. Knowingly making any misleading representation or incomplete or fraudulent comparison of insurance policies or insurers for the purpose of inducing, or tending to induce, a person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert an insurance policy, or to take out a policy of insurance with another insurer;

(2) High Pressure Tactics. Employing a method of marketing that has the effect of inducing the purchase of insurance, or tends to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance; and

(3) Cold Lead Advertising. Making use directly or indirectly of any method of marketing that fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.09 Testimonials {#sec-ins-2601.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.09}

or Endorsements by Third Parties.

(a) Testimonials and endorsements used in advertisements shall be genuine, represent the current opinion of the author, be applicable to the policy advertised and be accurately reproduced. The insurer, in using a testimonial or endorsement, makes as its own all of the statements contained in it, and the advertisement, including the statement, is subject to all the provisions of this part. When a testimonial or endorsement is used more than one year after it was originally given, a confirmation shall be obtained.

(b) A person shall be deemed a "spokesperson" if the person making the testimonial or endorsement:

(1) Has a financial interest in the insurer or a related entity as a stockholder, director, officer, employee or otherwise;

(2) Has been formed by the insurer, is owned or controlled by the insurer, its employees, or the person or persons who own or control the insurer;

(3) Has any person in a policy-making position who is affiliated with the insurer in any of the above described capacities; or

(4) Is in any way directly or indirectly compensated for making a testimonial or endorsement.

(c) The fact of a financial interest or the proprietary or representative capacity of a spokesperson shall be disclosed in an advertisement and shall be accomplished in the introductory portion of the testimonial or endorsement in the same form and with equal prominence. If a spokesperson is directly or indirectly compensated for making a testimonial or endorsement, the fact shall be disclosed in the advertisement by language substantially as follows: "Paid Endorsement." The requirement of this disclosure may be fulfilled by use of the phrase "Paid Endorsement" or words of similar import in a type style and size at least equal to that used for the spokesperson's name or the body of the testimonial or endorsement, whichever is larger. In the case of television or radio advertising, the required disclosure shall be accomplished in the introductory portion of the advertisement and shall be given prominence.

(d) The disclosure requirements of this regulation shall not apply where the sole financial interest or compensation of a spokesperson, for all testimonials or endorsements made on behalf of the insurer, consists of the payment of union scale wages required by union rules, and if the payment is actually the scale for TV or radio performances.

(e) An advertisement shall not state or imply that an insurer or an accident and health insurance policy has been approved or endorsed by any individual, group of individuals, society, association or other organizations, unless that is the fact, and unless any proprietary relationship between an organization and the insurer is disclosed. If the entity making the endorsement or testimonial has been formed by the insurer or is owned or controlled by the insurer or the person or persons who own or control the insurer, the fact shall be disclosed in the advertisement. If the insurer or an officer of the insurer formed or controls the association, or holds any policymaking position in the association, that fact shall be disclosed.

(f) When a testimonial refers to benefits received under an accident and health insurance policy, the specific claim data, including claim number, date of loss and other pertinent information shall be retained by the insurer for inspection for the period required under RSA 400-B or until the filing of the next regular report of examination of the insurer, whichever is the longer period of time. The use of testimonials that do not correctly reflect the present practices of the insurer or that are not applicable to the policy or benefit being advertised is not permissible.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.10 Use {#sec-ins-2601.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.10}

of Statistics.

(a) An advertisement relating to the dollar amounts of claims paid, the number of persons insured, or similar statistical information relating to an insurer or policy shall not use irrelevant facts, and shall not be used unless it accurately reflects all of the current and relevant facts. The advertisement shall not imply that the statistics are derived from the policy advertised unless that is the fact, and when applicable to other policies or plans shall specifically so state.

(1) An advertisement shall specifically identify the accident and health insurance policy to which statistics relate and where statistics are given that are applicable to a different policy, it shall be stated clearly that the data do not relate to the policy being advertised.

(2) An advertisement using statistics that describe an insurer, such as assets, corporate structure, financial standing, age, product lines or relative position in the insurance business, may be irrelevant and, if used at all, shall be used with extreme caution because of the potential for misleading the public. As a specific example, an advertisement for accident and health insurance that refers to the amount of life insurance which the company has in force or the amounts paid out in life insurance benefits is not permissible unless the advertisement clearly indicates the amount paid out for each line of insurance.

(b) An advertisement shall not represent or imply that claim settlements by the insurer are "liberal" or "generous," or use words of similar import, or that claim settlements are or will be beyond the actual terms of the contract. An unusual amount paid for a unique claim for the policy advertised is misleading and shall not be used.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.11 Identification {#sec-ins-2601.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.11}

of Plan or Number of Policies.

(a) An advertisement that uses the word "plan" without prominently identifying it as an accident and sickness insurance policy is prohibited.

(b) When a choice of the amount of benefits is referred to, an advertisement that is an invitation to contract shall disclose that the amount of benefits provided depends upon the plan selected and that the premium will vary with the amount of the benefits selected.

(c) When an advertisement that is an invitation to contract refers to various benefits that may be contained in 2 or more policies, other than group master policies, the advertisement shall disclose that the benefits are provided only through a combination of policies.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.12 Disparaging {#sec-ins-2601.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.12}

Comparisons and Statements. An advertisement shall not directly or indirectly make unfair or incomplete comparisons of policies or benefits or comparisons or non-comparable policies of other insurers, and shall not disparage competitors, their policies, services or business methods, and shall not disparage or unfairly minimize competing methods of marketing insurance.

(a) An advertisement shall not contain statements such as "no red tape" or "here is all you do to receive benefits."

(b) Advertisements that state or imply that competing insurance coverages customarily contain certain exceptions, reductions or limitations not contained in the advertised policies are prohibited unless the exceptions, reductions or limitations are contained in a substantial majority of the competing coverages.

(c) Advertisements that state or imply that an insurer's premiums are lower or that its loss ratios are higher because its organizational structure differs from that of competing insurers are prohibited.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.13 Jurisdictional {#sec-ins-2601.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.13}

Licensing and Status of Insurer.

(a) An advertisement that is intended to be seen or heard beyond the limits of the jurisdiction in which the insurer is licensed shall not imply licensing beyond those limits.

(b) An advertisement shall not create the impression directly or indirectly that the insurer, its financial condition or status, or the payment of its claims, or the merits, desirability, or advisability of its policy forms or kinds or plans of insurance are approved, endorsed or accredited by any division or agency of this state or the federal government. Terms such as "official" or words of similar import, used to describe any policy or application form are prohibited because of the potential for deceiving or misleading the public.

(c) An advertisement shall not imply that approval, endorsement or accreditation of policy forms or advertising has been granted by any division or agency of the state or federal government. Approval of either policy forms or advertising shall not be used by an insurer to imply or state that a governmental agency has endorsed or recommended the insurer, its policies, advertising or its financial condition.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.14 Identity {#sec-ins-2601.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.14}

of Insurer.

(a) The name of the actual insurer shall be stated in all of its advertisements. The form number or numbers of the policy advertised shall be stated in an advertisement that is an invitation to contract. An advertisement shall not use a trade name, an insurance group designation, name of the parent company of the insurer, name of the particular division of the insurer, service mark, slogan, symbol or other device that without disclosing the name of the actual insurer, would have the capacity and tendency to mislead or deceive as to the true identity of the insurer.

(b) An advertisement shall not use any combination of words, symbols, or physical materials that by their content, phraseology, shape, color or other characteristics are so similar to combination of words, symbols or physical materials used by agencies of the federal government or of this state, or otherwise appear to be of such a nature that it tends to confuse or mislead prospective insureds into believing that the solicitation is in some manner connected with an agency of the municipal, state or federal government.

(c) Advertisements, envelopes or stationery that employ words, letters, initials, symbols or other devices that are similar to those used in governmental agencies or by other insurers are not permitted if they may lead the public to believe:

(1) That the advertised coverages are somehow provided by or are endorsed by the governmental agencies or the other insurers;

(2) That the advertiser is the same as is connected with or is endorsed by the governmental agencies or the other insurers.

(d) An advertisement shall not use the name of a state or political subdivision of a state in a policy name or description.

(e) An advertisement in the form of envelopes or stationery of any kind may not use any name, service mark, slogan, symbol or any device in a manner that implies that the insurer or the policy advertised, or that any producer who may call upon the consumer in response to the advertisement, is connected with a governmental agency, such as the Social Security Administration.

(f) An advertisement may not incorporate the word "Medicare" in the title of the plan or policy being advertised unless, whenever it appears, the word is qualified by language differentiating it from Medicare. The advertisement, however, shall not use the phrase "[ ] Medicare Department of the [ ] Insurance Company," or language of similar import.

(g) An advertisement may not imply that the reader may lose a right or privilege or benefit under federal, state or local law if he or she fails to respond to the advertisement.

(h) The use of letters, initials or symbols of the corporate name or trademark that would have the tendency or capacity to mislead or deceive the public as to the true identity of the insurer is prohibited unless the true, correct and complete name of the insurer is in close conjunction and in the same size type as the letters, initials or symbols of the corporate name or trademark.

(i) The use of the name of an agency or "Underwriters" or "Plan" in type, size and location so as to have the capacity and tendency to mislead or deceive as to the true identity of the insurer is prohibited.

(j) The use of an address so as to mislead or deceive as to true identity of the insurer, its location or licensing status is prohibited.

(k) An insurer shall not use, in the trade name of its insurance policy, any terminology or words so similar to the name of a governmental agency or governmental program as to have the tendency to confuse, deceive or mislead the prospective purchaser.

(l) Advertisements used by producers of an insurer shall have prior written approval of the insurer before they may be used.

(m) A producer who makes contact with a consumer, as a result of acquiring that consumer's name from a lead-generating device, shall disclose that fact in the initial contact with the consumer. A producer or insurer may not use names produced from lead-generating devices that do not comply with the requirements of this part.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.15 Group {#sec-ins-2601.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.15}

or Quasi-Group Implications.

(a) An advertisement of a particular policy shall not state or imply that prospective insureds become group or quasi-group members covered under a group policy, and as members, enjoy special rates or underwriting privileges, unless that is the fact.

(b) This part prohibits the solicitations of a particular class, such as governmental employees, by use of advertisements which state or imply that their occupational status entitles them to reduced rates on a group or other basis when, in fact, the policy being advertised is sold only on an individual basis at regular rates.

(c) Advertisements that indicate that a particular coverage or policy is exclusively for "preferred risks" or a particular segment of the population or that a particular segment of the population is an acceptable risk, when the distinctions are not maintained in the issuance of policies, are prohibited.

(d) An advertisement to join an association, trust or discretionary group that is also an invitation to contract for insurance coverage shall clearly disclose that the applicant will be purchasing both membership in the association, trust or discretionary group and insurance coverage. The insurer shall solicit insurance coverage on a separate and distinct application that requires a separate signature. The separate and distinct applications required need not be on separate documents or contained in a separate mailing. The insurance program shall be presented so as not to conceal the fact that the prospective members are purchasing insurance as well as applying for membership, if that is the case. Similarly, it is prohibited to use terms such as "enroll" or "join" to imply group or blanket insurance coverage when that is not the fact.

(e) Advertisements for group or franchise group plans that provide a common benefit or a common combination of benefits shall not imply that the insurance coverage is tailored or designed specifically for that group, unless that is the fact.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.16 Introductory {#sec-ins-2601.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.16}

, Initial or Special Offers.

(a)(1) An advertisement of an individual policy shall not directly or by implication represent that a contract or combination of contracts is an introductory, initial or special offer, or that applicants will receive substantial advantages not available at a later date, or that the offer is available only to a specified group of individuals, unless that is the fact. An advertisement shall not contain phrases describing an enrollment period as "special," "limited," or similar words or phrases when the insurer uses the enrollment periods as the usual method of marketing accident and health insurance.

(2) This part prohibits any statement or implication to the effect that only a specific number of policies will be sold, or that a time is fixed for the discontinuance of the sale of the particular policy advertised because of special advantages available in the policy, unless that is the fact.

(b) An advertisement shall not offer a policy that utilizes a reduced initial premium rate in a manner that overemphasizes the availability and the amount of the initial reduced premium. When an insurer charges an initial premium that differs in amount from the amount of the renewal premium payable on the same mode, the advertisement shall not display the amount of the reduced initial premium either more frequently or more prominently than the renewal premium, and both the initial reduced premium and the renewal premium shall be stated in juxtaposition in each portion of the advertisement where the initial reduced premium appears.

(c) Special awards, such as a "safe drivers' award," shall not be used in connection with advertisements of accident and health insurance.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.17 Statements {#sec-ins-2601.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.17}

About an Insurer. An advertisement shall not contain statements that are untrue in fact, or by implication misleading, with respect to the assets, corporate structure, financial standing, age or relative position of the insurer in the insurance business. An advertisement shall not contain a recommendation by any commercial rating system unless it clearly indicates the purpose of the recommendation and the limitations of the scope and extent of the recommendations.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.18 Enforcement {#sec-ins-2601.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.18}

Procedures.

(a) Advertising File. Each insurer shall maintain at its home or principal office a complete file containing every printed, published or prepared advertisement of its individual policies and typical printed, published or prepared advertisements of its blanket, franchise and group policies hereafter disseminated in this or any other state, whether or not licensed in another state, with a notation attached to each advertisement that indicates the manner and extent of distribution and the form number of any policy advertised. The file shall be subject to regular and periodical inspection by the commissioner. All of these advertisements shall be maintained in a file for the period required pursuant to RSA 400-B or until the filing of the next regular report on examination of the insurer, whichever is the longer period of time.

(b) Certificate of Compliance. Each insurer required to file an annual statement shall file with the commissioner, with its annual statement, a certificate of compliance executed by an authorized officer of the insurer that states that, to the best of the officer's knowledge, information and belief, the advertisements that were disseminated by the insurer during the preceding statement year complied or were made to comply in all respects with the provisions of this part and the insurance laws of this state as implemented and interpreted by this part.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.19 Filing {#sec-ins-2601.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.19}

for Prior Review. The commissioner may, at his or her discretion, require filing of any accident and health insurance advertising material for review prior to use. The advertising material shall be filed by the insurer with the commissioner not less than 30 days prior to the date the insurer desires to use the advertisement.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2601.20 Penalties {#sec-ins-2601.20 omnilex-key=us-nh-regs-official--agency-ins--Ins 2601.20}

An insurer or its officers, directors, producers or employees that violate any of the provisions of this part, or knowingly participate in or abet such violation, shall be subject to the penalty provisions of RSA 400-A:15, III.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

Part Ins 2602 Advertisements of Life Insurance and Annuities

N.H. Code Admin. R. Ann. Ins 2602.01 Purpose {#sec-ins-2602.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.01}

The purpose of this part is to set forth minimum standards and guidelines to assure a full and truthful disclosure to the public of all material and relevant information in the advertising of life insurance policies and annuity contracts.

History

#6971, eff 4-1-99, EXPIRED: 4-1-07
#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.02 Applicability {#sec-ins-2602.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.02}

(a) This part shall apply to any life insurance or annuity advertisement intended for dissemination in this state. In variable contracts where disclosure requirements are established pursuant to federal regulation, this part shall be interpreted so as to eliminate conflict with federal regulations.

(b) All advertisements, regardless of by whom written, created, designed or presented, shall be the responsibility of the insurer, as well as the producer who created or presented the advertisement. Insurers shall establish and all times maintain a system of control over the content, form and method of dissemination of all advertisements of its policies. A system of control shall include regular and routine notification, at least once a year, to producers and others authorized by the insurer to disseminate advertisements of the requirement and procedures for company approval prior to the use of any advertisements that is not furnished by the insurer and that clearly sets forth within the notice the most serious consequence of not obtaining the required prior approval.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.03 Definitions {#sec-ins-2602.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.03}

For the purposes of this part:

(a)(1) "Advertisement" means material designed to create public interest in life insurance or annuities or in an insurer, or in an insurance producer; or to induce the public to purchase, increase, modify, reinstate, borrow on, surrender, replace or retain a policy including:

a. Printed and published material, audiovisual material and descriptive literature of an insurer or insurance producer used in direct mail, newspapers, magazines, radio and television scripts, billboards and similar displays, and the Internet or any other mass communication media;

b. Descriptive literature and sales aids of all kinds, authored by the insurer, its insurance producers, or third parties, issued, distributed or used by the insurer or insurance producer; including but not limited to circulars, leaflets, booklets, web pages, depictions, illustrations and form letters;

c. Material used for the recruitment, training and education of an insurer's insurance producers which is designed to be used or is used to induce the public to purchase, increase, modify, reinstate, borrow on, surrender, replace or retain a policy; and

d. Prepared sales talks, presentations and materials for use by insurance producers.

(2) "Advertisement" for the purposes of this part shall not include:

a. Communications or materials used within an insurer's own organization and not intended for dissemination to the public;

b. Communications with policyholders other than material urging policyholders to purchase, increase, modify, reinstate or retain a policy; and

c. A general announcement from a group or blanket policyholder to eligible individuals on an employment or membership list that a policy or program has been written or arranged; provided the announcement clearly indicates that it is preliminary to the issuance of a booklet explaining the proposed coverage.

(b) "Determinable policy elements" means elements that are derived from processes or methods that are guaranteed at issue and not subject to company discretion, but where the values or amounts cannot be determined until some point after issue. These elements include the premiums, credited interest rates (including any bonus), benefits, values, non-interest based credits, charges or elements of formulas used to determine any of these. These elements may be described as guaranteed but not determined at issue. An element is considered determinable if it was calculated from underlying determinable policy elements only, or from both determinable and guaranteed policy elements.

(c) "Guaranteed policy elements" means the premiums, benefits, values, credits or charges under a policy, or elements of formulas used to determine any of these that are guaranteed and determined at issue.

(d) "Insurance producer" means a person required to be licensed under RSA 402-J to sell, solicit or negotiate insurance, including annuities.

(e) "Insurer" means any individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyd's, fraternal benefit society, and any other legal entity which is defined as an "insurer" in Title XXXVII or issues life insurance or annuities in this state and is engaged in the advertisement of a policy.

(f) "Nonguaranteed elements" means the premiums, credited interest rates (including any bonus), benefits, values, non-interest based credits, charges or elements of formulas used to determine any of these, that are subject to company discretion and are not guaranteed at issue. An element is considered nonguaranteed if any of the underlying nonguaranteed elements are used in its calculation.

(g) "Policy" means any policy, plan, certificate, including a fraternal benefit certificate, contract, agreement, statement of coverage, rider or endorsement which provides for life insurance or annuity benefits.

(h) "Preneed funeral contract or prearrangement" means an arrangement by or for an individual before the individual's death relating to the purchase or provision of specific funeral or cemetery merchandise or services.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.04 Form {#sec-ins-2602.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.04}

and Content of Advertisements.

(a) Advertisements shall be truthful and not misleading in fact or by implication. The form and content of an advertisement of a policy shall be sufficiently complete and clear so as to avoid deception. It shall not have the capacity or tendency to mislead or deceive. Whether an advertisement has the capacity or tendency to mislead or deceive shall be determined by the commissioner from the overall impression that the advertisement may be reasonably expected to create upon a person of average education or intelligence within the segment of the public to which it is directed.

(b) No advertisement shall use the terms "investment," "investment plan," "founder's plan," "charter plan," "deposit," "expansion plan," "profit," "profits," "profit sharing," "interest plan," "savings," "savings plan," "private pension plan," "retirement plan" or other similar terms in connection with a policy in a context or under such circumstances or conditions as to have the capacity or tendency to mislead a purchaser or prospective purchaser of such policy to believe that he will receive, or that it is possible that he will receive, something other than a policy or some benefit not available to other persons of the same class and equal expectation of life.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.05 Disclosure {#sec-ins-2602.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.05}

Requirements.

(a) The information required to be disclosed by this part shall not be minimized, rendered obscure, or presented in an ambiguous fashion or intermingled with the text of the advertisement so as to be confusing or misleading.

(b) An advertisement shall not omit material information or use words, phrases, statements, references or illustrations if the omission or use has the capacity, tendency or effect of misleading or deceiving purchasers or prospective purchasers as to the nature or extent of any policy benefit payable, loss covered, premium payable, or state or federal tax consequences. The fact that the policy offered is made available to a prospective insured for inspection prior to consummation of the sale, or an offer is made to refund the premium if the purchaser is not satisfied or that the policy or contract includes a "free look" period that satisfies or exceeds regulatory requirements, does not remedy misleading statements.

(c) In the event an advertisement uses "non-medical," "no medical examination required," or similar terms where issue is not guaranteed, terms shall be accompanied by a further disclosure of equal prominence and in juxtaposition thereto to the effect that issuance of the policy may depend upon the answers to the health questions set forth in the application.

(d) An advertisement shall not use as the name or title of a life insurance policy any phrase that does not include the words "life insurance" unless accompanied by other language clearly indicating it is life insurance. An advertisement shall not use as the name or title of an annuity contract any phrase that does not include the word "annuity" unless accompanied by other language clearly indicating it is an annuity. An annuity advertisement shall not refer to an annuity as a CD annuity, or deceptively compare an annuity to a certificate of deposit.

(e) An advertisement shall prominently describe the type of policy advertised.

(f) An advertisement of an insurance policy marketed by direct response techniques shall not state or imply that because there is no insurance producer or commission involved there will be a cost saving to prospective purchasers unless that is the fact. No cost savings may be stated or implied without justification satisfactory to the commissioner prior to use.

(g) An advertisement for a life insurance policy containing graded or modified benefits shall prominently display any limitation of benefits. If the premium is level and coverage decreases or increases with age or duration, that fact shall be commonly disclosed. An advertisement of or for a life insurance policy under which the death benefit varies with the length of time the policy has been in force shall accurately describe and clearly call attention to the amount of minimum death benefit under the policy.

(h) An advertisement for the types of policies described in (f) and (g) above shall not use the words "inexpensive," "low cost," or other phrases or words of similar import when the policies being marketed are guaranteed issue.

(i) Premiums.

(1) An advertisement for a policy with non-level premiums shall prominently describe the premium changes.

(2) An advertisement in which the insurer describes a policy where it reserves the right to change the amount of the premium during the policy term, but which does not prominently describe this feature, is deemed to be deceptive and misleading and is prohibited.

(3) An advertisement shall not contain a statement or representation that premiums paid for a life insurance policy can be withdrawn under the terms of the policy. Reference may be made to amounts paid into an advance premium fund, which are intended to pay premiums at a future time, to the effect that they may be withdrawn under the conditions of the prepayment agreement. Reference may also be made to withdrawal rights under any unconditional premium refund offer.

(4) An advertisement that represents that a pure endowment benefit has a "profit" or "return" on the premium paid, rather than a policy benefit for which a specified premium is paid is deemed to be deceptive and misleading and is prohibited.

(5) An advertisement shall not represent in any way that premium payments will not be required for each year of the policy in order to maintain the illustrated death benefits, unless that is the fact.

(6) An advertisement shall not use the term "vanish" or "vanishing premium," or a similar term that implies the policy becomes paid up, to describe a plan using nonguaranteed elements to pay a portion of future premiums.

(j) Analogies between a life insurance policy or annuity contract's cash values and savings accounts or other investments and between premium payments and contributions to savings accounts or other investments shall be complete and accurate. An advertisement shall not emphasize the investment or tax features of a life insurance policy to such a degree that the advertisement would mislead the purchaser to believe the policy is anything other than life insurance.

(k) An advertisement shall not state or imply in any way that interest charged on a policy loan or the reduction of death benefits by the amount of outstanding policy loans is unfair, inequitable or in any manner an incorrect or improper practice.

(l) If nonforfeiture values are shown in any advertisement, the values shall be shown either for the entire amount of the basic life policy death benefit or for each $1,000 of initial death benefit.

(m) The words "free," "no cost," "without cost," "no additional cost," "at no extra cost," or words of similar import shall not be used with respect to any benefit or service being made available with a policy unless true. If there is no charge to the insured, then the identity of the payer shall be prominently disclosed. An advertisement may specify the charge for a benefit or a service or may state that a charge is included in the premium or use other appropriate language.

(n) No insurance producer may use terms such as "financial planner," "investment adviser," "financial consultant," or "financial counseling" in such a way as to imply that he or she is generally engaged in an advisory business in which compensation is unrelated to sales unless that actually is the case. This provision is not intended to preclude persons who hold some form of formal recognized financial planning or consultant designation from using this designation even when they are only selling insurance. This provision also is not intended to preclude persons who are members of a recognized trade or professional association having such terms as part of its name from citing membership, providing that a person citing membership, if authorized only to sell insurance products, shall disclose that fact. This provision does not permit persons to charge an additional fee for services that are customarily associated with the solicitation, negotiation or servicing of policies.

(o) Nonguaranteed Elements.

(1) An advertisement shall not utilize or describe nonguaranteed elements in a manner that is misleading or has the capacity or tendency to mislead.

(2) An advertisement shall not state or imply that the payment or amount of nonguaranteed elements is guaranteed. Unless otherwise specified in life illustrations, if nonguaranteed elements are illustrated, they shall be based on the insurer's current scale and the illustration shall contain a statement to the effect that they are not to be construed as guarantees or estimates of amounts to be paid in the future.

(3) Unless otherwise specified in life illustrations, an advertisement that includes any illustrations or statements containing or based upon nonguaranteed elements shall set forth, with equal prominence comparable illustrations or statements containing or based upon the guaranteed policy elements.

(4) An advertisement shall not use or describe determinable policy elements in a manner that is misleading or has the capacity or tendency to mislead.

(5) Advertisement may describe determinable policy elements as guaranteed but not determinable at issue. This description should include an explanation of how these elements operate, and their limitations, if any.

(6) If an advertisement refers to any nonguaranteed policy element, it shall indicate that the insurer reserves the right to change any such element at any time and for any reason. However, if an insurer has agreed to limit this right in any way; such as, for example, if it has agreed to change these elements only at certain intervals or only if there is a change in the insurer's current or anticipated experience, the advertisement may indicate any such limitation on the insurer's right.

(7) An advertisement shall not refer to dividends as "tax-free" or use words of similar import, unless the tax treatment of dividends is fully explained and the nature of the dividend as a return of premium is indicated clearly.

(8) An advertisement may not state or imply that illustrated dividends under either or both a participating policy or pure endowment will be or can be sufficient at any future time to assure without the future payment of premiums, the receipt of benefits, such as a paid-up policy, unless the advertisement clearly and precisely explains the benefits or coverage provided at that time and the conditions required for that to occur.

(p) An advertisement shall not state that a purchaser of a policy will share in or receive a stated percentage or portion of the earnings on the general account assets of the company.

(q) Testimonials, Appraisals, Analysis, or Endorsements by Third Parties.

(1) Testimonials, appraisals or analysis used in advertisements shall be genuine; represent the current opinion of the author; be applicable to the policy advertised, if any; and be accurately reproduced with sufficient completeness to avoid misleading or deceiving prospective insureds as to the nature or scope of the testimonial, appraisal, analysis or endorsement. In using testimonials, appraisals or analysis, the insurer or insurance producer makes as its own all the statements contained therein, and these statements are subject to all the provisions of this part.

(2) If the individual making a testimonial, appraisal, analysis or an endorsement has a financial interest in the insurer or related entity as a stockholder, director, officer, employee or otherwise, or receives any benefit directly or indirectly other than required union scale wages, that fact shall be prominently disclosed in the advertisement.

(3) An advertisement shall not state or imply that an insurer or a policy has been approved or endorsed by a group of individuals, society, association or other organization unless such is the fact and unless any proprietary relationship between an organization and the insurer is disclosed. If the entity making the endorsement or testimonial is owned, controlled or managed by the insurer, or receives any payment or other consideration from the insurer for making an endorsement or testimonial, that fact shall be disclosed in the advertisement.

(4) When an endorsement refers to benefits received under a policy for a specific claim, the claim date, including claim number, date of loss and other pertinent information shall be retained by the insurer for inspection for the period required pursuant to RSA 400-B after the discontinuance of its use or publication.

(r) An advertisement shall not contain statistical information relating to any insurer or policy unless it accurately reflects recent and relevant facts. The source of any statistics used in advertisement shall be identified.

(s) Policies Sold to Students.

(1) The envelope in which insurance solicitation material is contained may be addressed to the parents of students. The address may not include any combination of words which imply that the correspondence is from a school, college, university or other education or training institution nor may it imply that the institution has endorsed the material or supplied the insurer with information about the student unless such is a correct and truthful statement.

(2) All advertisements including, but not limited to, informational flyers used in the solicitation of insurance shall be identified clearly as coming from an insurer or insurance producer, if such is the case, and these entities shall be clearly identified as such.

(3) The return address on the envelope may not imply that the soliciting insurer or insurance producer is affiliated with a university, college, school or other educational or training institution, unless true.

(t) Introductory, Initial or Special Offers and Enrollment Periods.

(1) An advertisement of an individual policy or combination of policies shall not state or imply that the policy or combination of policies is an introductory, initial or special offer, or that applicants will receive substantial advantages not available at a later date, or that the offer is available only to a specified group of individuals, unless that is the fact. An advertisement shall not describe an enrollment period as "special" or "limited" or use similar words or phrases in describing it when the insurer uses successive enrollment periods as its usual method of marketing its policies.

(2) An advertisement shall not state or imply that only a specific number of policies will be sold, or that a time is fixed for the discontinuance of the sale of the particular policy advertised because of special advantages available in the policy.

(3) An advertisement shall not offer a policy that utilizes a reduced initial premium rate in a manner that overemphasizes the availability and the amount of the reduced initial premium. A reduced initial or first year premium may not be described as constituting free insurance for a period of time. When an insurer charges an initial premium that differs in amount from the amount of the renewal premium payable on the same mode, all references to the reduced initial premium shall be followed by an asterisk or other appropriate symbol that refers the reader to that specific portion of the advertisement that contains the full rate schedule for the policy being advertised.

(u) An advertisement of a particular policy shall not state or imply that prospective insureds shall be or become members of a special class, group, or quasi-group and as such enjoy special rates, dividends or underwriting privileges, unless that is the fact.

(v) An advertisement shall not make unfair or incomplete comparisons of policies, benefits, dividends or rates of other insurers. An advertisement shall not disparage other insurers, insurance producers, policies, services or methods of marketing.

(w) For individual deferred annuity products or deposit funds, the following shall apply:

(1) Any illustrations or statements containing or based upon nonguaranteed interest rates shall likewise set forth with equal prominence comparable illustrations or statements containing or based upon the guaranteed accumulation interest rates. The nonguaranteed interest rate shall not be greater than those currently being credited by the company unless the nonguaranteed rates have been publicly declared by the company with an effective date for new issues not more than 3 months subsequent to the date of declaration;

(2) If an advertisement states the net premium accumulation interest rate, whether guaranteed or not, it shall also disclose in close proximity thereto and with equal prominence, the actual relationship between the gross and the net premiums;

(3) If the contract does not provide a cash surrender benefit prior to commencement of payment of annuity benefits, an illustration or statement concerning the contract shall prominently state that cash surrender benefits are not provided; and

(4) Any illustrations, depictions or statements containing or based on determinable policy elements shall likewise set forth with equal prominence comparable illustrations, depictions or statements containing or based on guaranteed policy elements.

(x) An advertisement of a life insurance policy or annuity that illustrates nonguaranteed values shall only do so in accordance with current applicable state law relative to illustrating such values for life insurance policies and annuity contracts.

(y) An advertisement for the solicitation or sale of a preneed funeral contract or prearrangement as defined in Ins 2602.03 (h) that is funded or to be funded by a life insurance policy or annuity contract shall adequately disclose the following:

(1) The fact that a life insurance policy or annuity contract is being used to fund a prearrangement as defined in Ins 2602.03 (h); and

(2) The nature of the relationship among the soliciting agent or agents, the provider of the funeral or cemetery merchandise services, the administrator and any other person.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.06 Identity {#sec-ins-2602.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.06}

of Insurer.

(a) The name of the insurer shall be clearly identified in all advertisements about the insurer or its products, and if any specific individual policy is advertised it shall be identified either by form number or other appropriate description. If an application is a part of the advertisement, the name of the insurer shall be shown on the application. However, if an advertisement contains a listing of rates or features that is a composite of several different policies or contracts of different insurers, the advertisement shall so state, shall indicate, if applicable, that not all policies or contracts on which the composite is based may be available in all states, and shall provide a rating of the lowest rated insurer and reference the rating agency, but need not identify each insurer. If an advertisement identifies the issue insurers, insurance issuer ratings need not be stated.

(b) An advertisement shall not use a trade name, an insurance group designation, name of the parent company of the insurer, name of a particular division of the insurer, a reinsurer of the insurer, service mark, slogan, symbol or other device or reference without disclosing the name of the insurer, if the advertisement would have the capacity or tendency to mislead or deceive as to the true identity of the insurer or create the impression that a company other than the insurer would have any responsibility for the financial obligation under a policy.

(c) An advertisement shall not use any combination of words, symbols or physical materials that by their content, phraseology, shape, color or other characteristics are so similar to a combination of words, symbols or physical materials used by a governmental program or agency or otherwise appear to be of such a nature that they tend to mislead prospective insureds into believing that the solicitation is in some manner connected with a governmental program or agency.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.07 Jurisdictional {#sec-ins-2602.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.07}

Licensing and Status of Insurer.

(a) An advertisement that is intended to be seen or heard beyond the limits of the jurisdiction in which the insurer is licensed shall not imply licensing beyond those limits.

(b) An advertisement may state that an insurer or insurance producer is licensed in a particular state or states, provided it does not exaggerate that fact or suggest or imply that competing insurers or insurance producers may not be so licensed.

(c) An advertisement shall not create the impression that the insurer, its financial condition or status, the payment of its claims or the merits, desirability, or advisability of its policy forms or kinds of plans of insurance are recommended or endorsed by any governmental entity. However, where a governmental entity has recommended or endorsed a policy form or plan, that fact may be stated if the entity authorizes its recommendation or endorsement to be used in an advertisement.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.08 Statements {#sec-ins-2602.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.08}

About the Insurer. An advertisement shall not contain statements, pictures or illustrations that are false or misleading, in fact or by implication, with respect to the assets, liabilities, insurance in force, corporate structure, financial condition, age or relative position of the insurer in the insurance business. An advertisement shall not contain a recommendation by any commercial rating system unless it clearly defines the scope and extent of the recommendation including, but not limited to, the placement of insurer's rating in the hierarchy of the rating system cited.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.09 Enforcement {#sec-ins-2602.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.09}

Procedures.

(a) Each insurer shall maintain at its home or principal office a complete file containing a specimen of every printed, published or prepared advertisement of its individual policies and specimen copies of typical printed, published or prepared advertisements of its blanket, franchise and group policies, hereafter disseminated in this state, with a notation indicating the manner and extent of distribution and the form number of any policy advertised. The file shall be subject to inspection by the department. All advertisements shall be maintained in the file for the period required pursuant to RSA 400-B after discontinuance of its use or publication.

(b) If the commissioner determines that an advertisement has the capacity or tendency to mislead or deceive the public, the commissioner may require an insurer or insurance producer to submit all or any part of the advertising material for review or approval prior to use.

(c) Each insurer subject to the provisions of this part shall file with the commissioner with its annual statement a certificate of compliance executed by an authorized officer of the insurer stating that to the best of his or her knowledge, information and belief the advertisements that were disseminated by or on behalf of the insurer in this state during the preceding statement year, or during the portion of the year when these rules were in effect, complied or were made to comply in all respects with the provisions of these parts and the insurance laws of the state as implemented and interpreted by this part.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.10 Penalties {#sec-ins-2602.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.10}

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2602.11 Conflict {#sec-ins-2602.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2602.11}

With Other Laws or Rules. It is not intended that this part conflict with or supersede any rules currently in force or subsequently adopted in this state governing specific aspects of the sale or replacement of life insurance including, but not limited to, laws or rules dealing with life insurance cost comparison indices, deceptive practices in the sale of life insurance, replacement of life insurance policies, illustration of life insurance policies, and annuity disclosure. Consequently, no disclosure pursuant to or required under those rules shall be deemed to be an advertisement within the meaning of this part.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

Part Ins 2603 Advertisements of Medicare Supplement Insurance with Interpretive Guidelines

N.H. Code Admin. R. Ann. Ins 2603.01 Purpose {#sec-ins-2603.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.01}

The purpose of this part is to provide prospective buyers with clear and unambiguous statements in the advertisement of Medicare supplement insurance, to assure the clear and truthful disclosure of the benefits, limitations and exclusions of policies sold as Medicare supplement insurance. This purpose is intended to be accomplished by the establishment of guidelines and permissible and impermissible standards of conduct in the advertising of Medicare supplement insurance in a manner which prevents unfair, deceptive and misleading advertising and is conducive to accurate presentation and description to the insurance-buying public through the advertising media and material used by insurance producers and companies.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.02 Applicability {#sec-ins-2603.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.02}

(a) This part shall apply to any "advertisement" of Medicare supplement insurance as that term is defined herein, unless otherwise specified in this part, that the insurer knows or reasonably should know is intended for presentation, distribution or dissemination in this state when the presentation, distribution or dissemination is made either directly or indirectly by or on behalf of an insurer, agent, broker, producer or solicitor, as those terms are defined in Title XXXVII.

(b) Every insurer shall establish and at all times maintain a system of control over the content, form and method of dissemination of all of its Medicare supplement insurance advertisements. All such advertisements, regardless of by whom written, created, designed or presented, shall be the responsibility of the insurers benefiting directly or indirectly from their dissemination.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.03 Definitions {#sec-ins-2603.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.03}

(a)(1) " Advertisement" for the purpose of this part shall include:

a. Printed and published material, audio visual material and descriptive literature used by or on behalf of an insurer in direct mail, newspapers, magazines, radio scripts, TV scripts, billboards, internet displays and websites, and similar displays;

b. Descriptive literature and sales aids of all kinds issued by an insurer, agent, producer, broker or solicitor for presentation to members of the insurance-buying public; including, but not limited to, circulars, leaflets, booklets, depictions, illustrations, form letters and lead generating devices of all kinds as defined in this part; and

c. Prepared sales talks, presentations and material for use by agents, brokers, producers and solicitors, whether prepared by the insurer or the agent, broker, producer or solicitor.

(2) The definition of "advertisement" includes advertising material included with a policy when the policy is delivered and material used in the solicitation of renewals and reinstatements.

(3) The definition of "advertisement" does not include:

a. Material to be used solely for the training and education of an insurer's employees, agents or brokers;

b. Material used in-house by insurers;

c. Communications within an insurer's own organization not intended for dissemination to the public;

d. Individual communications of a personal nature with current policyholders other than material urging the policyholders to increase or expand coverages;

e. Correspondence between a prospective group or blanket policyholder and an insurer in the course of negotiating a group or blanket contract;

f. Court approved material ordered by a court to be disseminated to policyholders; or

(b) "Medicare supplement insurance" means a group or individual policy of accident and health insurance or a subscriber contract of hospital and medical service associations or health maintenance organizations that is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare by reason of age.

(c) "Certificate" means, for the purposes of this part, any certificate issued under a group Medicare supplement policy, which certificate has been delivered or issued for delivery in this state.

(d) "Insurer" means, for the purposes of this part, any individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyds, fraternal benefit society, health maintenance organization, hospital service corporation, medical service corporation, prepaid health plan and any other legal entity which is defined as an "insurer" in Title XXXVII and is engaged in the advertisement of itself, or Medicare supplement insurance.

(e) "Exception" means, for the purpose of this part, any provision in a policy whereby coverage for a specified hazard is entirely eliminated; it is a statement of a risk not assumed under the policy.

(f) "Reduction" means, for the purpose of this part, any provision that reduces the amount of the benefit; a risk of loss is assumed but payment upon the occurrence of the loss is limited to some amount or period less than would be otherwise payable had the reduction not been used.

(g) "Limitation" means, for the purposes of this part, any provision that restricts coverage under a policy other than an exception or a reduction.

(h) “Institutional advertisement” means, for purposes of this part, an advertisement having as its sole purpose the promotion of the reader’s, viewer’s, or listener’s interest in the concept of Medicare supplement insurance or the promotion of the insurer as a seller of Medicare supplement insurance.

(i) "Invitation to inquire" means, for the purposes of this part, an advertisement having as its objective the creation of a desire to inquire further about Medicare supplement insurance that is limited to a brief description of coverage, and that shall contain a provision in the following or substantially similar form:

"This policy has [exclusions] [limitations] [reductions of benefits] [terms under which the policy may be continued in force or discontinued]. For costs and complete details of the coverage, call [or write] your insurance agent or the company [whichever is applicable]."

(j) "Invitation to contract" means, for the purposes of this part, an advertisement that is neither an institutional advertisement nor an invitation to inquire.

(k) "Person" means, for the purposes of this part, a natural person, association, organization, partnership, trust, group, discretionary group, corporation or any other entity.

(l) "Medicare" means "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or Title I, art I of Public Law 89-97, as enacted by the Eighty-Ninth Congress of the United States of America, and popularly known as the "Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof," or words of similar import.

(m) "Lead-generating device" means, for the purposes of this part, any communication directed to the public that, regardless of form, content or stated purpose, is intended to result in the compilation or qualification of a list containing names and other personal information to be used to solicit residents of this state for the purchase of Medicare supplement insurance.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.04 Method {#sec-ins-2603.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.04}

of Disclosure of Required Information. All information required to be disclosed by this part shall be set out conspicuously and in close conjunction with the statements to which the information relates or under appropriate captions of such prominence that it shall not be minimized, rendered obscure or presented in an ambiguous manner or fashion or intermingled with the context of the advertisement so as to be confusing or misleading.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.05 Form {#sec-ins-2603.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.05}

and Content of Advertisements.

(a) The format and content of a Medicare supplement insurance advertisement shall be sufficiently complete and clear to avoid deception or the capacity or tendency to mislead or deceive. Whether an advertisement has a capacity or tendency to mislead or deceive shall be determined by the commissioner of insurance from the overall impression that the advertisement may be reasonably expected to create upon a person of average education or intelligence, within the segment of the public to which it is directed.

(b) Advertisements shall be truthful and not misleading in fact or in implication. Words or phrases whose meanings are clear only by implication or by the consumer's familiarity with insurance terminology shall not be used.

(c) An insurer shall clearly identify its Medicare supplement insurance policy as an insurance policy. A policy trade name shall be followed by the words..."Insurance Policy" or similar words clearly identifying the fact that an insurance policy or health benefits product (in the case of health maintenance organizations, prepaid health plans and other direct service organizations) is being offered.

(d) No insurer, agent, broker, producer, solicitor or other person shall solicit a resident of this state for the purchase of Medicare supplement insurance in connection with or as the result of the use of any advertisement by such person or any other person, where the advertisement:

(1) Contains any misleading representations or misrepresentations, or is otherwise untrue, deceptive or misleading with regard to the information imparted, the status, character or representative capacity of such person or the true purpose of the advertisement; or

(2) Otherwise violates the provisions of this part.

(b) No insurer, agent, broker, solicitor or other person shall solicit residents of this state for the purchase of Medicare supplement insurance through the use of a true or fictitious name that is deceptive or misleading with regard to the status, character, or proprietary or representative capacity of the person or the true purpose of the advertisement.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.06 Advertisements {#sec-ins-2603.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.06}

of Benefits, Losses Covered or Premiums Payable.

(a) Deceptive Words, Phrases or Illustrations Prohibited.

(1) No advertisement shall omit information or use words, phrases, statements, references or illustrations if the omission of the information or use of such words, phrases, statements, references or illustrations has the capacity, tendency or effect of misleading or deceiving purchasers or prospective purchasers as to the nature or extent of any policy benefit payable, loss covered or premium payable. The fact that the policy offered is made available to a prospective insured for inspection prior to consummation of the sale or an offer is made to refund the premium if the purchaser is not satisfied, does not remedy misleading statements.

(2) No advertisement shall contain or use words or phrases such as "all," "full," "complete," "comprehensive," "unlimited," "up to," "as high as," "this policy will help fill some of the gaps that Medicare and your present insurance leave out," "this policy pays all that Medicare doesn't" or similar words and phrases, in a manner which exaggerates any benefit beyond the terms of the policy.

(3) An advertisement that also is an invitation to join an association, trust or discretionary group shall solicit insurance coverage on a separate and distinct application that requires separate signature for each application. The separate and distinct application required for an advertisement which is also an invitation to join an association, trust or discretionary group need not be on a separate document or contained in a separate mailing. The insurance program shall be presented so as not to mislead or deceive the prospective members that they are purchasing insurance as well as applying for membership, if that is the case.

(4) An advertisement shall not contain descriptions of policy limitations, exceptions or reductions, worded in a positive manner to imply that is a benefit, such as describing a waiting period as a "benefit builder' or stating "even preexisting conditions are covered after 6 months." Words and phrases used in an advertisement to describe the policy limitations, exceptions and reductions shall fairly and accurately describe the negative features of the limitations, exceptions and reductions of the policy offered.

(5) An advertisement of Medicare supplement insurance sold by direct response shall not state or imply that "because no insurance agent will call and no commissions will be paid to 'agents' that is a low cost plan" or use other similar words or phrases because the cost of advertising and servicing the policies is a substantial cost in marketing by direct response.

(b) Exceptions, Reductions and Limitations.

(1) An advertisement that is an invitation to contract shall disclose those exceptions, reductions and limitations affecting the basic provisions of the policy.

(2) When a policy contains a waiting, elimination, probationary or similar time period between the effective date of the policy and the effective date of coverage under the policy or a time period between the date a loss occurs and the date benefits begin to accrue for the loss, an advertisement that is subject to the requirements of the preceding paragraph shall disclose the existence of these periods.

(3) An advertisement shall not use the words "only" "just," "merely," "minimum," or similar words or phrases to describe the applicability of any exceptions and reductions, such as "This policy is subject to the following minimum exceptions and reductions."

(2) When a Medicare supplement insurance policy does not cover losses resulting from preexisting conditions, no advertisement of the policy shall state or imply that the applicant's physical condition or medical history will not affect the issuance of the policy or payment of a claim under the policy. This part prohibits the use of the phrase "no medical examination required" and phrases of similar import, but does not prohibit explaining "automatic issue." If an insurer requires a medical examination for a specified policy, the advertisement shall disclose that a medical examination is required.

(3) When an advertisement contains an application form to be completed by the applicant and returned by mail, the application form shall contain a question or statement that reflects the preexisting condition provisions of the policy immediately preceding the blank space for the applicant's signature. For example, such an application form shall contain a question or statement substantially as follows:

Do you understand that this policy will not pay benefits during the first 6 months after the issue date for a disease or physical condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the policy issue date?

YES

Or substantially the following statement:

I understand that the policy applied for will not pay benefits for any loss incurred during the first 6 months after the issue date due to a disease or physical condition for which I received medical advice or for which treatment was recommended by or received from a physician within 6 months before the issue date.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.07 Necessity {#sec-ins-2603.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.07}

for Disclosing Policy Provisions Relating to Renewability, Cancellability and Termination. An advertisement that is an invitation to contract shall disclose the provisions relating to renewability, cancellability and termination and any modification of benefits, losses covered or premiums because of age or for other reasons, in a manner which shall not minimize or render obscure the qualifying conditions.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.08 Testimonials {#sec-ins-2603.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.08}

or Endorsements by Third Parties.

(a) Testimonials and endorsements used in advertisements shall be genuine, represent the current opinion of the author, be applicable to the policy advertised and be accurately reproduced. The insurer, in using a testimonial or endorsement, makes as its own all of the statements contained therein, and the advertisement, including the statement, is subject to all he provisions of this part. When a testimonial or endorsement is used more than one year after it was originally given, a confirmation shall be obtained.

(b) A person shall be deemed a "spokesperson" if the person making the testimonial or endorsement:

(1) Has a financial interest in the insurer or a related entity as a stockholder, director, officer, employee or otherwise;

(2) Has been formed by the insurer, is owned or controlled by the insurer, its employees, or the person or persons who own or control the insurer;

(3) Has any person in a policy-making position who is affiliated with the insurer in any of the above described capacities; or

(4) Is in any way directly or indirectly compensated for making a testimonial or endorsement.

(c) The fact of a financial interest or the proprietary or representative capacity of a spokesperson shall be disclosed in an advertisement and shall be accomplished in the introductory portion of the testimonial or endorsement in the same form and with equal prominence thereto. If a spokesperson is directly or indirectly compensated for making a testimonial or endorsement, that fact shall be disclosed in the advertisement by language substantially as follows: "Paid Endorsement." The requirement of this disclosure may be fulfilled by use of the phrase "Paid Endorsement" or words of similar import in a type style and size at least equal to that used for the spokesperson's name or the body of the testimonial or endorsement; whichever is larger. In the case of television or radio advertising, the required disclosure shall be accomplished in the introductory portion of the advertisement and shall be given prominence.

(d) The disclosure requirements of this part shall not apply where the sole financial interest or compensation of a spokesperson, for all testimonials or endorsements made on behalf of the insurer, consists of the payment of union scale wages required by union rules, and if the payment is actually for the scale for TV or radio performances.

(e) An advertisement shall not state or imply that an insurer or a Medicare supplement insurance policy has been approved or endorsed by any individual, group of individuals, society, association or other organization, unless such is the fact, and unless any proprietary relationship between an organization and the insurer is disclosed. If the entity making the endorsement or testimonial has been formed by the insurer or is owned or controlled by the insurer or the person or persons who own or control the insurer, that fact shall be disclosed in the advertisement. If the insurer or an officer of the insurer formed or controls the association, or holds any policymaking position in the association, that fact shall be disclosed.

(f) When a testimonial refers to benefits received under a Medicare supplement insurance policy, the specific claim data, including claim number, date of loss, and other pertinent information shall be retained by the insurer for inspection for a period of 4 years or until the filing of the next regular report of examination of the insurer, whichever is the longer period of time. The use of testimonials that do not correctly reflect the present practices of the insurer or that are not applicable to the policy or benefit being advertised is not permissible.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.09 Use {#sec-ins-2603.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.09}

of Statistics.

(a) An advertisement relating to the dollar amounts of claims paid, the number of persons insured, or similar statistical information relating to any insurer or policy shall not use irrelevant facts, and shall not be used unless it accurately reflects all of the relevant facts. Such an advertisement shall not imply that the statistics are derived from a policy advertised unless such is the fact, and when applicable to other policies or plans shall specifically so state.

(1) An advertisement shall specifically identify the Medicare supplement insurance policy to which statistics relate and, where statistics are given which are applicable to a different policy, it shall be stated clearly that the data do not relate to the policy being advertised.

(2) An advertisement using statistics that describe an insurer, such as assets, corporate structure, financial standing, age, product lines or relative position in the insurance business, may be irrelevant and, if used at all, shall be used with extreme caution because of the potential for misleading the public. As a specific example, an advertisement for Medicare supplement insurance that refers to the amount of life insurance that the company has in force or the amounts paid out in life insurance benefits is not permissible unless the advertisement clearly indicates the amount paid out for each line of insurance.

(b) An advertisement shall not represent or imply that claim settlements by the insurer are "liberal" or "generous," or use words of similar import, or state or imply that claim settlements are or will be beyond the actual terms of the contract. An unusual amount paid for a unique claim for the policy advertised is misleading and shall not be used.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.10 Disparage {#sec-ins-2603.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.10}

Comparisons and Statements. An advertisement shall not directly or indirectly make unfair or incomplete comparisons of non-comparable policies of other insurers, and shall not disparage competitors, their policies, services or business methods, and shall not disparage or unfairly minimize competing methods of marketing insurance.

(a) An advertisement shall not contain statements such as "no red tape" or "here is all you do to receive benefits."

(b) Advertisements that state or imply that competing insurance coverages customarily contain certain exceptions, reductions or limitations not contained in the advertised policies are unacceptable unless the exceptions, reductions or limitations are contained in a substantial majority of the competing coverages.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.11 Jurisdictional {#sec-ins-2603.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.11}

Licensing and Status of Insurer.

(a) An advertisement that is intended to be seen or heard beyond the limits of the jurisdiction in which the insurer is licensed shall not imply licensing beyond those limits.

(b) An advertisement shall not create the impression directly or indirectly that the insurer, its financial condition or status; or the payment of its claims; or the merits, desirability or advisability of its policy forms or kinds of plans of insurance are approved, endorsed or accredited by any division or agency of this state or the United States government.

(c) An advertisement shall not imply that approval, endorsement or accreditation of policy forms or advertising has been granted by any division or agency of this state or the federal government. "Approval" of either policy forms or advertising shall not be used by an insurer to imply or state that a governmental agency has endorsed or recommended the insurer, its policies, advertising or its financial conditions.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.12 Identity {#sec-ins-2603.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.12}

of Insurer.

(a) The name of the actual insurer shall be stated in all of its advertisements. The form number or numbers of the policy advertised shall be stated in an advertisement that is an invitation to contract. An advertisement shall not use a trade name, an insurance group designation, name of the parent company of the insurer, name of a particular division of the insurer, service mark, slogan, symbol or other device that with or without disclosing the name of the actual insurer would have the capacity and tendency to mislead or deceive as to the true identity of the insurer.

(b) No advertisement shall use any combination of words, symbols or physical materials that by their content, phraseology, shape, color or other characteristics are so similar to combinations of words, symbols or physical materials used by agencies of the federal government or of this state, or otherwise appear to be of such a nature that it tends to confuse or mislead prospective insureds into believing that the solicitation is in some manner connected with an agency of the municipal, state or federal government.

(c) Advertisements, envelopes or stationery that employ words, letters, initials, symbols or other devices that are so similar to those used by governmental agencies or other insurers are not permitted if they may lead the public to believe:

(1) That the advertised coverages are somehow provided by or are endorsed by the governmental agencies or the other insurers; or

(2) That the advertiser is the same as, is connected with or is endorsed by the governmental agencies or the other insurers.

(d) No advertisement shall use the name of a state or political subdivision thereof in a policy name or description.

(e) No advertisement in the form of envelopes or stationary of any kind may use any name, service mark, slogan, symbol or any device in such a manner that implies that the insurer or the policy advertised, or that any agent who may call upon the consumer in response to the advertisement is connected with a governmental agency, such as the Social Security Administration.

(f) No advertisement may incorporate the word "Medicare" in the title of the plan or policy being advertised unless, whenever it appears, the word is qualified by language differentiating it from Medicare. Such an advertisement, however shall not use the phrase "__________Medicare Department of the _______________Insurance Company," or language of similar import.

(g) No advertisement shall be used that fails to include the disclaimer to the effect of "Not Connected with or endorsed by the U.S. government or the federal Medicare program."

(h) No advertisement may imply that the reader may lose a right or privilege or benefit under federal, state or local law if he fails to respond to the advertisement.

(i) The use of letters, initials or symbols of the corporate name or trademark that would have the tendency or capacity to mislead or deceive the public as to the true identity of the insurer is prohibited unless the true, correct and complete name of the insurer is in close conjunction and in the same size type as the letters, initials or symbols of the corporate name or trademark.

(j) The use of the name of any agency or "Underwriters" or "___ Plan" in type, size and location so as to have the capacity and tendency to mislead or deceive as to the true identity of the insurer is prohibited.

(k) The use of an address so as to mislead or deceive as to the true identity of the insurer, its location or licensing status is prohibited.

(l) No insurer may use, in the trade name of its insurance policy, any terminology or words so similar to the name of a governmental agency or governmental program as to have the tendency to confuse, deceive or mislead the prospective purchaser.

(m) All advertisements used by agents, producers, brokers or solicitors of an insurer shall have prior written approval of the insurer before they may be used.

(n) An agent who makes contact with a consumer, as a result of acquiring that consumer's name from a lead generating device, shall disclose that fact in the initial contact with the consumer.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.13 Group {#sec-ins-2603.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.13}

or Quasi-Group Implications.

(a) An advertisement of a particular policy shall not state or imply that prospective insureds become group or quasi-group members covered under a group policy and as such enjoy special rates or underwriting privileges, unless that is the fact.

(b) This part prohibits the solicitation of a particular class, such as governmental employees, by use of advertisements that state or imply that their occupational status entitles them to reduced rates on a group or other basis when, in fact, the policy being advertised is sold only on an individual basis at regular rates.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.14 Introductory {#sec-ins-2603.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.14}

, Initial or Special Offers.

(a) (1) An advertisement of an individual policy shall not directly or by implication represent that a contract or combination of contracts is an introductory, initial or special offer, or that applicants will receive substantial advantages not available at a later date, or that the offer is available only to a specified group of individuals, unless such is the fact. An advertisement shall not contain phrases describing an enrollment period as "special," "limited," or similar words or phrases when the insurer uses such enrollment periods as the usual method of advertising Medicare supplement insurance.

(2) An enrollment period during which a particular insurance product may be purchased on an individual basis shall not be offered within this state unless there has been a lapse of not less than 6 months between the close of the immediately preceding enrollment period for the same product and the opening of the new enrollment period. The advertisement shall indicate the date by which the applicant shall mail the application, which shall be not less than 10 days and not more than 40 days from the date that the enrollment period is advertised for the first time. This part applies to all advertising media, i.e., mail, newspapers, radio, television, magazines, internet displays, and periodicals, by any one insurer. It is not applicable to solicitations of employees or members of a particular group or association that otherwise would be eligible under specific provisions of RSA 415. The phrase "any one insurer" includes all the affiliated companies of a group of insurance companies under common management or control.

(3) This part prohibits any statement or implication to the effect that only a specific number of policies will be sold, or that a time is fixed for the discontinuance of the sale of a particular policy advertised because of special advantages available in the policy, unless that is the fact.

(4) The phrase "a particular insurance product" in (2) of this subsection means an insurance policy that provides substantially different benefits than those contained in any other policy. Different terms of renewability, an increase or decrease in the dollar amounts of benefits, or an increase or decrease in any elimination period or waiting period from those available during an enrollment period for another policy shall not be sufficient to constitute the product being offered as a different product eligible for concurrent or overlapping enrollment periods.

(c) Special awards, such as a "safe driver’s award" shall not be used in connection with advertisements of Medicare supplement insurance.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.15 Statements {#sec-ins-2603.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.15}

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.16 Enforcement {#sec-ins-2603.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.16}

Procedures.

(a) Advertising File. Each insurer shall maintain at its home or principal office a complete file containing every printed, published or prepared advertisement of its individual policies and typical printed, published or prepared advertisements of its blanket, franchise and group policies hereafter disseminated in this or any other state, whether or not licensed in such other state, with a notation attached to each advertisement that shall indicate the manner and extent of distribution and the form number of any policy advertised. The file shall be available for inspection by this department. All such advertisements shall be maintained in the file for a period of either 4 years or until the filing of the next regular report of examination of the insurer, whichever is the longer period of time.

(b) Certificate of Compliance. Each insurer required to file an annual statement which is now or which hereafter becomes subject to the provisions of this part shall file with this department, with its annual statement, a certificate of compliance executed by an authorized officer of the insurer wherein it is stated that, to the best of his/her knowledge, information and belief, the advertisements that were disseminated by the insurer during the preceding statement year complied or were made to comply in all respects with the provisions of this part and the insurance laws of this state as implemented and interpreted by this part.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2603.17 Filing {#sec-ins-2603.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 2603.17}

for Prior Review. The commissioner may, at his or her discretion, require the filing with this department, for review prior to use, of any Medicare supplement insurance advertising material. The advertising material shall be filed by the insurer with this department not less than 30 days prior to the date the insurer desires to use the advertisement.

Appendix

INTERPRETIVE GUIDELINES

FOR RULES GOVERNING ADVERTISEMENTS OF

MEDICARE SUPPLEMENT INSURANCE

Guideline 1

Disclosure is one of the principal objectives of this part and this section states specifically that the rules shall assure truthful and adequate disclosure of all material and relevant information. This part specifically prohibits some previous advertising techniques.

Guideline 2

This part applies to any "advertisement" as that term is defined in Ins 2603.03 (a), (h), (i) and (j) unless otherwise specified in this part. This part applies to group, blanket and individual Medicare supplement insurance advertisements. Certain distinctions, however, are applicable to these categories. Among them is the level of conversance with insurance, a factor which is covered by Ins 2603.05 (a).

Guideline 3-A

The scope of the term "advertisement" extends to the use of all media for communications to the general public, to the use of all media for communications to specific members of the general public, and to use of all media for communications by agents, brokers, producers and solicitors.

Guideline 3-I

A "brief description of coverage" in an invitation to inquire may consist of an explanation of Medicare benefits, minimum benefits, standards for Medicare supplement policies, and the manner in which the advertised Medicare supplement insurance policy supplements the benefits of Medicare and meets or exceeds the minimum benefit requirements. An invitation to inquire shall not refer to cost or the maximum dollar amount of benefits payable.

As with all Medicare supplement insurance advertisements, an invitation to inquire shall not:

(1) Employ devices that are designed to create undue anxiety in the minds of the elderly or excite fear of dependence upon relatives or charity;

(2) Exaggerate the gaps in Medicare coverage;

(3) Exaggerate the value of the benefits available under the advertised policy;

(4) Otherwise violate the provisions of this part.

Guideline 4

This part permits the use of either of the following alternative methods of disclosure:

(1) The first alternative provides for the disclosure of exceptions, limitations, reductions and other restrictions conspicuously and in close conjunction with the statements to which the information relates. This may be accomplished by disclosure in the description of the related benefits or in a paragraph set out in close conjunction with the description of policy benefits.

(2) The second alternative provides for the disclosure of exceptions, limitations, reductions and other restrictions not in conjunction with the provisions describing policy benefits but under appropriate captions of such prominence that the information shall not be minimized, rendered obscure or otherwise made to appear unimportant. The phrase "under appropriate captions" means that the title shall be accurately descriptive of the captioned material. Appropriate captions include the following: "Exceptions," "Exclusions," "Conditions Not Covered," and "Exceptions and Reductions." The use of captions such as, or similar to, the following are not acceptable because they do not provide adequate notice of the significance of the material: "Extent of Coverage," "Only these Exclusions," or "Minimum Limitations."

In considering whether an advertisement complies with the disclosure requirements of this part, this rule must be applied in conjunction with the form and content standards contained in Ins 2603.05.

Guideline 5-A

This part shall be applied in conjunction with Ins 2603.01 and Ins 2603.05. These parts refer specifically to "format and content" of the advertisement and the "overall" impression created by the advertisement. This involves factors such as, but not limited to, the size, color and prominence of type used to describe benefits. The word "format" means the arrangement of the text and the captions.

This part requires distinctly different advertisements for publication in newspapers or magazines of general circulation, as compared to scholarly, technical or business journals and newspapers. Where an advertisement consists of more than one piece of material, each piece of material shall, independent of all other pieces of material, conform to the disclosure requirements of this part.

Guideline 5-B

This part prohibits the use of incomplete statements and words or phrases that have the tendency or capacity to mislead or deceive because of the reader's unfamiliarity with insurance terminology. Therefore, words, phrases and illustrations used in an advertisement shall be clear and unambiguous, if the advertisement uses insurance terminology, sufficient description of a word, phrase or illustration shall be provided by definition or description in the context of the advertisement. As implied in Guideline 5-A, distinctly different levels of comprehension to the subscribers of various publications may be anticipated.

Guideline 6-A(1)

This part prohibits the use of incomplete statements and words or phrases that create deception by omission or commission. The following examples are illustrations of the prohibitions created by the rule:

(1) An advertisement that describes any benefits that vary by age shall disclose the fact.

(2) An advertisement that uses a phrase such as "no age limit" shall disclose that premiums may vary by age or that benefits may vary by age if such is the case.

(3) Advertisements, applications, requests for additional information and similar materials are unacceptable if they state or imply that the recipient has been individually selected to be offered insurance, or has had his eligibility for insurance individually determined in advance, when in fact the advertisement is directed to all persons in a group or to all persons whose names appear on a mailing list.

(4) Advertisements for group or franchise group plans that provide a common benefit or a common combination of benefits shall not imply that the insurance coverage is tailored or designed specifically for that group, unless such is the fact.

(5) It is unacceptable to use terms such as "enroll" or "join" with reference to group or blanket insurance coverage when such is not the case.

(6) An advertisement that states or implies immediate coverage is provided is unacceptable unless suitable administrative procedures exist so that the policy is issued within 15 working days after the application is received by the insurer.

(7) Applications, request forms for additional information, and similar related materials are unacceptable if they resemble paper currency, bonds or stock certificates; or use any name, service mark, slogan, symbol or any device in such a manner that implies that the insurer or the policy advertised is connected with a government agency, such as the Social Security Administration or the Department of Health and Human Services.

(8) An advertisement that uses the word "plan" without identifying it as a Medicare supplement insurance policy is not permissible.

(9) An advertisement that implies in any manner that the prospective insured may realize a profit from obtaining Medicare supplement insurance is not permissible.

(10) An advertisement that fails to disclose any waiting or elimination periods is unacceptable.

(11) Examples of benefits payable under a policy shall not disclose only maximum benefits unless the maximum benefits are paid for loss from common or probable illnesses or accidents, rather than exceptional or rare illnesses or accidents or periods of confinement for these exceptional or rare accidents or illnesses.

(12) When a range of benefit levels is set forth in an advertisement, it shall be made clear that the insured will receive only the benefit level written or printed in the policy selected and issued.

(13) Advertisements for policies whose premiums are modest because of their limited amount of benefits shall not describe premiums as "low, "low-cost," "budget" or use qualifying words of similar import. This part also prohibits the use of words such as "only" and "just" in conjunction with statements of premium amounts when used to imply a bargain.

(14) An advertisement that exaggerates the effects of statutorily mandated benefits or required policy provisions or that implies that these provisions are unique to the advertised policy is unacceptable. For example, the phrase, "Money Back Guarantee," is an exaggerated description of the 30 day right to examine the policy and is not acceptable.

(15) An advertisement that implies that a common type of policy or a combination of common benefits is "new," "unique," "a bonus," "a breakthrough," or is otherwise unusual is unacceptable. Also, the addition of a novel method of premium payment to an otherwise common plan of insurance does not render it "new."

(16) An advertisement may not omit the word "covered" when referring to benefits payable under its policy. Continued reference to "covered" is not necessary where this fact has been prominently disclosed in the advertisement.

(17) An advertisement shall state that benefits payable under the policy are based upon Medicare eligible expenses, if such is the case.

(18) An advertisement that fails to disclose that the definition of "hospital" does not include a nursing home, convalescent home or extended are facility, as the case may be, is unacceptable.

(19) A television, radio, mail, internet, or newspaper advertisement, or lead generating device that is designed to produce leads either by use of a coupon, a request to write or to call the company, or a subsequent advertisement prior to contact shall include information disclosing that an insurance agency may contact the applicant if such is the fact.

(20) Advertisements for policies designed to supplement Medicare shall not employ devices that are designed to create undue anxiety in the minds of the elderly. Such phrases as "here is where most people over 65 learn about the gaps in Medicare," or "Medicare is great, but..." or which otherwise exaggerate the gaps in Medicare coverage are unacceptable. Phrases or devices that unduly excite fear of dependence upon relatives or charity are unacceptable. Phrases or devices that imply that long sicknesses or hospital stays are common among the elderly are unacceptable.

(21) An advertisement that is an invitation to contract implying that the coverage is supplemental to Medicare, if it does not explain the manner in which it is supplemental to Medicare coverage, is not acceptable.

(22) An advertisement that is an invitation to contract for Medicare supplement insurance is unacceptable if the advertisement:

(a) Fails to disclose in clear language which of the Medicare benefits the policy is not designed to supplement or if it otherwise implies that Medicare provides only those benefits that the policy is designed to supplement;

(b) Describes the in-patient hospital coverage of Medicare as "Medicare hospital," or "Medicare Part A" when the policy does not supplement the non-hospital or the psychiatric hospital benefits of Medicare Part A;

(c) Fails to describe clearly the operation of the part or parts of Medicare that the policy is designed to supplement; or

(d) Describes those Medicare benefits not supplemented by the policy in such a way as to minimize their importance relative to the Medicare benefits that are supplemented.

(23) Advertisements that indicate that a particular coverage or policy is exclusively for "preferred risks" or a particular segment of the population, or that particular segments of the population are acceptable risks, when such distinctions are not maintained in the issuance of policies, are not acceptable.

(24) An advertisement that contains statements such as "anyone can apply," or "anyone can join," other than with respect to a guaranteed issue policy for which administrative procedures exist to assure that the policy is issued within a reasonable period of time after the application is received by the insurer, is unacceptable.

(25) An advertisement that uses a phrase or term such as "here is all you do to apply," "simply," or "merely" to refer to the act of applying for a policy that is not a guaranteed issue policy is unacceptable unless it refers to the fact that the application is subject to acceptance or approval by the insurer.

(26) Advertisements that state or imply that premiums will not be changed in the future are not acceptable unless the advertised policies so provide.

(27) An advertisement that does not require the premium to accompany the application shall not overemphasize that fact and shall make the effective date of that coverage clear.

(28) An advertisement that is an invitation to contract that fails to disclose the amount of any deductible or the percentage of any co-insurance factor is not acceptable.

Guideline 6-A(2)

This part recognizes that certain words and phrases in advertising may have a tendency to mislead the public as to the extent of benefits under an advertised policy. Consequently, the terms (and those specified in this part do not represent a comprehensive list but only examples) shall be used with caution to avoid any tendency to exaggerate benefits and shall not be used unless the statement is literally true in every instance. The use of the following phrases based on such terms or having the same effect shall be similarly restricted: "pays hospital, surgical, etc., bills," "pays dollars to offset the cost of medical care," "safeguards your standard of living," "pays full coverage," "pays complete coverage," or "pays for financial needs." Other phrases may or may not be acceptable depending upon the nature of the coverage being advertised.

This part also prohibits words or phrases that exaggerate the effect of benefit payment on the insured's general well-being, such as "worry-free savings plan," "guaranteed savings," "financial peace of mind," and "you will never have to worry about hospital bills again."

Advertisements that are an invitation to contract for policies designed to supplement Medicare benefits are unacceptable if they fail to disclose that no hospital confinement benefits will be payable for that portion of a Medicare benefit period for which Medicare pays all hospital confinement expenses (currently 60 days) other than the initial deductible if the policy so provides. The length of the period shall be state in days.

Guideline 6-A(4)

Explanations shall not minimize nor describe restrictive provisions in a positive manner. Negative features shall be accurately set forth. Any limitation on benefits precluding preexisting conditions shall also be restated under a caption concerning exclusions or limitations, notwithstanding that the preexisting condition exclusion has been disclosed elsewhere in the advertisement. (See Guideline 6-C for additional comments on preexisting conditions.)

Guideline 6-A(5)

This part should be applied in conjunction with Ins 2603.10. Phrases such as "we cut cost to the bone" or "we deal direct with you so our costs are lower" shall not be used.

Guideline 6-B(1)

An advertisement that is an invitation to contract as defined in Ins 2603.03 (j) shall recite the exceptions, reductions and limitations as required by this part and in a manner consistent with Ins 2603.04.

If an exception, reduction or limitation is important enough to use in a policy, it is of sufficient importance that its existence in the policy should be referred to in the advertisement regardless of whether it may also be the subject matter of a provision of the Uniform Individual Accident and Sickness Policy Provision Law.

Some advertisements disclose exceptions, reductions and limitations as required, but the advertisement is so lengthy that it obscures the disclosure. Where the length of an advertisement has this effect, special emphasis shall be given by changing the format to show the restrictions in a manner that does not minimize, render obscure or otherwise make them appear unimportant.

Guideline 6-C(1)

This part implements the objective of Ins 2603.06(a)(4) by requiring in negative terms a description of the effect of a preexisting condition exclusion because such an exclusion is a restriction on coverage. The subdivision also prohibits the use of the phrase "preexisting condition" without an appropriate definition or description of the term and prohibits stating a reduction in the statutory time limit as an affirmative benefit. The words "appropriate definition or description" mean that the term "preexisting condition" shall be defined as it is used by the company's claims department.

Guideline 6-C(2)

The phrase "no health questions" or words of similar import shall not be used if the policy excludes preexisting conditions.

Use of a phrase such as "guaranteed issue," or "automatic issues," if the policy excludes preexisting conditions for a certain period, shall be accompanied by a statement disclosing that fact in a manner which does not minimize, render obscure or otherwise make it appear unimportant and is otherwise consistent with Ins 2603.04.

Guideline 6-C(3)

Some states require approval of the application even when the application is not attached to the policy when issued. This part does not change such a requirement. The text of this guideline should be modified to reflect the rule applicable in the particular state.

Guideline 7

Advertisements of cancellable Medicare supplement policies shall state that the contract is cancellable or renewable at the option of the company as the case may be. With respect to noncancellable policies and guaranteed renewable policies, the policy provisions, with respect to renewability, shall be set forth and defined where appropriate.

This part also requires a statement of the qualifying conditions that constitute limitations on the permanent nature of the coverage. These customarily fall into 3 categories (1) age limits, (2) reservation of a right to increase premiums, and (3) the establishment of aggregate limits. For example, "noncancellable and guaranteed renewable" does not fulfill the requirements of this part if the policy contains a terminal age. In such a case, a proper statement would be "Noncancellable and guaranteed renewal to age ____." If a guaranteed renewable policy reserves the right to increase premiums, the statement shall be expanded into language similar to "guaranteed renewable to age," but the company reserves the right to increase premium rates on a class basis." If the contract contains an aggregate limit after which no further benefits are payable, the above statement shall be amplified with the phrase "subject to a maximum aggregate amount of $50,000" or similar language. A Medicare supplement insurance policy may have one or more of the 3 basic limitations and an advertisement shall describe each of those which the policy contains. Over 50 percent of new individual policy issues are guaranteed renewable; therefore, the fact that a policy is guaranteed renewable shall not be exaggerated.

An advertisement for a Medicare supplement insurance policy that provides for age step-rated premium rates based upon the policy year or the insured's attained age shall disclose the rate increases and the times or ages at which the premium increases.

Guideline 8-A

This part shall be applied in conjunction with Ins 2603.08 and requires that all such statements shall be genuine and not fictitious. Under this part, the manufacturing, substantive editing or "doctoring up" of a testimonial is clearly prohibited as being false and misleading to the insurance-buying public. However, language that would be unacceptable under this part shall be edited out of a testimonial.

Guideline 8-C

This part requires that both approval or endorsement of a policy by an individual, group of individuals, society, association or other organization be factual and that any proprietary relationship between the sponsoring or endorsing organization and the insurer be disclosed. For example, if the dividend under an association group case is payable to the association, disclosure of that fact is required. Also, if the insurer or an officer of the insurer formed or controls the association, that fact shall be disclosed. This guideline also applies to Ins 2603.08(e).

Guideline 9-A

An advertisement shall specifically identify the Medicare supplement insurance policy to which statistics relate and, where statistics are given that are applicable to a different policy, it shall be stated clearly that the data does not relate to the policy being advertised.

An advertisement that states the dollar amount of claims paid shall also indicate the period over which the claims have been paid.

If the term "loss ratio" is used, it shall be properly explained in the context of the advertisement and, unless the state has issued a rule otherwise defining the term, it shall be calculated on the basis of premiums earned to losses incurred and shall not be on a yearly run-off basis.

Guideline 9-C

This part does not require that statistics for this state be used since such statistics as hospital charges and average stays may vary from state to state. When nationwide statistics are used, that fact should be noted, unless the statistics on the particular point are substantially the same in a state to which the advertisement is directed. Statistics may only be used if they are current and credible.

Guideline 10

This part prohibits disparaging, unfair or incomplete comparisons of policies or benefits that would have a tendency to decline or mislead the public. This part does not preclude the use of comparisons by health maintenance organizations, prepaid health plans and other direct service organizations that describe the difference between their prepaid health benefits coverage and indemnity insurance coverage.

Guideline 11-A

This part prohibits advertisements that imply that an insurer is licensed beyond the limits of those jurisdictions where it is actually licensed. An advertisement that contains testimonials from persons who reside in a state in which the insurer is not licensed or that refers to claims of persons residing in states in which the insurer is not licensed implies licensing in those states and, therefore, is in violation of this part unless the advertisement states that the insurer is not licensed in those states.

Guideline 11-B

Although this part permits a reference to an insurer being licensed in a state where the advertisement appears, it does not allow exaggeration of the fact of that licensing nor does it permit the suggestion that competing insurers may not be so licensed because, in most states, an insurer must be licensed in the state to which it directs its advertising.

Terms such as "official," or words of similar import, used to describe any policy or application form are not permissible because of the potential for deceiving or misleading the public. This guideline also applies to Ins 2603.11(c).

Guideline 14-A(1)

This part prohibits advertising representing that a product is offered on an introductory, initial or special offer basis or otherwise which (a) will not be available later; or (b) is available only to certain individuals, unless such is the fact. This part prohibits the repetitive use of such advertisements. Where an insurer uses enrollment periods as the usual method of advertising these policies, this part prohibits describing an enrollment period as a special opportunity or offer for the applicant.

Guideline 14-A(2)

This part restricts the repetitive use of enrollment periods. The requirement of reasonable closing dates and waiting periods between enrollment periods was adopted to eliminate the abuses that formerly existed. This part does not limit just the use of enrollment periods. It requires that a particular insurance product offered in an enrollment period through any advertising media, including the prepared presentations of agents, cannot be offered again in the state until 6 months from the close of the enrollment period. Thus, an insurer shall choose whether to use enrollment periods or open enrollment for a product. (See Ins 2603.14(a)(4) for the definition of "a particular insurance product.")

This part does not prohibit multiple advertising during an enrollment period through any and all media published or transmitted within this state as long as the enrollment periods for all such advertisements have the same expiration date.

This part does not prohibit the solicitation of members of a group or association for the same product even though there has not been a lapse of 6 months since the close of a preceding enrollment period that was open to the general public for the same product.

This part does not require separation by 6 months of enrollment periods for the same insurance product in this state if the advertising material is directed by an admitted insurer to persons by direct mail on the basis that a common relationship exists with an entity. Examples would be a bank and its depositors, a department store to its charge account customers, or an oil company to its credit card holders, and more than one of these organizations is sponsoring an insurance product at different times if providing the insurance under such methods is not otherwise prohibited by law. However, the 6 month rule does apply to one specific sponsor to the same persons in this state on the basis of their status as customers of that one specific entity only.

Guideline 14-A(4)

This part defines the meaning of "a particular insurance product" in Ins 2603.14(a)(2) and prohibits advertising of products having minor variations such as different periods or different amounts of daily hospital indemnity benefits, in a succession of enrollment periods.

Guideline 15

This part is closely related to the requirement of Ins 2603.09 concerning the use of statistics. This part prohibits insurances that have been organized for only a brief period of time advertising that they are "old" and also prohibits emphasizing the size and magnitude of the insurer. Also, the occupations of the persons comprising the insurer's board of directors or the public's familiarity with their names or reputations is irrelevant and shall not be emphasized. The preponderance of a particular occupation or profession among the board of directors of an insurer does not justify the advertisement of a plan of insurance offered to the general public as insurance designed or recommended by members of that occupation or profession. For example, it is unacceptable for an insurance company to advertise a policy offered to the general public as "the physicians' policy" or the "the doctors' plan" simply because there is a preponderance of physicians or doctors of the insurer. This part prohibits the use of recommendation of a commercial rating system unless the purpose, meaning and limitations of the recommendation are clearly indicated.

Guideline 16

The text of Ins 2603.16(a) is identical to the text of the first paragraph of the enforcement section of previous drafts of this part except the last sentence of the subsection has been revised to require that the advertising file be maintained either for a period of 4 years (rather than 3 as previously) or until the next regular examination of the insurer, whichever is the longer period of time.

Guideline 17

Filing of all Medicare supplement advertisements is required by this part.

History

#9398, eff 3-1-09; ss by #11173, eff 12-5-16

Part Ins 2604 All Other Advertisements of Life, Accident, and Health Insurance

N.H. Code Admin. R. Ann. Ins 2604.01 Purpose {#sec-ins-2604.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.01}

The purpose of this part is to ensure that all advertisements that relate to life, accident or health insurance policies sold in this state that are not regulated under Ins 2601, Ins 2602, or Ins 2603, present clear and accurate information to the public and do not mislead consumers about the characteristics or operations of any insurance plan or product.

History

#6971, eff 4-1-99, EXPIRED: 4-1-07
#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.02 Applicability {#sec-ins-2604.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.02}

and Scope. This part shall apply to life, accident or health insurance policies that are not regulated under Ins 2601, Ins 2602, or Ins 2603 and to any entity which holds a license to sell, issue or administer these policies in this state.

History

#6971, eff 4-1-99, EXPIRED: 4-1-07
#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.03 Definitions {#sec-ins-2604.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.03}

For the purpose of this part, the following definitions shall apply:

(a) “Advertisement” means:

(1) Printed and published material and literature an insurer uses in newspapers, magazines, radio and TV scripts, billboards and similar displays to describe its plans and products;

(2) Descriptive literature and sales aids issued by an insurer for presentation to members of the public, including but not limited to circulars, leaflets, booklets, depictions, illustrations, and form letters;

(3) Prepared sales talks, presentations and material for use by producers; and

(4) Product descriptions, illustrations, web pages and other materials available on the internet.

(b) “Exception” means any provision in a policy which eliminates coverage for a specified hazard through a statement of a risk the policy does not assume.

(c) “Insurer” means any individual, producer, corporation, association, partnership, health maintenance organization, reciprocal exchange, interinsurer, fraternal benefit society, and any other legal entity engaged in the advertisement of a policy as herein defined.

(d) “Limitation” means any provision in a policy which restricts coverage under the policy that is not an exception or a reduction.

(e) “Policy” means any, plan, certificate, contract, agreement, statement of coverage, rider or endorsement that provides life, accident or health benefits or medical, surgical or hospital expense benefits whether on a cash indemnity, reimbursement, or service basis. “Policy” does not include the disability and double indemnity benefits included in insurance lines defined in RSA 401:1, III, or any policy that is regulated by Ins 2601, Ins 2602, Ins 2603, or Ins 3600.

(f) “Policy elimination period” means any period between the policy’s effective date and the effective date of coverage for specified illness if such illness is not covered as of the policy’s effective date, or any period between the time loss occurs and the time coverage begins.

(g) “Reduction” means any provision in a policy that reduces a benefit amount wherein the policy does assume some risk of loss, but the insurer limits payment to an amount or period of time that is less than the policy would cover if the contract did not include the reduction provision.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.04 Reference {#sec-ins-2604.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.04}

to Policy Form Numbers. All printed advertisements except general invitations to inquire about the details of policies shall carry a reference number for any contract form mentioned in the advertisement.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.05 Advertisements {#sec-ins-2604.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.05}

in General.

(a) Advertisements shall be truthful and not misleading in fact or in implication.

(b) Advertisements shall use words or phrases whose meaning is direct and unambiguous and not words or phrases whose meaning is clear only by implication.

(d) Advertisements containing disclosures required pursuant to this part shall present:

(1) Required disclosures in close proximity to the information to which they relate so that the information to which a disclosure relates is clear to consumers;

(2) Disclosures shall be set out under appropriate captions of sufficient prominence so that the disclosures appear clear and conspicuous and do not become intermingled with other text; and

(3) Disclosures shall be set out in full and complete, in a manner that does not render the information unclear, confusing, ambiguous, or obscure.

(e) An advertisement shall not directly or indirectly make unfair or incomplete comparisons of policies or benefits. Advertisements shall not falsely or maliciously disparage competitors, their policies, services or business methods.

(f) A policy advertisement shall not state or imply that prospective policyholders become group or quasi-group members, and as such enjoy special rates or underwriting privileges, unless such is the fact.

(g) An advertisement shall not contain untrue statements about the time within which claims are paid, or the number of claims paid. An advertisement shall not contain statements that imply that claim settlements will be liberal or generous beyond the terms of the policy.

(h) An advertisement shall not contain statements about the insurer’s assets, corporate structure, financial standing, age or relative position in the insurance industry that are untrue or misleading.

(i) Insurers shall maintain complete control over the content, form and method of dissemination of its advertisements at all times. The sponsoring insurer shall be responsible for all advertisements, regardless of whether another party has written, created, or designed the advertisement.

(j) Disclosed information shall be set out in type size at least as large as the statements to which the information relates, and in a font style the same as or comparable with the font style used for the statements to which the information relates.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.06 Advertisements {#sec-ins-2604.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.06}

of Benefits Payable, Losses Covered or Premiums Payable.

(a) An insurer shall not use misleading words, phrases, statements, references or illustrations, or omit information that might mislead or deceive the consumer as to:

(1) Any policy benefit payable;

(2) Any loss covered; or

(3) Any premium payable.

(b) When an advertisement describes any policy benefit payable, loss covered or premium payable, the insurer shall use only words and phrases in the advertisement that give complete and clear information and do not mislead or deceive, as follows:

(1) An advertisement shall not use the following words and phrases: "all," "full," "complete," "comprehensive," "unlimited," "this policy will pay your hospital and surgical bills," or "this policy will replace your income," or similar words and phrases to refer to any coverage that is, in fact, subject to any exception, reduction or limitation, unless the advertisement includes appropriate disclosure;

(2) An advertisement shall not use words or phrases such as "up to," "as high as," or similar words or phrases to describe the dollar amount payable for any losses or expenses except:

a. When the contract provides benefit payments for such losses or expenses actually sustained by a policyholder in all cases; or

b. When the advertisement includes appropriate disclosure of either:

The complete schedule of payments provided by the contract; or
The specific loss or expense for which the contract pays the represented dollar amount, as well as a statement indicating that the actual benefit will vary in amount depending on the particular kind of loss or expense incurred; and

(3) When an insurer advertises a policy that provides surgical benefits, and the advertisement refers to specific dollar amounts for coverage of surgical procedures, the insurer shall:

a. Derive a list of 6 commonly performed surgical procedures for which the advertised policy provides coverage, and the insurer shall periodically review and update this list, to ensure its continuing validity; and

b. Disclose this list of procedures, along with the relevant maximum and minimum benefit limits from the insurer’s surgical schedule for each of the listed procedures.

(c) An advertisement shall list the surgical procedures in terms that the average reader understands easily. An advertisement for a policy that covers only one disease or a list of specified diseases shall not imply coverage beyond the terms of the policy. The advertisement shall not use a synonymous term for any disease to imply broader coverage than is the fact.

(d) Advertisements shall not refer to policy benefits when the benefits paid vary for the same loss occurring under different conditions, or when the benefits are paid only when a loss occurs under certain conditions, unless the advertisement discloses these conditions.

(e) An advertisement shall not use phrases that indicate that the policy pays a specific amount for hospital room and board expenses without disclosing the maximum daily benefit and the maximum time limit for hospital room and board expenses.

(f) An advertisement shall not represent the weekly, monthly, or other periodic benefits payable under a contract without disclosing:

(1) Any limits on the time period over which such benefits will be paid; or

(2) The number of payments that will be made if the contract limits such benefits in time or number.

(g) No advertisement shall use the following words or phrases "extra cash," "extra income," "extra pay," or substantially similar words or phrases that could lead the public to believe that the contract advertised will enable them to financially profit from being hospitalized.

(h) No advertisement shall represent or imply that a contract may continue indefinitely or for any period of time, when:

(1) The contract permits the insurer to non-renew or cancel the policy; or

(2) The contract permits the insurer to terminate the policy under any circumstances over which the insured has no control, during the period of time represented.

(i) An advertisement that refers to any coverage as being limited to a certain age group shall disclose such limitation. When applicable, such advertisement shall state clearly that the insured will receive reduced benefits upon attaining a certain age.

(j) An advertisement that refers to a contract that may be renewed, cancelled, or terminated shall disclose any and all related provisions, including possible modification of policy terms relating to benefits, coverages or premiums, and any qualifying conditions.

(k) No insurer shall state or imply that a consumer shall obtain coverage, or guaranteed issuance of a policy, unless the insurer has maintained administrative procedures and sufficient staff to ensure that it will issue the policy within a maximum of 15 days after receiving the application.

(l) An advertisement of a hospital indemnity policy that includes words or phrases describing the policy’s benefits shall disclose:

(1) The actual amounts payable per day; and

(2) The fact that the insurer will pay such benefits during hospital confinement only.

(m) No advertisement shall depict scenes that could scare a reader into purchasing a policy. Such scenes include but shall not be limited to scenes of hospital operating rooms, disabled persons, bed patients in or out of the hospital, doctors' offices, accident scenes, or scenes of other tragedies.

(n) All printed advertisements for policies that include certain exceptions, reductions or limitations shall display and use a separate box clearly distinguishable from the remainder of the advertisement to set forth the required disclosures.

(o) The box required in (n) above shall be as follows:

(1) For black and white advertisements, the box shall carry a border that stands out due to its size from the remainder of the advertisement; and

(2) For color advertisements, the box shall carry a border that stands out due to its color from the remainder of the advertisement.

(p) An advertisement may omit a schedule, chart or a detailed explanation, otherwise required by this part, from the box if the box includes a reference to the exact location where the schedule, chart or explanation appears elsewhere in the advertisement.

(q) The box required in (n) above shall include a statement that indicates the policy might contain exceptions, reductions or limitations in addition to those set forth in the box.

(r) The box required in (n) above shall only use negative language to describe policy limitations and exclusions, so that the language indicates what the policy does not cover, rather than what the policy does cover.

(s) Exceptions, reductions, or limitations of benefits described in the box required in (n) above shall include:

(1) Treatment of preexisting conditions;

(2) Policy elimination periods;

(3) The fact that indemnity is payable only when the insured is confined to a hospital;

(4) The fact that confinement in rest homes, nursing homes, V.A. hospitals, or other types of extended care in a facility are not covered;

(5) The fact that the policy does not cover certain deductibles;

(6) The fact that the policy does not duplicate benefits provided by federal or state legislation, such as workers compensation; and

(7) The fact that the policy covers hospital bills and not doctors’ bills or vice versa.

(t) When an advertisement refers to terms or conditions of the policy, including but not limited to specific dollar amounts, or policy benefits, and times or ages in connection with coverage eligibility, it shall also disclose any related exception, reduction or limitation.

(u) Advertisements for policies that include any exception, reduction or limitation related to a preexisting condition, shall:

(1) Disclose the extent to which any loss is not covered if the cause of such loss is traceable to a condition existing prior to the effective date of the policy;

(2) Not state or imply that the insurer will issue a policy or pay claims under the policy regardless of the applicant’s physical condition or medical history, when the policy does not cover losses traceable to preexisting conditions;

(3) Not use the phrase “no medical examination required” or phrases of similar meaning when the policy does not cover losses traceable to preexisting conditions; and

(4) For policies that do not require a medical examination, disclose any conditions pertaining to or involving the insured’s health that would limit benefits paid under the contract.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.07 Testimonials {#sec-ins-2604.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.07}

(a) When an advertisement uses a testimonial, the testimonial shall:

(1) Be genuine;

(2) Apply to the policy advertised;

(3) Be accurately reproduced; and

(4) Disclose:

a. When the author of a testimonial has received compensation for the testimonial; and

b. When the author of a testimonial has a financial interest in the company or a related entity as a stockholder, director, compensated employee, or any other interest.

(b) The insurer shall be responsible for all of the statements contained in any testimonial as if such testimonials were stated directly by the insurer.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.08 Use {#sec-ins-2604.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.08}

of Statistics.

(a) An advertisement shall not use statistics unless the advertisement accurately reflects all the relevant facts related to the stated statistic.

(b) Statistics shall include, but not be limited to:

(1) The dollar amounts of claims paid;

(2) The time within which claims are paid;

(3) The number of claims paid; or

(4) The number of persons insured.

(c) An advertisement that uses statistics shall not imply that the statistics are derived from the policy advertised unless such is the fact.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.09 Inspection {#sec-ins-2604.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.09}

of Policy. An advertisement shall not attempt to cure misleading or deceptive statements by offering the consumer a free policy inspection or premium refund.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.10 Identification {#sec-ins-2604.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.10}

of Plan or Number of Policies.

(a) When an advertisement refers to a choice in the amount of benefits, it shall disclose that the amount of benefits and the premium depend upon the selected plan.

(b) When an advertisement refers to various benefits, that might be contained in 2 or more policies, the advertisement shall disclose that the insured can obtain such benefits only by combining these policies. This requirement shall not apply to group master policies.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.11 Jurisdictional {#sec-ins-2604.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.11}

Licensing.

(a) An advertisement that appears or airs in New Hampshire beyond the limits of the jurisdiction in which the insurer is licensed, or which originates in New Hampshire and appears or airs beyond the limits of the jurisdiction in which the insurer is licensed, shall not imply in the advertisement that the insurer is licensed beyond those limits.

(b) Direct mail advertisements that appear in New Hampshire from beyond the limits of the licensure jurisdiction, and direct mail advertisements that originate in New Hampshire and are sent beyond the limits of the licensure jurisdiction, shall indicate that the insurer is licensed in a specified state or states only, or is not licensed in a specified state or states. Direct mail advertisements shall use language such as "This Company is licensed only in State "A" or "This Company is not licensed in State B", or "This policy is not available to residents of .......".

(c) Any advertisement that originates outside the state of New Hampshire, but that can reasonably be expected to be seen or heard in this state, shall comply with this part, except when the advertisement prominently sets forth an appropriate disclaimer such as: "This policy is not available to residents of New Hampshire."

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.12 Identity {#sec-ins-2604.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.12}

of Insurer.

(a) All advertisements shall make the insurer’s identity clear. An advertisement shall not use a trade name, service mark, slogan, symbol or other device that could mislead or deceive as to the true identity of the insurer.

(b) An advertisement that uses an address other than the insurer's home office shall properly identify such address as a district office, branch office, or other office. An advertisement that uses a designation such as "Disability Division" shall not give such designation greater prominence than the name of the insurer. An advertisement shall not use such a designation except in connection with any address other than the insurer’s actual office address.

(c) No advertisement or sales solicitation material shall use any combination of words and/or physical materials that resemble combinations or words and/or physical materials used by agencies of the federal government or the state of New Hampshire, in any manner that might confuse and/or mislead prospective insureds to believe that the solicitation relates to an agency of the state or federal government.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.13 Introductory {#sec-ins-2604.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.13}

, Initial or Special Offers.

(a) An advertisement shall not falsely state or imply that a particular policy or combination of policies is an introductory, initial, special or limited enrollment policy.

(b) An advertisement shall not contain phrases such as "special enrollment," "special limited enrollment," "enrollment deadline," "acceptance period," or similar words or phrases that falsely imply:

(1) That an interested party shall apply by a specific deadline to obtain the particular contract advertised, or to obtain any contract of the same insurer which offers substantially similar coverage;

(2) That the insurer shall receive an interested party’s application by a prescribed date and that it will not accept the application thereafter;

(3) That the policy shall not be available at a future date; and

(4) That an applicant shall receive advantages not available at a later date if he or she applies immediately.

(c) An advertisement shall not state that the insurer requires an enrollment period, when less than 90 days separates the ending date of one enrollment period and the beginning date of the next enrollment period for the same contract, or any substantially similar contract the insurer offers in the state.

(d) An insurer shall not advertise or use a first month premium rate of less than 1/12 of the annual premium for any contract, except when the insurer substantiates that it reduces benefits paid during the first month of the contract in proportion to the premium it charges during that period.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.14 Third {#sec-ins-2604.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.14}

Party Approval and Endorsement.

(a) An advertisement shall not state or imply that a governmental agency has approved an insurer or a policy, or has examined an insurer's financial condition and found it satisfactory, unless such is the fact.

(b) An advertisement shall not state or imply that any individual, group, society, association, or other organization has approved or endorsed an insurer or a policy unless such is the fact.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.15 Advertising {#sec-ins-2604.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.15}

File.

(a) Each insurer shall maintain at its home or principal office a complete file that contains:

(1) Every printed, published or prepared advertisement of individual policies; and

(2) Typical printed, published or prepared advertisements for blanket, franchise and group policies that the insurer has published.

(b) The required file shall include such advertisements appearing in this state or any other state, whether or not the insurer carriers a license in such other state.

(c) The insurer shall attach a notation to each advertisement that indicates the manner and extent of distribution and the form number of any policy advertised.

(d) The insurer shall maintain all advertisements in the file for a period of not less than 3 years.

(e) The insurer shall make the advertising file available to the commissioner or his or her designee for inspection.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.16 Soliciting {#sec-ins-2604.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.16}

Names of Prospective Insureds. Any advertisement which the insurer uses to solicit leads for prospective applicants shall disclose that an agent for the insurer will contact the applicant if such is the fact.

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

N.H. Code Admin. R. Ann. Ins 2604.17 Penalty {#sec-ins-2604.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 2604.17}

Provisions. Any insurer who knowingly violates any requirement of this part shall be subject to the penalty provisions of RSA 400-A:15.

APPENDIX

Rule

Statute

Ins 2601.01

RSA 400-A:15, I; 406-A:1, I; 406-A:3; 417:3; 417:4, I, III

Ins 2601.02

RSA 400-A:15, I; 406-A:1, I; 406-A:3; 417:3; 417:4, I, III; 402-H:5

Ins 2601.03

RSA 400-A:15, I; 406-A:1, I; 406-A:3; 417:3; 417:4, I, III

Ins 2601.04

RSA 400-A:15, I; 417:4, I, III

Ins 2601.05

RSA 417:4, I

Ins 2601.06

RSA 406-A:1; 406-A:3; 417:1; 417:3; 417:4, I, III, XIII

Ins 2601.07

RSA 417:4, I, III

Ins 2601.08

RSA 417:4, I, III

Ins 2601.09

RSA 417:4, I, II, III, IV, VI

Ins 2601.10

RSA 417:4, I, II, III, IV, VI

Ins 2601.11

RSA 417:4, I, III, XIII

Ins 2601.12

RSA 417:4, I, III, IV

Ins 2601.13

RSA 406-A:1; 406-A:3; 417:1; 417:3; 417:4, I, III

Ins 2601.14

RSA 406-A:1; 406-A:3; 417:1; 417:3; 417:4, I, III

Ins 2601.15

RSA 417:4, I, III

Ins 2601.16

RSA 417:4, I, III, IX

Ins 2601.17

RSA 417:4, IV, VI

Ins 2601.18

RSA 400-B

Ins 2601.19

RSA 400-A:15, I; 406-A:1, I; 406-A:3

Ins 2601.20

RSA 400-A:15, III; 417:10; 417:13

Ins 2602.01

RSA 400-A:15, I; 406-C:8; 417:3; 417:4, III

Ins 2602.02

RSA 400-A:15, I; 406-C:8; 417:3; 417:4, III

Ins 2602.03

RSA 400-A:15, I; 406-C:8; 417:3; 417:4, III

Ins 2602.04

RSA 400-A:15, I; 406-C:8; 417:4, I, III, VIII

Ins 2602.05

RSA 400-A:15, I; 406-C:8; 417:4, I, III, VIII

Ins 2602.06

RSA 406-C:8; 417:3; 417:4, I, III

Ins 2602.07

RSA 406-C:8; 417:3; 417:4, I, III

Ins 2602.08

RSA 417:4, IV, VI

Ins 2602.09

RSA 400-A:15, I; 400-B; 406-C:8; 417:1; 417:3; 417:4, I, II, III

Ins 2602.10

RSA 400-A:15, III; 417:10; 417:13

Ins 2602.11

RSA 400-A:15, III

Ins 2603.01

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.02

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.03

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.04

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.05

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.06

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.07

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.08

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.09

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.10

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.11

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.12

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.13

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.14

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.15

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.16

RSA 415-F:3, III, IV; 415-F:7

Ins 2603.17

RSA 415-F:3, III, IV; 415-F:7

Ins 2604.01

RSA 406-A:1; 406-A:3; 406-C:8; 417:1; 417:3; 417:4, I, III

Ins 2604.02

RSA 406-A:1; 406-A:3; 406-C:8; 417:1; 417:3; 417:4, I, III

Ins 2604.03

RSA 406-A:1; 406-A:3; 406-C:8; 417:1; 417:3; 417:4, I, III

Ins 2604.04

RSA 417:4, I, III

Ins 2604.05

RSA 406-A:1; 406-A:3; 406-C:8; 417:1; 417:3; 417:4, I, III, XIII, XIV

Ins 2604.06

RSA 417:4, I, III, VIII, IX, XII, XIII, XIV

Ins 2604.07

RSA 417:4, I, II, III, IV, VI

Ins 2604.08

RSA 417:4, I, II, III, IV, VI

Ins 2604.09

RSA 406-A:1, 406-A:3, 406-C:8; 417:4, I, II, III, IX, XII, XV

Ins 2604.10

RSA 417:1; 417:3; 417:4

Ins 2604.11

RSA 406-A:1; 406-A:3; 406-C:8; 417:1; 417:3; 417:4, I, III

Ins 2604.12

RSA 406-A:1; 406-A:3; 406-C:8; 417:1; 417:3; 417:4, I, III

Ins 2604.13

RSA 406-A:1; 406-A:3; 406-C:8; 417:1; 417:3; 417:4 I, II, III, XII

Ins 2604.14

RSA 417:4, I, II, III, IV, VI

Ins 2604.15

RSA 400-B:3

Ins 2604.16

RSA 406-A:1; 406-A:3; 406-C:8; 417:1; 417:3; 417:4, I, II, III

Ins 2604.17

RSA 400-A:15, III; 417:10; 417:13

History

#9333, eff 12-5-08; ss by #11173, eff 12-5-16

Chapter Ins 2700 Managed Care

Part Ins 2701 Health and Dental Benefit Plan Network Adequacy

N.H. Code Admin. R. Ann. Ins 2701.01 Purpose {#sec-ins-2701.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.01}

The purpose of these rules is to establish standards for determining whether a carrier’s provider network is sufficient in numbers, types, and geographic location of providers to ensure that covered persons will have access to health care services without unreasonable delay.

History

#7701, eff 8-1-02; ss by #9722, eff 8-1-10; ss by #12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.02 Scope {#sec-ins-2701.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.02}

These rules shall apply to all insurers offering or issuing policies of health and dental insurance in the state of New Hampshire when the plan design and benefits include a provider network with differential payment or coverage associated with use of an in-network provider.

History

#7701, eff 8-1-02; ss by #9722, eff 8-1-10; ss by #12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.03 Definitions {#sec-ins-2701.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.03}

(a) “Commissioner” means the insurance commissioner.

(b) “Covered benefits” means those health care services and other medical services, including dental benefits, to which a covered person is entitled under the terms of a health benefit plan.

(c) “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.

(d) “Health benefit plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of covered benefits with respect to any “health coverage” as defined in RSA 420-G:2, IX and any network-based coverage for dental services.

(e) “Health carrier” means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the covered costs of health care services, including an insurance company, a health maintenance organization, a health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services.

(f) “Network” means the group of participating providers contracted under a network plan.

(g) “Network plan” means a health benefit plan that either requires a covered person to use or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier.

(h) “Participating provider” means a person or entity who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, co-payments, or deductibles, directly or indirectly from the health carrier.

(i) “Primary care provider” means a physician licensed by the New Hampshire board of medicine or a board of medicine of another appropriate jurisdiction who has successfully completed a residency program accredited by the Accreditation Council for Graduate Medical Education or approved by the American Osteopathic Association in family practice, internal medicine, or pediatrics, or an advanced registered nurse practitioner licensed by the New Hampshire board of nursing in the advanced practice categories of family practice, internal medicine, or pediatrics, or a doctor of naturopathic medicine authorized and licensed to practice naturopathic medicine under RSA 328-E.

(j) “Retail pharmacy” means any licensed pharmacy that is not a mail order pharmacy and is open to dispense prescription drugs to the walk-in public without being required to receive medical services from a provider or institution affiliated with that pharmacy.

(k) “Urgent services” means health care services that are provided to treat a medical or behavioral health condition or symptomatic illness of a covered person that, if not treated within 48 hours, presents a risk of serious harm.

History

#7701, eff 8-1-02; ss by #9722, eff 8-1-10 (from Ins 2701.01); ss by #12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.04 Basic Access Requirement {#sec-ins-2701.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.04}

(a) Each health carrier offering a network plan shall maintain a network of primary care providers, dental providers, specialists, institutional providers, and other ancillary health care personnel that is sufficient in numbers and types of providers to ensure that all covered health care services are accessible to covered persons without unreasonable delay.

(b) A health carrier’s network of participating providers shall be considered sufficient to meet the basic access requirement in Ins 2701.04(a) if it meets all of the standards contained in Ins 2701.04 through Ins 2701.13. The evaluation of network adequacy shall be based on the most recent United States census data for populations under 65 years of age.

(c) The basic access requirement in Ins 2701.04(a) shall be met in each county in which the health carrier is actively marketing a health benefit plan. For the purpose of this paragraph, “actively marketing” means advertising in publications published within the county or initiating contact with a potential policyholder in person, by phone, or by mail.

(d) In any county in which compliance with Ins 2701.04(a) is required and in which a health carrier’s network is insufficient to meet one of the access standards in Ins 2701.06 and in which the carrier has not been granted an exception pursuant to Ins 2701.08 or Ins 2701.14, the health carrier shall cover services provided by a non-participating provider located within the applicable geographic area at no greater cost to the covered person than if the services were obtained from a participating provider. Coverage under this paragraph shall be subject to all other terms and conditions of the covered person’s health benefit plan, including, but not limited to, referral and authorization requirements. Nothing in this paragraph shall be construed to require a health carrier to provide coverage for services provided by a non-participating provider who has been excluded from the health carrier’s network for failing to meet any applicable credentialing standards.

(e) A health carrier shall not actively solicit new policyholders in any county in which compliance with Ins 2701.04(a) is required and in which it does not meet the access standards in Ins 2701.06, unless the health carrier has been granted an exception under Ins 2701.08.

(f) Nothing in (e) above shall be construed to prohibit a health carrier from:

(1) Advertising in publications distributed within the county which are published outside of the county;

(2) Responding to inquiries initiated by a potential policyholder; or

(3) Issuing or renewing coverage as required by federal or state law, including RSA 420-G.

History

#7701, eff 8-1-02; ss by #9722, eff 8-1-10 (from Ins 2701.02); ss by #12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.05 Reasonable Access to Health Care Services {#sec-ins-2701.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.05}

(a) To constitute reasonable access to health care services, a provider network shall supply access consistent with the geographic accessibility standards in Ins 2701.06 to the services listed in Ins 2701.07.

(b) To be deemed adequate for each of the listed services, the network shall include, within the applicable geographic area, a sufficient number of providers for which the service in question is within their scope of practice. In addition to physicians, providers may include nurse practitioners, osteopaths, social workers, psychologists, naturopaths, midwives, physician assistants, clinical nurse specialists, dentists, dental hygienists, or any provider trained and appropriately licensed and, when required, adequately supervised by a physician in compliance with New Hampshire laws and rules.

(c) To constitute reasonable access to health services, the network shall include providers whose services are integral to care in a hospital, ambulatory surgery center, or similar facility, specifically those services provided by anesthesiologists, pathologists, emergency physicians, and radiologists. When a carrier is unable to assure that an in-network provider of those services is always accessible at an in-network facility, the carrier shall assure that any necessary out-of-network services are provided with no additional cost share to the member, beyond member responsibility were those services provided by an in-network provider.

(d) Access to medically necessary health care services through the use of telemedicine or telehealth may be used to satisfy the network adequacy geographic access requirements when an acceptable standard of care can be met by the provider offering the service.

History

#7701, eff 8-1-02; ss by #9722, eff 8-1-10 (from Ins 2701.03); ss by #12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.06 Standards for Geographic Accessibility {#sec-ins-2701.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.06}

(a) Geographic access standards shall be calculated based on population densities of persons under the age of 65. Geographic access standards shall be measured in terms of distance or travel times for a person under normal conditions from specific zip codes.

(b) A carrier shall meet the service specific requirement by county for persons living in one of the 2 zip codes for the following counties:

(1) Coos – Lancaster 03584 or Berlin 03570;

(2) Carroll – Conway 03813 or Wolfeboro 03894;

(3) Belknap – Laconia 03246 or Alton 03809;

(4) Sullivan – Claremont 03743 or Newport 03773;

(5) Strafford – Rochester 03867 or Dover 03820;

(6) Cheshire – Keene 03431 or Jaffrey 03452;

(7) Hillsborough – Nashua 03060 or Manchester 03103; and

(8) Rockingham – Portsmouth 03801 or Derry 03038.

(c) A carrier shall meet the service specific requirement for Merrimack County for persons living in the Concord 03301 zip code.

(d) A carrier shall meet the service specific requirement for Grafton County for persons living in 2 of the following zip codes:

(1) Littleton 03561;

(2) Plymouth 03264; or

(3) Lebanon 03748.

(e) Geographic access standards are based on the following county groupings: “Rural”, “Middle”, and “Urban”. Maximum travel distances or times are based on the service type, county, and specific zip code within the county as follows:

(1) For urban counties, including Strafford, Hillsborough, and Rockingham counties:

a. Ten miles or 15 minutes driving time for core services;

b. Twenty miles or 30 minutes driving time for common services; and

c. Forty miles or one hour driving time for specialized services;

(2) For middle counties, including Merrimack, Belknap, Cheshire, Grafton, Carroll, and Sullivan counties:

a. Twenty miles or 40 minutes driving time for core services;

b. Forty miles or 80 minutes driving time for common services; and

c. Seventy miles or 2 hours driving time for specialized services; and

(3) For rural counties, including Coos county:

a. Thirty miles or one hour driving time for core services;

b. Eighty miles or 2 hours driving time for common services; and

c. One hundred twenty-five miles or 2½ hours driving time for specialized services.

History

#7701, eff 8-1-02; ss by #9722, eff 8-1-10 (from Ins 2701.04); ss by #12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.07 Classification of Services as “Core”, “Common”, and “Specialized” {#sec-ins-2701.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.07}

(a) The purpose of this section is to classify services into 3 categories, core, common, and specialized, for the purposes of network adequacy reviews.

(b) The following services shall be classified as “Core” services for purposes of network adequacy review:

(1) Alcohol or drug treatment in an ambulatory setting for any of the following:

a. Crisis intervention;

b. Detoxification; or

c. Medical or somatic treatment;

(2) Alcohol or drug assessment;

(3) Alcohol or drug case management;

(4) Alcohol or drug services group counseling by clinician;

(5) Alcohol or drug intensive outpatient treatment;

(6) Alcohol or drug methadone or equivalent administration;

(7) Alcohol or drug subacute detox;

(8) Alcohol or drug treatment medication training and support;

(9) Ambulance;

(10) Behavioral health (BH) or Substance use disorder (SUD) comprehensive community support services;

(11) BH or SUD comprehensive medication services;

(12) Behavioral health counseling and therapy, or screening to determine eligibility for admission to a treatment program;

(13) Behavioral health partial hospitalization;

(14) Behavioral health short term residential;

(15) Chiropractic;

(16) Contraceptive services;

(17) Dental diagnostic services;

(18) Dental preventive services;

(19) Dental restorative services;

(20) Diagnostic physical therapy (PT) evaluation;

(21) Individual or group counseling for mental health (MH) or SUD;

(22) Mammogram;

(23) PT procedures not requiring specialized equipment;

(24) Preventive and associated routine care, adult;

(25) Preventive and associated routine care, pediatric;

(26) Routine electrocardiogram (EKG);

(27) Routine immunizations and injections, adult;

(28) Routine immunizations and injections, pediatric;

(29) Screening and assessment services for MH or SUD;

(30) Suture of non-life-threatening wound;

(31) Therapeutic behavioral services provided in segments defined by number of minutes or on a per diem basis;

(32) Urgent care; and

(33) Venipuncture or collection of capillary blood.

(1) Allergen immunotherapy;

(2) Ankle X-ray;

(3) Appling splints;

(4) Asthma or bronchial care;

(5) Audiologic function tests;

(6) Biopsy of skin lesions;

(7) Cardiac monitoring or stress testing;

(8) Cardioversion;

(9) Cataract surgery;

(10) Chemotherapy;

(11) Chest X-ray;

(12) Complex closure of wounds;

(13) Corpus uteri biopsy or endometrial sampling;

(14) Cystoscopy;

(15) Dental adjunctive general services;

(16) Dental endodontics;

(17) Dental implant service;

(18) Dental oral and maxillofacial surgery;

(19) Dental orthodontics;

(20) Dental periodontics;

(21) Dental prosthodontics which are removable;

(22) Destruction of skin lesions;

(23) Developmental, hearing, and vision testing, pediatric;

(24) Diagnosis and therapy for rheumatic disease;

(25) Electroencephalography (EEG);

(26) Echocardiography;

(27) Electromyography;

(28) Endoscopy;

(29) Excision of lesions, benign;

(30) Eye care medical treatment;

(31) Eye exam;

(32) Gastrointestinal endoscopy;

(33) General psychiatric care on an inpatient basis;

(34) Incision and drainage, deep abscess;

(35) Injection of eye drug;

(36) Injection of spine;

(37) Injection of tendon or joint;

(38) Insertion or removal of intrauterine contraceptive device;

(39) Knee arthroscopy;

(40) Laparoscopic surgery;

(41) Laryngoscopy;

(42) Nasal endoscopy;

(43) Non-routine venipuncture;

(44) Occupational therapy;

(45) Osteopathic manipulation;

(46) Paring or cutting benign lesion;

(47) Partial mastectomy;

(48) Peripherally inserted central catheter (PICC);

(49) Psychiatric diagnostic evaluation with medical services;

(50) Renal dialysis;

(51) Routine endoscopy;

(52) Routine pre-natal care;

(53) Skin graft;

(54) Speech therapy;

(55) Spinal injection or nerve block;

(56) Surgical debridement of nails;

(57) Thoracentesis;

(58) Wax or foreign body removal from ear;

(59) Wound debridement; and

(61) X-ray absorptiometry or bone density study.

(d) The following services shall be classified as “Specialized” services for purposes of network adequacy review:

(1) Alcohol or drug acute detox;

(2) Allergy testing;

(3) Amputation of toe or foot;

(4) Arthrodesis;

(5) Biopsy or excision of lymph nodes;

(6) Bone biopsy or procedure to obtain tissue;

(7) Breast repair or reconstruction;

(8) Bronchoscopy;

(9) Cardiac catheterization;

(10) Complete mastectomy;

(11) Complex endoscopy;

(12) Dental prosthodontics which are fixed;

(13) Draw blood off cardiovascular venous device;

(14) Emergency endotracheal intubation;

(15) Excision of lesions, malignant;

(16) Hysterectomy;

(17) Incision and drainage, skin or wound;

(18) Insertion of central venous catheter;

(19) Low back disk surgery;

(20) Magnetic resonance imaging (MRI) of lower extremity;

(21) Radiation therapy;

(22) Radiation treatment;

(23) Radiation treatment management;

(24) Repair of shoulder joint;

(25) Replacement of aortic valve;

(26) Routine obstetrical care with vaginal delivery;

(27) Spinal bone autograft or allograft;

(28) Spinal instrumentation;

(29) Surgical laparoscopy;

(30) Surgical vascular endoscopy;

(31) Tibia fracture treatment;

(32) Total hip replacement;

(33) Total knee replacement; and

(34) Treatment of ankle fracture.

(e) All other covered services shall be available from providers within New England.

(f) Prescription medications from a retail pharmacy shall be available within the time and distance standards equal to those associated with the “Core” services for a specific county.

History

#7701, eff 8-1-02; ss by #9399, eff 3-1-09; ss by #9722, eff 8-1-10 (from Ins 2701.05); ss by #12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.08 Exceptions {#sec-ins-2701.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.08}

(a) The department shall grant a carrier an exception to the standards for geographic accessibility in Ins 2701.06 where:

(1) A health carrier demonstrates that an insufficient number of qualified providers or facilities are available in the county to meet the geographic accessibility standards contained in Ins 2701.06;

(2) A health carrier demonstrates that the carrier’s failure to develop a provider network in a given county that is sufficient in number and type of providers to meet all of the standards in Ins 2701.06 is due to the refusal of a local provider to accept a commercially reasonable rate, fee, term, or condition and that the health carrier has taken steps to effectively mitigate the detrimental impact on covered persons;

(3) A health carrier demonstrates that the required service can be obtained through the use of telemedicine or telehealth from an in-network participating provider;

(4) A health carrier arranges to pay for the required service from an out-of-network provider, and the member is informed prior to the treatment that they can access services from the provider with no additional cost sharing beyond the benefit patient responsibility to an in-network provider; or

(5) A health carrier has requested and been granted a waiver under Ins 2701.14 with respect to another component of the geographic accessibility standard.

(b) The department shall grant a carrier an exception excluding one or more of the services listed in Ins 2701.07 from the network adequacy analysis where a health carrier can establish that the service in question is not a covered service for the health benefit plan to which the network applies and that exclusion of the service is appropriate for that coverage.

History

#7701, eff 8-1-02; ss by #9399, eff 3-1-09 ss by #9722, eff 8-1-10 (from Ins 2701.06); ss by #12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.09 Standards for Waiting Times for Appointments and Access to After-Hours Care {#sec-ins-2701.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.09}

(a) Standard waiting times for appointments shall be measured from the initial request for an appointment.

(b) For behavioral health services, the carrier shall ensure that covered persons may obtain an initial appointment with an in-network provider within:

(1) Six hours for a non-life-threatening emergency;

(2) Forty-eight hours for urgent care; and

(3) Ten business days for an initial or evaluation visit.

(c) For primary care provider services, the carrier shall ensure that covered persons may obtain an initial appointment with an in-network provider within:

(1) Forty-eight hours for urgent care; and

(2) Thirty days for other routine care, including an initial or evaluation visit.

(d) For substance use disorder services for which prior authorization requirements are governed by RSA 420-J:17, health carriers shall comply with the requirements of that section.

(e) For services not governed by RSA 420-J:17, health carriers shall ensure that all covered persons have access to a utilization reviewer to make prior approval or pre-authorization decisions if required under the terms of the coverage.

History

#9722, eff 8-1-10 (from Ins 2701.07); ss by #12565, eff 8-1-18 (formerly Ins 2701.07)

N.H. Code Admin. R. Ann. Ins 2701.10 Choice of and Access to Providers of Specialty Care {#sec-ins-2701.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.10}

(a) Each health carrier shall establish policies and procedures through which a member with a condition that requires care from a specialist may obtain a referral to a network specialist or specialist group practice, subject to the utilization review procedures used by the health carrier. For purposes of this provision, “referral” means a referral for care to be provided by a network specialist or specialist group practice that authorizes a visit or series of visits with the specialist or specialist group practice for either a specific time period or a limited number of visits and which is provided according to a treatment plan developed by the covered person’s primary care provider, a specialist, the covered person, and the plan. The carrier shall not require an additional referral to the same specialist or specialist group practice within 6 months, when the patient is expected by the referring provider to need care for at least this period of time. The carrier shall accept a referral that is made to a specialist group practice and shall not require the referring provider to specify an individual practitioner in the referral.

(b) Each health carrier shall ensure that covered persons may obtain a referral to a health care provider outside of the health carrier’s network when the health carrier does not have a health care provider with appropriate training and experience within its network who can meet the particular health care needs of the covered person. Services provided by out-of-network providers shall be subject to the utilization review procedures used by the health carrier. The covered person shall not be responsible for any additional costs incurred by the health carrier under this paragraph other than any applicable co-payment, coinsurance, or deductible.

History

#9722, eff 8-1-10 (from Ins 2701.08); ss by #12565, eff 8-1-18 (formerly Ins 2701.08)

N.H. Code Admin. R. Ann. Ins 2701.11 Reporting Requirement {#sec-ins-2701.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.11}

(a) Each health carrier shall, by July 1 or at the time its plans and rates for the upcoming plan year are filed with the department for review, include a network provider listing for each of the health benefit plans that the carrier offers in this state using a template provided by the commissioner. The network adequacy filing shall include a certification of compliance with the requirements of this part and shall be signed by an authorized representative of the company. The carrier shall certify that the provider listing is accurate with provider contracts effective at the time of the submission. If there are anticipated losses of in-network providers that will take place within the following 60 days, the carrier shall disclose this with the network filing. The carrier may indicate that a potential contract dispute and the anticipated provider losses are confidential, and the department shall not release this information if so designated. The carrier shall identify any services or locations in which the provider contract excludes services the provider typically performs and that are a covered benefit.

(b) The network adequacy filing prepared by the health carrier shall use a template provided by the commissioner which shall describe and contain the following:

(1) A description of the network associated with each health benefit plan offered by the carrier, including a list of the network providers as follows:

a. For each plan, required information shall include:

Plan identifier;
Network name; and
New Hampshire hospitals in network;

b. For each provider, required information shall include:

Provider name;
Carrier specific provider identifier number;
National provider identifier (NPI) number;
Provider address; and
Indication of any services included in the network adequacy requirement that are exclusively provided through telemedicine or telehealth; and

c. For each network, required information shall include:

Network name;
Network ID; and
Network URL;

(2) The health carrier’s procedures for making referrals within and outside its network;

(3) The health carrier’s process for monitoring and assuring on an ongoing basis the sufficiency of its network to meet the health care needs of persons who enroll in managed care plans;

(4) The health carrier’s method of informing covered persons of the requirements and procedures for gaining access to network providers, including but not limited to the following:

a. The process for choosing and changing network providers;

b. The process for providing and approving emergency, urgent, and specialty care;

c. The identity of all of the plan’s participating providers and facilities, including a specification of those participating providers, if any, that are accessible only at a reduced benefit level; and

d. Whether and when referral options are restricted to less than all providers in the network who are qualified to provide covered specialty services;

(5) The health carrier’s system for ensuring the coordination of care for covered persons referred to specialty providers, for covered persons using ancillary services, including social services, behavioral health services, and other community resources, and for ensuring appropriate discharge planning;

(6) The health carrier’s process for enabling covered persons to change primary care providers; and

(7) The health carrier’s proposed plan for providing care in the event of contract termination between the health carrier and any of its participating providers or in the event of the health carrier’s insolvency or other inability to continue operations, explaining how impacted covered persons will be notified of the contract termination, or the health carrier’s insolvency or other cessation of operations, and transferred to other providers in a timely manner.

(c) If the identical provider network is associated with more than one health benefit plan, a single network adequacy filing shall be prepared for that network, and a single health care certification of compliance report shall be filed. The network adequacy report shall identify all health benefit plans using the identical provider network.

(d) In addition to the annual network adequacy filing, a carrier shall notify the commissioner in writing, including identifying the providers, within 10 days of any of the following events:

(1) The net loss of 10% or more of its total number of primary care providers in any county within any 30-day period;

(2) The net loss of 10% or more of its total number of providers performing individual or group counseling for mental health or substance use disorders in any county within any 30-day period;

(3) The loss of one or more network hospitals; or

(4) In the carrier’s estimation, the product network is no longer meeting a network adequacy standard with respect to one or more counties.

(e) The carrier shall supply the commissioner with a new provider file within ten days of a request by the commissioner.

(f) A carrier introducing a new product with a new network shall submit the network adequacy report in conjunction with the rate and form filing, reflecting the network contracts in place as of the date of filing. If the network associated with the new product is unchanged except for typical minor changes that take place over time as providers move in and out of regions, the carrier is not required to submit a network filing but shall identify the previously submitted network associated with the new product.

History

#12565, eff 8-1-18 (formerly Ins 2701.09)

N.H. Code Admin. R. Ann. Ins 2701.12 Provider Directories {#sec-ins-2701.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.12}

(a) For each of its network plans, a health carrier shall electronically post and maintain a current and accurate provider directory in accordance with the following requirements and with the information and search functions described in (c) below:

(1) In making the directory available electronically, the health carrier shall ensure that the general public is able to view all of the current providers for a plan through a clearly identifiable link or tab, without creating or accessing an account or entering a policy or contract number;

(2) The health carrier shall update the provider directory for each network plan at least monthly;

(3) The health carrier shall periodically audit its provider directories for accuracy and retain documentation of such an audit to be made available to the commissioner upon request;

(4) For each network plan, a health carrier shall include, in an electronic directory, the following information stated in plain language:

a. A description of the criteria the carrier used to build its provider network;

b. If applicable, a description of the criteria the carrier used to tier providers;

c. If applicable, a description of the different provider tiers or levels in the network and, for each provider, hospital, or other type of facility in the network, identification of the tier in which each is placed; and

d. If applicable, disclosure that a specific provider is a network plan provider only for the specific services listed with the disclosure;

(5) A health carrier shall clearly indicate which provider directory applies to which network plan, including the specific name of the network plan as marketed and issued in this state;

(6) A health carrier shall include a customer service email address and telephone number or electronic link that covered persons or the general public may use to notify the health carrier of inaccurate provider directory information; and

(7) For the information required pursuant to (b), (c), and (d) below, a health carrier shall indicate in the directory the source of the information and any limitations, if applicable.

(b) For each network plan, the health carrier’s electronic provider directory shall include the following information in a searchable format:

(1) For health care professionals:

a. Name;

b. Gender;

c. Participating office location(s);

d. Specialty, if applicable;

e. Medical group affiliations, if applicable;

f. Facility affiliations, if applicable;

g. Participating facility affiliations, if applicable;

h. Languages spoken other than English, if applicable; and

i. Whether accepting new patients;

(2) For hospitals:

a. Hospital name;

b. Hospital type, for example, acute, rehabilitation, children’s, cancer, etc.;

c. Participating hospital location; and

d. Hospital accreditation status; and

(3) For facilities other than hospitals:

a. Facility name;

b. Facility type;

c. Types of services performed; and

d. Participating facility location(s).

(c) For each network plan, a health carrier shall make available in its electronic provider directory, the following information:

(1) For health care professionals:

a. Contact information;

b. Board certification(s); and

c. Languages spoken other than English by clinical staff, if applicable; and

(2) For hospitals and other facilities, a telephone number.

(d) Each directory shall include a date and a customer service telephone number and be accompanied by a disclosure by the health carrier that the information in the directory is accurate as of the date of printing and that covered persons or prospective covered persons should consult the carrier’s electronic provider directory or call the customer service number to obtain current provider directory information.

History

#12565, eff 8-1-18

N.H. Code Admin. R. Ann. Ins 2701.13 Enforcement {#sec-ins-2701.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.13}

If the commissioner determines that a health carrier has not contracted with a sufficient number of participating providers to assure that covered persons have accessible health care services in a geographic area or that a health carrier’s health care certification of compliance report does not assure reasonable access to covered benefits, the commissioner shall issue an order requiring the health carrier to institute a corrective action, or shall use other enforcement powers under RSA 420-J to ensure that covered persons have access to covered benefits.

History

#12565, eff 8-1-18 (formerly Ins 2701.10)

N.H. Code Admin. R. Ann. Ins 2701.14 Waiver of Rules {#sec-ins-2701.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 2701.14}

(1) Applying the rule provision would cause confusion or would be misleading to

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) The commissioner shall report publicly any waiver granted on the department’s website at https://www.nh.gov/insurance/.

History

#12565, eff 8-1-18

Part Ins 2702 Parity in Mental Health and Substance Use Disorder Benefits

N.H. Code Admin. R. Ann. Ins 2702.01 Purpose {#sec-ins-2702.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2702.01}

The purpose of these rules is to implement the requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as amended, for group health insurance coverage that is provided to employers.

History

#9809, eff 11-8-10; ss by #12685, eff 12-3-18

N.H. Code Admin. R. Ann. Ins 2702.02 Scope and Applicability {#sec-ins-2702.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2702.02}

The requirements of this part shall apply to all health insurance issuers offering health insurance coverage in connection with a group health insurance plan that provides coverage to a group employer.

History

#9809, eff 11-8-10; ss by #12685, eff 12-3-18

N.H. Code Admin. R. Ann. Ins 2702.03 Definitions {#sec-ins-2702.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2702.03}

(a) “Group health insurance coverage” means, for the purpose of Ins 2702, health coverage sold under RSA 420-G:2 IV.

(b) “Mental health benefits” means benefits with respect to services for mental health conditions, as defined under the terms of group health insurance coverage, and in accordance with applicable federal and state law.

(c) “Substance use disorder benefits” means benefits with respect to services for substance use disorders, as defined under the terms of the group health insurance coverage, and in accordance with applicable federal and state law.

History

#9809, eff 11-8-10; ss by #12685, eff 12-3-18

N.H. Code Admin. R. Ann. Ins 2702.04 Parity Requirements {#sec-ins-2702.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2702.04}

Group health insurance coverage offered by an insurer in connection with a group health plan issued to an employer and that provides health coverage sold under RSA420-G:2, IX must offer mental health and substance use disorder benefits coverage as required under RSA 415:18-a in compliance with the federal MHPAEA of 2008, as amended, and federal regulations adopted thereunder.

History

#9809, eff 11-8-10; ss by #12685, eff 12-3-18

N.H. Code Admin. R. Ann. Ins 2702.05 Waiver of Rules {#sec-ins-2702.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2702.05}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

History

#9809, eff 11-8-10; ss by #12685, eff 12-3-18

Part Ins 2703 External Review

N.H. Code Admin. R. Ann. Ins 2703.01 Applicability and Scope {#sec-ins-2703.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.01}

(a) Except as provided in (b) below, the external review requirements set forth in this part shall apply to all health carriers that makes an adverse determination concerning a covered person.

(b) The external review requirements set forth in this part shall not apply to determinations relating to health care services, items, or drugs available under the coverages of programs listed below:

(1) Long-term care insurance, as defined by RSA 415-D:3, V;

(2) Coverage under a plan through Medicare, Medicaid, and the state Children’s Health Insurance Program, under Title XXI of the Social Security Act, including services provided under these programs but through a contracted health carrier;

(3) Health care services provided to inmates by the department of corrections;

(4) The federal employees health benefits program;

(5) Coverage issued under chapter 55 of title 10 of the United States Code regarding medical and dental care for members of the Armed Forces;

(6) Coverage issued as supplemental to liability insurance, workers’ compensation or similar insurance, automobile medical-payment insurance, or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket or individual basis; or

(7) Health care services provided pursuant to a health plan not regulated by the state, such as self-funded plans administered by an administrative services organization or third-party administrator.

(c) The external review procedures set forth in this chapter shall not be utilized to adjudicate claims or allegations of health care provider malpractice, professional negligence, or other professional fault against participating providers or medical directors.

History

#7539, eff 8-1-01; ss by 8862, eff 5-1-07 (from 2703.02); ss by#10918, eff 9-1-15; ss by #14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.02 Definitions {#sec-ins-2703.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.02}

For the purpose of this part:

(a) "Adverse determination" means “adverse determination” as defined in RSA 420-J:3, I;

(b) “Authorized representative” means authorized representative” as defined in RSA 420-J:3 III;

(d) “Coverage denial” means a denial, reduction, or termination by a health carrier of a requested health care service, supply, or drug, or a denial of payment for such, which is made on the basis of a finding by the health carrier that the requested service, supply, or drug is specifically excluded from coverage under the terms of the covered person’s health benefit plan and is therefore not a covered benefit;

(e) “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan;

(f) “Department” means the insurance department;

(g) “Disclose” means to release, transfer, or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information;

(h) “Final adverse determination” means an adverse determination that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier’s standard, second level grievance review process as set forth in RSA 420-J:5, V or expedited, second level grievance review process as set forth in RSA 420-J:5, V(e)(1);

(i) "Health care services" means "health care services" or "health services" as defined in RSA 420-J:20, XXII namely "services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury or disease." This term includes "health services";

(j) "Health carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurance company, a health maintenance organization, a health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services;

(k) “Health information” means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to:

(1) The past, present, or future physical, mental, or behavioral health or condition of an individual or a member of the individual’s family;

(2) The provision of health care services to an individual; or

(3) Payment for the provision of health care services to an individual;

(l) "Independent review organization" means “independent review organization” as defined in RSA 420-J:3, XXIII-a;

(m) “Protected health information” means health information:

(1) That identifies an individual who is the subject of the information; or

(2) With respect to which there is a reasonable basis to believe that the information could be used to identify an individual;

(n) “Utilization review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques can include ambulatory review, prospective review, second opinion, concurrent review, or retrospective review; and

(o) “Utilization review organization” means an entity that conducts utilization review, other than a health carrier performing a review for its own health plans.

History

#7539, eff 8-1-01; ss by #8862, eff 5-1-07 (from Ins 2703.01); ss by #10918, eff 9-1-15; ss by #14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.03 The Right to External Review {#sec-ins-2703.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.03}

(a) A covered person shall have the right to independent external review of an adverse determination made by a health carrier as provided in RSA 420-J:5-a.

(b) Coverage denials concerning requested health care services, items, or drugs that could not be considered a covered benefit under any circumstance shall not be eligible for external review. However, a covered person may receive external review of a benefit denial if it is also an adverse determination.

(1) Experimental or investigational treatments, where the health carrier denies requested care because the covered person’s health benefit plan does not cover experimental or investigational treatment, but the covered person requests external review on the basis that the treatment in question is not experimental or investigational;

(2) Cosmetic procedures, where the health carrier denies requested care because the covered person’s health benefit plan does not cover cosmetic procedures, but the covered person requests external review on the basis that the service is needed for medical rather than cosmetic reasons;

(3) Access to out-of-network health care professionals or providers, where the health carrier denies a referral because treatment by out-of-network professionals or providers is not covered unless the appropriate clinical expertise is not available within the health carrier’s network, but the covered person requests external review on the basis that the health carrier’s provider network does not include professionals or providers with the appropriate clinical expertise;

(4) Coverage for drugs that are not on the formulary, but the covered person requests external review on the basis that the specific drug is medically necessary and there is no alternative drug available on the formulary; and

(5) Coverage for health services necessary to diagnose a medical condition, such as infertility, even if interventions to overcome the condition, such as interventions to achieve pregnancy, are excluded from coverage.

(d) In addition to the appeal rights that exist upon completion of internal review, a covered person shall have the right to independent external review when, pursuant to the provisions of RSA 420-J:5-a, I(b), the health carrier agrees to submit the determination to independent external review prior to completion of internal review.

History

#7539, eff 8-1-01; ss by #8862, eff 5-1-07; ss by #10918, eff 9-1-15; ss by #14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.04 Notice of Right to External Review {#sec-ins-2703.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.04}

(a) Health carriers shall prominently display on the carrier’s website notice of the right to external review and shall ensure the covered person received written notice electronically or by mail of the right to external review in each of the following circumstances:

(1) At the time the policy, certificate, membership booklet, or other evidence of coverage is provided to covered persons;

(2) At the time the final adverse determination is provided to covered persons upon completion of internal grievance review or expedited internal grievance review;

(3) Pursuant to the provision of RSA 420-J:5-a, I(b), if the health carrier has agreed to submit the determination to independent external review prior to completion of internal review; and

(4) If the covered person has requested standard or expedited internal grievance review, and the health carrier has failed to issue a decision within the required time frames, at the expiration of the time period for issuing the decision.

(b) The notice of the right to external review shall be:

(1) In bold;

(2) Set out in at least 16 point type, and the remainder of the text in at least 12 point type; and

(3) Printed as follows:

“NOTICE OF RIGHT TO AN EXTERNAL APPEAL

OF YOUR HEALTH INSURER’S DECISION

You may have a legal right to have our decision reviewed by an organization that is independent and neutral after we have made our final decision or earlier if we agree. This process is called Independent External Review and is overseen by the New Hampshire Insurance Department. There is no cost to you for an external appeal.

YOU MUST ASK FOR THIS REVIEW NO LATER THAN 180

DAYS AFTER THE DATE OF OUR FINAL DENIAL DECISION

A request for independent external review may be completed electronically through a secure portal on the New Hampshire Insurance Department’s website https://www.insurance.nh.gov/consumers/health-insurance/independent-external-review.

To request an independent external review, consult the Managed Care Consumer Guide to External Appeal at https://www.insurance.nh.gov/sites/g/files/ehbemt861/files/imported-files/ex_rev_guide.pdf and fill out the Request for Independent External Appeal of a Health Care Decision at https://www.insurance.nh.gov/sites/g/files/ehbemt861/files/imported-files/external-health-review-application-form.pdf. Please attach all supporting documentation.

If your medical condition is such that waiting for the standard external review process to be completed would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, you may be eligible for expedited external review.

You may file your completed Request for Independent External Appeal of a Health Care Decision by uploading to the Department’s secure online portal https://www.insurance.nh.gov/consumers/health-insurance/independent-external-review or by mailing or delivering the required documentation to:

Independent External Review

New Hampshire Insurance Department

21 South Fruit St., Suite 14

Concord, NH 03301

If you have any questions about the external review process, please call the New Hampshire Insurance Department at 1-800-852-3416 and ask to speak to a consumer assistant.”

History

#7539, eff 8-1-01; ss by #8862, eff 5-1-07; ss by #10918, eff 9-1-15; ss by #14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.05 Request for External Review {#sec-ins-2703.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.05}

(a) The commissioner shall develop and make available on the department’s website an application form for requesting external review consistent with RSA 420-J:5-a through 420-J:5-e and a consumer manual with directions for how to pursue external review of an adverse determination.

(b) A covered person shall be able to request an external review by the following methods:

(1) Uploading the completed request form for independent external appeal of a health care decision and supporting documentation to the department’s secure online portal at https://www.insurance.nh.gov/consumers/health-insurance/independent-external-review; and

(2) Mailing or delivering the completed request form for independent external appeal of a health care decision and supporting documentation to:

Independent External Review

New Hampshire Insurance Department

21 South Fruit St., Suite 14

Concord, NH 03301

History

#7539, eff 8-1-01; ss by #8862, eff 5-1-07; ss by #10918, eff 9-1-15; ss by #14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.06 Responsibilities of Health Carriers {#sec-ins-2703.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.06}

(a) The health carrier shall pay the cost of the external review to the independent review organization within 5 days of receiving notice of the acceptance of the external review.

(b) Failure by the health carrier or the covered person to provide the documents and information required in RSA 420-J:5-b, IV(a) or RSA 420-J:5-b, VII within the specified time frame shall not delay the conduct of the external review. If, upon receipt of a notice from the insurance department, the health carrier or its designee utilization review organization has failed to provide the documents and information within the specified time frame, the commissioner shall terminate the external review and reverse the adverse determination or final determination.

(c) Upon receipt of a notice of an independent review organization decision reversing an adverse determination, the health carrier shall approve the coverage that was the subject of the adverse determination and provide written confirmation of its approval to the insurance department within 48 hours of receipt of notice. The confirmation provided to the insurance department shall include a copy of the claim redetermination notice.

(d) The health carrier may reconsider the adverse determination at any time prior to receiving the external review decision.

(e) Immediately upon making the decision to reverse its adverse determination, the health carrier shall notify the covered person, and if applicable, the covered person’s authorized representative, the selected independent review organization, and the commissioner in writing of its decision and shall approve the coverage that was the subject of the adverse determination or final adverse determination. The selected independent review organization shall terminate the external review upon receipt of the notice from the health carrier and verification that coverage was approved. The health carrier shall be entitled to a refund of half of the fee paid to the independent review organization if the carrier reverses its decision prior to the independent review organization’s decision on the external review request.

(f) If the expedited external review concerns a concurrent review determination, the service shall be continued pending the completion of the external review process. A covered person shall not be held liable to either the health plan, the hospital, the physician, or the services provider for the cost of services in excess of the applicable co-payment, coinsurance, or deductible incurred, pending the independent review organization's determination of an expedited external review.

History

#14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.07 Certification of Independent Review Organizations {#sec-ins-2703.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.07}

(a) An independent review organization seeking certification shall supply the following information in a form as adopted by the commissioner and made available on the department’s website:

(1) Name, address, and telephone number of the organization;

(2) The name, address, and telephone number of the chief executive officer;

(3) The tax status and federal employer tax identification number;

(4) The list of states where the organization is incorporated, licensed, certified, or otherwise authorized to conduct business;

(5) A description of the organizational structure that identifies and explains the lines of authority within the organization itself and if applicable within a holding company or parent subsidiary system;

(6) A description of the management of the organization, including the files and management responsibilities of the staff;

(7) A description of the contracted service providers and clinical peer reviewers, as well as a description of the procedures used to ensure the adequacy of the network of clinical peer reviewers retained by the organization and the procedures used to ensure that the peer reviewers are adequately trained and appropriately licensed;

(8) A list of all reviewers in the clinical peer review network including the name, license number, and clinical discipline of each reviewer;

(9) A description and copy of the quality assurance program established by the organizations, which specifically address the policies and procedures used to protect the confidentiality of medical and treatment records;

(10) The name of the medical director, and a description of the medical director's qualifications;

(11) A description of the procedures that will be used to ensure that standard and expedited appeals are conducted within the required time frames;

(12) A description of the current financial status of the organization, including the most recent certified financial statement;

(13) A list of fees that will be charged for independent review and an explanation of the methodology used to develop the fee schedule;

(14) A conflict of interest attestation signed by each owner, officer, director, medical director, or management employee of the applicant, which shall be supported by personal information including the name, address, telephone number, and the person's 10 year employment history;

(15) A statement verifying that any person subject to the requirement of filing a conflict of interest attestation has submitted a report of their history of legal actions, as well as a report of their affiliation with other health care corporations; and

(16) Evidence of accreditation by a nationally recognized private accrediting entity with established and maintained standards for independent review organizations.

(b) The application for certification shall be signed by the chief executive officer or the board chairman who shall attest to its accuracy.

History

#7539, eff 8-1-01; ss by #8862, eff 5-1-07; ss by #10918, eff 9-1-15; ss by #14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.08 Independent Review Organizations Requirements {#sec-ins-2703.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.08}

(a) The independent review organization shall retain all files, records, and data received or created in conjunction with external reviews conducted for at least 5 years.

(b) Any and all reports, records, files, or data received or created in conjunction with external reviews conducted shall be provided to the commissioner within 10 days of the request.

(c) An independent review organization and the commissioner shall not disclose protected health information regarding covered persons that is collected in the external appeal process and shall take reasonable steps to monitor the security of the confidential data.

(d) An independent review organization shall report any breach in confidentiality immediately to the commissioner. All aspects of both the standard external review process and the expedited external review process shall meet or exceed the minimum standards for state external review processes set forth in 45 CFR § 147.136.

History

#14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.09 General Provisions Regarding External Review {#sec-ins-2703.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.09}

(a) The commissioner shall periodically review the accreditation for all certified independent review organizations.

(b) Certified independent review organizations that fail to maintain their accreditation by a nationally recognized private accrediting entity with established and maintained standards for independent review organizations shall immediately report the loss of accreditation to the commissioner.

(c) An independent review organization shall establish and review annually policies and procedures that cover all aspects of both the standard external review process and the expedited external review process set forth in this part and shall include, at minimum, a quality assurance mechanism in place that ensures external reviews are conducted within the specified time frames of RSA 420-J:5-b and RSA 420-J:5-c and required notices are provided in a timely manner, the selection of an adequate number of qualified and impartial clinical reviewers, confidentiality of records and clinical review criteria, and that any person employed by or under contract with the independent review organization complies with the same requirements.

History

#7539, eff 8-1-01; ss by #8862, eff 5-1-07; ss by #10918, eff 9-1-15; ss by #14595, eff 5-22-26, EXPIRES: 5-22-36

N.H. Code Admin. R. Ann. Ins 2703.10 Waiver of Rules {#sec-ins-2703.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2703.10}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

History

#14595, eff 5-22-26, EXPIRES: 5-22-36

Part Ins 2704 Pharmacy Benefits Managers

N.H. Code Admin. R. Ann. Ins 2704.01 Purpose {#sec-ins-2704.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.01}

The purpose of this part is to provide for the regulation and registration of pharmacy benefits managers (PBMs) and to set forth rules which the commissioner deems necessary to carry out the provisions of RSA 402-N.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.02 Definitions {#sec-ins-2704.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.02}

(a) “Annual report” means a report of the data required to be submitted annually in accordance with RSA 402-N:6.

(b) "Commissioner" means the insurance commissioner.

(c) “Covered benefits” means those health care services and other medical services to which a covered person is entitled under the terms of a health benefit plan, including pharmacy benefits.

(d) “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.

(e) “Contracted copayment” means a fixed amount a covered person is responsible to pay for covered prescriptions as set forth in the health benefit plan, or the price for filling the prescription as contracted between the health carrier or its pharmacy benefits manager and the pharmacy, whichever is less.

(f) “Department” means the New Hampshire Insurance Department.

(g) “Health benefit plan” means a plan, policy, or certificate of insurance that constitutes health coverage as defined in RSA 420-G:2, IX.

(h) “Health carrier” means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the covered costs of health care services, including an insurance company, a health maintenance organization, a health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services.

(i) “New Hampshire pharmacy board” means the board established in RSA 318:2.

(j) “Participating pharmacy” means a pharmacy that, under a contract with the health carrier or its contractor or subcontractor, including any pharmacy benefits manager, has agreed to provide pharmacy services to covered persons with an expectation of receiving payment, other than coinsurance, co-payments, or deductibles, directly or indirectly, from the health carrier.

(k) “Pharmacist” means a person defined in RSA 402-N:1, V.

(l) “Pharmacy benefits manager”' means a “pharmacy benefits manager” as defined in RSA 402-N:1, VIII.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.03 Registration {#sec-ins-2704.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.03}

(a) No person or entity shall manage the prescription drug coverage provided by a health carrier without registering with the department as a PBM. All PBMs shall complete and submit an application PBM-R “Application for Registration: Initial Application or Renewal Application” (May 2020), available at: https://www.nh.gov/insurance/companies/applications/index.htm.

(b) The registration application shall be completed and signed by an officer or authorized representative of the PBM and filed with the department along with a filing fee of $500.

(c) A PBM shall notify the commissioner in writing of any change in the information required to be filed under these rules, including a change of address or name, no later than 30 days after the change.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.04 Registration Renewal and Annual Reports {#sec-ins-2704.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.04}

(a) All PBMs shall submit a renewal fee of $100 and complete and submit a renewal application PBM-R “Application for Registration: Initial Application or Renewal Application” (May 2020), available at: https://www.nh.gov/insurance/companies/applications/index.htm, by March 1 each year.

(b) No registration shall be renewed unless the PBM has submitted an annual report as required by RSA 402-N:6, I.

(1) Carrier plan code or name;

(2) Health carrier’s National Association of Insurance Commissioners company code;

(3) Plan code as defined in Ins 4010.07(c);

(4) Total amount spent on drugs prior to rebates; and

(5) Aggregate amount of all rebates collected from pharmaceutical manufacturers that were

attributable to patient utilization in New Hampshire.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.05 Claims Processing {#sec-ins-2704.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.05}

(a) Every health carrier that provides prescription benefits as a covered benefit under a health benefit plan shall ensure that prescription benefit claims are adjusted and paid in accordance with the requirements of Ins 1001 and RSA 420-J:8-a.

(b) Any health carrier or PBM shall require all participating pharmacies to charge any covered person the lesser of:

(1) The pharmacy’s usual and customary price for filling the prescription; or

(2) The contracted copayment.

(c) The health carrier or PBM shall not be in violation of this section when the conditions set forth in RSA 420-J:8-a, IV exist or the claim has been submitted fraudulently or with inaccurate or misrepresented information.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.06 Complaint Process {#sec-ins-2704.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.06}

(a) Any pharmacy that fills prescriptions as a covered benefit under a health benefit plan and is adversely affected by the failure of a health carrier or a PBM to comply with RSA 420-J:7-b, X or RSA 415:26 may file a complaint with the commissioner.

(b) Complaints alleging violations of RSA 420-J:b, X or RSA 415:26 and received directly from pharmacies or referred from the New Hampshire pharmacy board to the commissioner shall be investigated by the commissioner in accordance with the provisions of RSA 400-A:16.

(c) The commissioner shall only investigate substantiated complaints that relate to a fully insured plan within the commissioner’s jurisdiction.

(d) A “substantiated complaint” means a complaint that includes all the following information:

(1) The name, address, and license number of the pharmacy filing the complaint;

(2) The name and license number of, and the contact information for, a pharmacist who supports the allegations in the complaint filed;

(3) Information concerning the prescription, including the name of the prescription dispensed and the quantity and dose of the prescription dispensed, with units expressed in terms of volume, number of tablets or capsules, weight, or in other measurement;

(4) The name of the health carrier and the name of the pharmacy benefits manager, if a pharmacy benefits manager is involved in the prescription claim made by the consumer;

(5) A legible copy of the front and back of the consumer’s insurance card for prescription benefits;

(6) The name of the subscriber to the health benefit plan, if that information is not shown on the consumer’s insurance card;

(7) The date the pharmacy dispensed the prescription to the consumer;

(8) The name of the consumer that requested coverage for the prescription at issue in the complaint; and

(9) Written evidence that supports the allegations of violation.

(e) The commissioner shall inform the pharmacy if the filed complaint is unsubstantiated and what missing information is needed.

(f) The commissioner shall hold any complaint that is not substantiated in pending status for 90 days from the date of the notice described in (e) to allow the pharmacy to submit required missing information. If missing information is not provided within 90 days of the date of the notice described in (e), the complaint that is not substantiated shall be closed.

(g) Any consumer may file a complaint with the commissioner. Consumer complaints shall be investigated in accordance with RSA 400-A:15-e.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.07 Enforcement {#sec-ins-2704.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.07}

A PBM shall be subject to the provisions of RSA 402-N:2, III for the following reasons:

(a) Failure to comply with any provisions of this part or of RSA 402-N;

(b) Failure to comply with any lawful order of the commissioner;

(d) Filing an application or any necessary forms with the department which contain fraudulent information or omissions;

(e) Misappropriation, conversion, illegal withholding, or refusal to pay over, upon proper demand, any monies that belong to a person otherwise entitled to them and that have been entrusted to the PBM;

(f) Evidence that an owner, principal, officer, partner, manager, director, trustee, or the PBM itself has:

(1) Had an insurance license or an application for an insurance license in any state denied, suspended, or revoked;

(2) Been the subject of a fine, penalty, order, withdrawal, or informal settlement with any state insurance department; or

(3) Pled guilty or no contest to any felony or misdemeanor; or

(g) Failure to meet any qualification for which registration would have been refused had such failure then existed and been known to the Department.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.08 Reporting to the New Hampshire Board of Pharmacy {#sec-ins-2704.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.08}

(a) The commissioner shall prepare public reports with regard to the complaints received from pharmacies or the New Hampshire board of pharmacy under this part.

(b) The public report shall contain the following information:

(1) A unique numerical identifier for each complaint received;

(2) The name, address, and license number of the pharmacy filing the complaint;

(3) The name and license number of the pharmacist who supports the allegations in the complaint filed;

(4) The name of the health carrier and the name of the PBM, if a PBM is involved in the prescription claim made by the consumer;

(5) The date the complaint was received;

(6) The nature of the complaint received, to include the prescription at issue, the facts concerning the complaint, and the section of rule or law that is alleged to have been violated;

(7) The status of the investigation or an indication that the complaint is in pending status, awaiting information from the pharmacy;

(8) The date of the final resolution of the complaint, if the complaint has been resolved; and

(9) A description of the final resolution of the complaint, to include the legal and factual findings of the commissioner as to the alleged violation.

(c) The report shall be posted electronically on the department’s website at http://www.nh.gov/insurance/ at least quarterly and shall also be transmitted to the New Hampshire board of pharmacy.

(d) The commissioner shall provide to any complaining pharmacy, upon request, a report of the status of complaints filed by that pharmacy, which shall contain the information set forth in (b) above.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.09 Confidentiality {#sec-ins-2704.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.09}

In accordance with RSA 400-A:16, III, RSA 402-N:6, II, and except as otherwise provided in this part, all information collected, obtained, or otherwise in the control or possession of the commissioner from any source relating to any investigation pursuant to this part shall be confidential by law and privileged, shall not be subject to RSA 91-A, shall not be subject to subpoena, and shall not be subject to discovery or admissible as evidence in any private civil action.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.10 Periodic Audit {#sec-ins-2704.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.10}

(a) The commissioner shall examine a PBM pursuant to RSA 400-A:37 and RSA 402-N:7. The cost of the audit shall be paid by the PBM pursuant to RSA 402-N:7. Audits shall include premium collection, claims processing, and marketing practices.

(b) The PBM shall have continuing access to all books and records in order to fulfill its contractual obligations.

(1) Be owned by the health carrier or the PBM;

(2) Conform to the standards of insurance record keeping required of insurers subject to filing an annual audited financial statement pursuant to RSA 400-A:36;

(3) Be retained for 5 years from the date of their creation; and

(4) Be subject to examination by the commissioner or the insurer for which the records are kept.

(d) Upon termination of an agreement between the PBM and the health carrier pursuant to the termination provisions in the agreement, the records may be transferred to a new PBM in lieu of the required 5 year retention. If such a transfer occurs, the new PBM shall acknowledge in writing receipt and responsibility for the transferred records.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.11 Inquiry by Commissioner {#sec-ins-2704.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.11}

(a) The commissioner shall address any inquiries to the PBM concerning its PBM business. The PBM shall reply in writing within 10 working days to any inquiry made by the commissioner pursuant to RSA 400-A:16, II.

(b) A PBM shall keep all complaints on file for a period of 5 years. Complaint information shall be made available to the department by the PBM upon the commissioner's request.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

N.H. Code Admin. R. Ann. Ins 2704.12 Waiver of Rules {#sec-ins-2704.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 2704.12}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) Any waiver granted shall expire no later than the end of the registration period. Upon renewal of the registration, the applicant may request another waiver.

History

(See Revision Note at part heading for Ins 2704) #13059, eff 6-29-20

Part Ins 2705 Uniform Prior Authorization Forms and Electronic Standard for Prescription Drug Benefits

N.H. Code Admin. R. Ann. Ins 2705.01 Purpose {#sec-ins-2705.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.01}

The purpose of these rules is to provide administrative simplification in the prior authorization process for prescription drugs, to encourage the use of electronic prior authorization technology, and to support adoption by health insurers, pharmacy benefits managers, and utilization review entities of nationally recognized standards or processes for electronic prior authorization of prescription drugs.

History

#12125, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 2705.02 Scope {#sec-ins-2705.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.02}

(a) These rules shall apply to:

(1) All health carriers, health maintenance organizations, health services corporations, and preferred provider programs in the state of New Hampshire in connection with managed care coverage governed by RSA 420-J or when using a utilization review entity subject to RSA 420-E;

(2) Any pharmacy benefits manager with which any of the aforementioned entities contracts to perform prior authorization services for prescription drug benefits; and

(3) All utilization review entities.

(b) These rules shall not apply to the Medicaid managed care program under RSA 126-A:5, XIX.

History

#12125, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 2705.03 Definitions {#sec-ins-2705.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.03}

(a) “Carrier clinical review criteria” means written criteria that use nationally accepted standards of medical practice consistent with RSA 420-J:6 VI, and that have been adopted and made public by a health insurer, pharmacy benefits manager, or utilization review entity for determining the circumstances in which use of a particular prescription drug is appropriate.

(b) “Electronic prior authorization” (ePA) means prior authorization processes conducted through a health carrier’s web portal or any other secure electronic manner of transmission.

(d) “Health insurer” means those health insurance companies subject to this rule pursuant to Ins 2705.02(a)(1).

(e) “Health maintenance organization” means “health maintenance organization” as defined in RSA 420-B:1.

(f) “Health services corporation” means “health services corporation” as defined in RSA 420-A:1.

(g) “Pharmacy benefits manager” means a person who performs pharmacy benefits management services, including a person acting on behalf of a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management services for a covered entity. “Pharmacy benefits management” means the administration of prescription drug benefits provided by a covered entity under the terms and conditions of the contract between the pharmacy benefits manager and the covered entity and the provision of mail order pharmacy services.

(h) “Preferred provider program” means a program in which a health insurer contracts with or designates preferred providers as defined in RSA 420-C:2.

(i) “Prescribing provider” means any person who is lawfully entitled to prescribe, administer, dispense, or distribute prescription drugs to patients.

(j) “Prescription drug” means:

(1) A drug dispensed from a pharmacy directly to the consumer which, under federal law, is required, prior to being dispensed or delivered, to be labeled with any of the following statements:

a. “Caution: federal law prohibits dispensing without prescription”;

b. “Caution: federal law restricts this drug to use by or on the order of the licensed veterinarian”; or

c. “RX only”; or

(2) A drug which is required by any applicable federal or state law or regulation to be dispensed on prescription only and that is dispensed from a pharmacy directly to the consumer.

(k) “Prior authorization” means utilization review conducted prior to a patient’s service or course of treatment.

(l) “Uniform prior authorization forms” means the forms set forth in Ins 2705.04(a) and to be used by health insurers, pharmacy benefits managers, and utilization review entities for prior authorization of prescription drugs pursuant to RSA 420-J:7-b, IV-c (b) and RSA 420-E:4-a, II. “Uniform prior authorization forms” includes both the versions of the forms that are prepopulated pursuant to Ins 2705.04(c) and those that are not prepopulated.

(m) “Utilization review entity” means any person, partnership, or corporation which provides utilization review services subject to RSA 420-E.

History

#12125, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 2705.04 Format of Uniform Prior Authorization Forms {#sec-ins-2705.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.04}

(a) The appearance of the uniform prior authorization forms shall be as illustrated in Appendix B.

(b) Health insurers, pharmacy benefits managers, and utilization review entities shall reproduce and accept the uniform prior authorization forms without changes except as provided in (c) below.

(c) Health insurers shall ensure that Section A “Destination of Request” of the uniform prior authorization forms is prepopulated before the forms are made available and accessible online pursuant to Ins 2705.05(a).

(d) The uniform prior authorization forms shall be completed as follows:

(1) Section A shall be pre-populated pursuant to paragraph (c) above, with the following information:

a. Insurer or Pharmacy Benefits Manager (PBM) Name – company to which the form shall be submitted;

b. Phone # – phone number for contacting the company regarding prior authorization;

c. Fax # – secure fax number for submitting the request; and

d. Electronic Prior Authorization Webpage – webpage for submitting prior authorization requests electronically, as applicable;

(2) Section B shall be completed by the prescribing provider to indicate the type of request being made by checking the appropriate box(es) to indicate:

a. Whether the request is being made for the first time or is a request for continuation or renewal of an existing prior authorization; and

b. Whether expedited review is being requested and, if so, the treating provider shall initial to make the following attestation:

“By initialing here, I, as the treating provider, attest to the fact that this request meets the URAC (Utilization Review Accreditation Commission) health accreditation standards for urgent care in that adherence to the standard timelines: a) could seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function; or b) would subject the patient to severe pain that cannot be adequately managed without the treatment being requested”;

(3) Section C shall be completed by the prescribing provider to provide identifying information about the patient for whom the drug is being requested as follows:

a. Patient’s Full Name – first, middle, and last name (or middle initial) of patient

and any suffix;

b. DOB – patient’s month, day, and year of birth;

c. Member ID # - patient’s insurer or PBM member identification number as displayed on the patient’s insurance card; and

d. Group # - patient’s insurer or PBM group number as displayed on the patient’s insurance card;

(4) Section D shall be completed by the prescribing provider to provide identifying and contact information for the prescribing provider as follows:

a. Prescribing Provider – name of the provider prescribing the medication being requested;

b. Phone # – phone number for contacting the prescribing provider regarding the prior authorization request;

c. Address – mailing address for sending prior authorization determinations to the prescribing provider;

d. Secure Fax # – secure fax number for sending prior authorization determinations to the prescribing provider;

e. Specialty – the prescribing provider’s specialty (if multiple, include the specialty relevant to the request);

f. Prescribing Provider NPI # - the prescribing provider’s National Provider Identifier number;

g. Prescribing Provider DEA # - the number assigned to the prescribing provider by the U.S. Drug Enforcement Administration allowing the provider to write prescriptions for controlled substances;

h. Prescriber Point of Contact (POC) Name – a person in the provider’s office (if different than the prescribing provider) that can be contacted regarding the prior authorization request;

i. POC Phone # – phone number for contacting the POC regarding the prior authorization request;

j. POC Secure Fax # – secure fax number for sending prior authorization determinations to the POC;

k. POC Email – email address for contacting the POC regarding the prior authorization request (not required); and

l. Signature / Date – form must be signed and dated by the prescribing provider or an authorized designee;

(5) Section E shall be completed by the prescribing provider to provide information about the patient’s diagnosis and the medication being requested as follows:

a. Primary Diagnosis Related to the Medication Request – patient’s diagnosis related to which the medication is being requested;

b. Medication Requested – medication name;

c. Strength – medication strength being prescribed;

d. Quantity – quantity of the medication being prescribed;

e. Dosing Schedule – frequency of administration of medication being prescribed;

f. Length of Therapy – duration prescribed for medication;

g. Date of Prescription – date medication was prescribed;

h. Current Treatment – indicate if this is an ongoing treatment and, if it is, the date it was started; and

i. Dispense as Written (DAW) Specified – indicate if an alternate version or medication is not to be substituted for the requested medication; if yes, provide rationale for DAW by checking the appropriate box(es) as listed below and providing additional information as required:

“1. Alternate therapies contraindicated or previously tried (please provide more information in Section F);

Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change (specify anticipated significant adverse clinical outcome in space below);
Medical need for increase in current dosage, strength and / or frequency (specify in space below: (1) dosage, strength(s) and / or frequency(s) tried; (2) medical reason);
Absence of appropriate formulation or indication of the drug (specify in space below); and
Other (specify in space below)”; and

(6) Section F shall be completed by the prescribing provider to provide information about the patient’s health and treatment if it is relevant to the medication being requested as follows:

a. Drug Allergies - patient’s current drug allergies;

b. Height - patient’s current height;

c. Weight - patient’s current weight;

d. Relevant Lab Values/Test Results – the name, results, and date of any laboratory or other tests that are relevant to the request;

e. Previous Medications and/or Non-Pharmacologic Therapies Tried /Failed – any alternate prescription drug or non-pharmacologic therapies tried by the patient for the same purpose for which the requested medication is being prescribed, to include (as relevant) medication or therapy name; strength; dosing schedule prescribed; date prescribed/started; date stopped; and description of adverse reaction or failure;

f. Contraindications to alternate therapies – the name of any alternate therapy that cannot be used because it may be harmful and description of the contraindication(s); and

h. Additional information – the prescribing provider may provide any additional information to support this request.

History

#12125, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 2705.05 Use of Uniform Prior Authorization Forms and Electronic Standard for Prescription Drug Benefits {#sec-ins-2705.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.05}

(a) Health insurers shall ensure that the version of the uniform prior authorization form that they have prepopulated pursuant to Ins 2705.04(c) is available and accessible in a centralized location online.

(b) Except as provided in (c) below, health insurers, pharmacy benefits managers, and utilization review entities shall treat the information submitted via uniform prior authorization forms as sufficient information upon which a decision regarding the prior authorization request shall be made as follows:

(1) Health insurers, pharmacy benefits managers, and utilization review entities shall not require prescribing providers to provide information in excess of the information required on the uniform prior authorization forms; and

(2) Health insurers, pharmacy benefits managers, and utilization review entities shall not:

a. Require or allow prescribing providers to submit information on a form other than the uniform prior authorization forms, even if the other form contains the same information as the uniform prior authorization forms; or

b. Require or request that prescribing providers submit any form or information in addition to the uniform prior authorization forms.

(c) Following receipt of uniform prior authorization forms that have been filled out and submitted, health insurers, pharmacy benefits managers, and utilization review entities may request that prescribing providers submit additional information to clarify information specifically requested on the uniform prior authorization forms only to the extent that:

(1) The prescribing provider provided information that conflicts with the records of the health insurer, pharmacy benefits manager, or utilization review entity; or

(2) The prescribing provider did not provide the information requested by the uniform prior authorization forms, including but not limited to clinical information that is needed in accordance with the carrier clinical review criteria and that would typically be supplied in Section F, except that prescribing providers shall not be required to complete Section A “Destination of Request” of the uniform prior authorization forms or ePA.

(d) Failure of a prescribing provider to complete section F or any portion thereof shall not be grounds for denial of prior authorization by a health insurer, pharmacy benefits manager, or utilization review entity, except to the extent the information not provided is required under the carrier clinical review criteria, and the health insurer, pharmacy benefits manager, or utilization review entity has inquired about the information in accordance with (c)(2) above.

History

#12125, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 2705.06 Standards for Electronic Prior Authorization Processes {#sec-ins-2705.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.06}

(a) The information collected by health insurers, pharmacy benefits managers, and utilization review entities via ePA, telephonically, or through any other manner of transmission shall be the same as the information collected via the uniform prior authorization forms except as specified in (b) below, or in accordance with a waiver granted under Ins 2705.09 below.

(b) Prescription drug prior authorization procedures conducted through ePA, telephonically, or through any other manner of transmission shall not require the prescribing provider to provide more information than is required by the uniform prior authorization forms, except that health insurers, pharmacy benefits managers, and utilization review entities may:

(1) Ask for the same information in a different manner via ePA, including converting questions on the uniform prior authorization forms that require free-form text into one or more questions with multiple choice or drop-down options;

(2) Ask for the following additional information via ePA:

a. Patient address; and

b. Patient gender;

(3) Eliminate Section A “Destination of Request” in ePA; and

(4) Ask for less information via ePA.

(c) Upon review of an ePA request and consistent with Ins 2705.05, a health insurer, pharmacy benefits manager, or utilization review entity may request additional clinical information or clarification necessary to render a decision on the ePA request. Such additional information may only be requested when it is required by the carrier clinical review criteria.

(d) ePA processes shall be completed via secure electronic transactions via secure web portals.

(e) ePA processes shall comply with all applicable state and federal laws, including but not limited to the Health Insurance Portability and Accountability Act of 1996.

History

#12125, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 2705.07 Outreach to Prescribing Providers {#sec-ins-2705.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.07}

Health insurers, pharmacy benefits managers, and utilization review entities shall educate contracted and other prescribing providers about the uniform prior authorization forms, including in partnership with membership organizations that represent those prescribing providers.

History

#12125, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 2705.08 Revisions {#sec-ins-2705.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.08}

(a) Upon receipt of a rulemaking petition under RSA 541-A:4 asserting that one or more provisions in these rules prevents health insurers, pharmacy benefits managers, and utilization review entities from adopting nationally recognized standards or processes for electronic prior authorization of prescription drugs, including those provided by the National Council for Prescription Drug Programs or an equivalent organization, the commissioner shall consider amending Ins 2705 to eliminate such conflict.

(b) Upon receipt of a rulemaking petition under RSA 541-A:4 outlining the need for and proposed content of one or more additional prior authorization forms for specific types, classifications, or categories of prescription drugs, the commissioner shall consider amending Ins 2705 to create one or more medication-specific versions of the uniform prior authorization forms.

History

#12125, eff 3-8-17

N.H. Code Admin. R. Ann. Ins 2705.09 Waivers to Support Use of National ePA Standards {#sec-ins-2705.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2705.09}

(a) Upon written request of a health insurer, pharmacy benefits manager, or utilization review entity, the department shall grant in writing a waiver of the requirements of one or more provisions of Ins 2705.06 upon a showing by the health insurer, pharmacy benefits manager, or utilization review entity, that:

(1) The health insurer, pharmacy benefits manager, or utilization review entity has adopted or plans to adopt the use of a nationally recognized standard for ePA of prescription drugs, including but not limited to standards provided by the National Council for Prescription Drug Programs or an equivalent organization;

(2) One or more provisions in these rules prevent the effective use of the nationally recognized standard;

(3) The modifications permitted under Ins 2705.06(b) do not effectively address the conflict between the rule and the national standard; and

(4) The waiver request outlines with specificity the requested modification to the uniform requirements of this part that will eliminate the conflict.

(b) A health insurer, pharmacy benefits manager, or utilization review entity that has been granted a waiver pursuant to (a) above shall comply with all provisions of Ins 2705 except as expressly described in the department’s written document granting the waiver.

History

#12125, eff 3-8-17

Part Ins 2706 Independent Dispute Resolution for Surprise Medical Bills

N.H. Code Admin. R. Ann. Ins 2706.01 Purpose {#sec-ins-2706.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.01}

The purpose of this part is to implement the provisions of RSA 420-J, RSA 417-F, RSA 358-T, RSA 358-A:2, XIX, and RSA 417:4, XV(a)(15) wherein the general court, through Chapter 143 of the laws of 2024, has addressed surprise medical bills by creating standards and procedures for the protection of health insurance consumers and for dispute resolution between a health carrier and a nonparticipating provider or emergency facility regarding the fair value of health care items or services.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.02 Scope {#sec-ins-2706.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.02}

This part shall apply to all health carriers, all self-funded health plans that opt in, all parties in the independent dispute resolution IDR process, and all independent dispute resolution entities. This part shall apply to coverage and reimbursement for out-of-network services provided on or after the 2026 effective date of this chapter.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.03 Definitions {#sec-ins-2706.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.03}

(a) For the purposes of this part, the definitions in RSA 420-J:3 shall apply whenever any word or phrase defined under RSA 420-J:3 is used in this part unless a more detailed definition appears in this section or in subsequent sections.

(b) With respect to the following words or phrases used in this part, the following definitions shall apply:

(1) “Batched qualified IDR items and services” means multiple qualified IDR items or services that are considered jointly as part of one payment determination by a certified IDR entity for purposes of the state IDR process in accordance with section Ins 2706.06 of this part;

(2) “Bundled payment arrangement” means an arrangement under which:

a. A provider or facility bills for multiple items or services furnished to a single patient under a single service code that represents multiple items or services, for example, a diagnosis related group (DRG) code; or

b. A health carrier or plan makes an initial payment or notice of denial of payment to a provider or facility under a single service code that represents multiple items or services furnished to a single patient, for example, a DRG code;

(3) “Business day” means any weekday that is not a federal holiday or a New Hampshire state holiday;

(4) “Emergency department of a hospital” means “emergency department of a hospital” as defined in 42 U.S.C. §300gg-111(a)(3)(A) and as further defined in 45 CFR§149.30;

(5) “Emergency medical condition” means “emergency medical condition” as defined in RSA 420-J:3, XV. The term includes the definitions in 42 U.S.C. §300gg-111(a)(3)(B) and 45 CFR §149.110(c)(1);

(6) “Emergency services” means “emergency services” as defined in RSA 420-J:3, XVI, namely “health care services, including mental use disorder treatment services, that meet the definition of emergency services 42 U.S.C. §300gg-111(a)(3)(C) and as further defined in 45 CFR §149.110(c)(2);

(7) “Episode of care” means the period of time during which all of the health care services that are needed to care for a patient’s clinical condition or to complete a procedure are delivered;

(8) “Independent freestanding emergency department” means “independent freestanding emergency department” as defined in 42 U.S.C. §300gg-111(a)(3)(D) and as further defined in 45 CFR §149.30;

(9) “Nonparticipating emergency facility” means “nonparticipating emergency facility” as defined in RSA 420-J:3, XXVI-a. The term includes the definition in 42 U.S.C. §300gg-111(a)(3)(F)(i) and as further defined in 45 CFR §149.30;

(10) “Nonparticipating provider” means “nonparticipating provider” as defined in RSA 420-J:3, XXVII-b. The term includes the definition in 42 U.S.C. §300gg-111(a)(3)(G)(i) and as further defined in 45 CFR §149.30;

(11) “Notice of denial of payment” means “notice of denial of payment” as defined in 45 CFR §149.30;

(12) “Out-of-network rate” means “out-of-network rate” as defined in 42 U.S.C. §300gg-111(a)(3)(K) and as further defined in 45 CFR §149.30;

(13) “Participating emergency facility” means “participating emergency facility” as defined in 42 U.S.C. §300gg-111(a)(3)(F)(ii) and as further defined in 45 CFR§149.30;

(14) “Participating health care facility” means “participating health care facility” as defined in 45 CFR §149.30;

(15) “Qualifying payment amount” or “QPA” means “qualifying payment amount” as defined in RSA 420-J:3 XXIX-a. The term includes the definition in 42 U.S.C. §300gg-111(a)(3)(E) and as further defined in 45 CFR§140(a)(16);

(16) “Recognized amount” means “recognized amount” as defined in 42 U.S.C. §300gg-111(a)(3)(H) and as further defined in 45 CFR §149.30;

(17) “Same or similar item or service” means “same or similar item or service” as defined in 45 CFR §149.140(a)(13);

(18) “Service code” means “service code” as defined in 45 CFR §149.140(a)(14);

(19) “Specified state law” means “specified state law” as defined in 42 U.S.C. §300gg-111(a)(3)(I) and as further defined in 45 CFR §149.30;

(20) “Treating provider” means “treating provider” as defined in 45 CFR§149.30; and

(21) “Visit” means “visit” as defined in 45 CFR §149.30.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.04 Option to Pursue Either the State or the Federal IDR Process. {#sec-ins-2706.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.04}

(a) Under this part, a provider or facility that is party to a fair value dispute about items or services to which the prohibition on balance billing in RSA 358-T applies may choose to pursue either the state or the federal IDR process on a case-by-case basis.

(b) The authority of the commissioner to administer the state IDR process set out in this part shall arise on a case-by-case basis with respect to specific items or services as providers or facilities choose to invoke the state IDR process to determine the fair value of that item or service.

(c) The administration of this part shall not preempt or displace the authority or obligation of the secretary of the federal department of health and human services to administer the federal IDR process as provided under 42 U.S.C. section 300gg-111 whenever the provider or facility to which the prohibition on balance billing in RSA 358-T applies does not choose to invoke the state IDR process.

(d) If a provider or facility that is party to a fair value dispute about items or services to which the prohibition on balance billing in RSA 358-T applies invokes the state IDR process by submission of a notice of IDR initiation under Ins 2706.07(b)(2) below within the 4-day period following the 20th day of open negotiation, and is found eligible for the state IDR process by the commissioner, then both parties shall be precluded from accessing the federal IDR process under 42 U.S.C. section 300gg-111. If the provider or facility does not invoke the state IDR process set out in this part or is found ineligible for the state IDR process, then either the provider or facility or the health carrier or plan may make application for review pursuant to the federal IDR process under 42 U.S.C. section 300gg-111 after the expiration of 30 days of open negotiation as provided in 42 U.S.C. section 300gg-111(c)(1)(B).

(e) If a provider, facility, health carrier, or plan that is party to a fair value dispute invokes the federal IDR process by submission of a notice of IDR initiation as specified in 42 U.S.C. section 300gg-111(c)(1)(B) and has been found to be eligible for that IDR process, then both parties shall be precluded from accessing the state IDR process under this part with respect to determining the fair value of that item or service. If an item or service that is the subject of a fair value dispute is not eligible for the federal IDR process due solely to the applicability of a cooling off period as set out in 42 U.S.C. section 300gg-111(c)(5)(E)(ii) and in federal, in-force regulations promulgated thereunder, this item or service shall nonetheless be eligible for the state IDR process under this part.

(f) If a provider or facility initiates the state IDR process by submission of a notice of IDR initiation under Ins 2706.07(b)(2) and is found eligible for the state IDR process by the commissioner, then the disputing parties shall be limited to the state IDR process for determining the fair value of all other items and services that are part of the same episode of care, and both parties shall be precluded from accessing the federal IDR process under 42 U.S.C. section 300gg-111 with respect to all such items or services.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.05 Coverage and Notice Requirements. {#sec-ins-2706.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.05}

(a) If a health carrier or a self-funded plan that has opted in is offering group or individual health benefit plans and provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in an independent freestanding emergency department, the health carrier or plan shall cover emergency services, as defined in this part, and this coverage shall be provided in accordance with 45 CFR §149.110(b).

(b) If a health carrier or a self-funded plan that has opted in is offering group or individual health insurance coverage and provides or covers any benefits with respect to items and services, other than emergency services, furnished to a covered person, beneficiary, or enrollee by a nonparticipating provider with respect to a visit at a participating health care facility, unless the provider has satisfied the notice and consent criteria of 45 CFR §149.420(c) through (i) with respect to such items and services, the carrier or plan shall cover the items and services when furnished by a nonparticipating provider in accordance with 45 CFR §149.120 (c).

(c) When providing any paper or electronic remittance advice to a provider or facility that does not have a contractual relationship directly or indirectly with a health carrier or plan offering group or individual health insurance coverage with respect to the furnishing of the item or service under the plan or coverage in response to a claim for payment for health care items and services furnished by that provider or facility, the carrier or plan shall use claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) pursuant to 45 CFR §162.1602 and §162.1603 and as specified in guidance issued by the federal secretaries of the Treasury, Labor, and Health and Human Services, or as required under any applicable adopted standards and operating rules under 45 CFR part 162.

(d) Cost sharing for services covered under (a) and (b) shall be calculated using the QPA, unless the billed amount or the allowed amount is less than the QPA. In such instances, cost sharing for services covered under (a) and (b) shall be calculated using the lesser of the billed amount or allowed amount.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.06 Methodology for Calculating Qualifying Payment Amount {#sec-ins-2706.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.06}

(a) For the purposes of this section, in addition to the definitions set forth in Ins 2706.03, the definitions set out in 45 CFR §149.140(a) shall apply.

(b) The methodology that health carriers or plans shall use for calculation of the median contracted rate shall be as set out in 45 CFR §149.140(b).

(c) The methodology that health carriers or plans shall use for calculation of the QPA shall be as set out in 45 CFR §149.140(c).

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.07 Notice Requirements Regarding the QPA {#sec-ins-2706.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.07}

(a) In cases in which the recognized amount with respect to an item or service furnished by a nonparticipating provider or nonparticipating emergency facility is the QPA, the health carrier or plan shall provide in writing, with each initial payment or notice of denial of payment, to the provider or facility notice of the following:

(1) The QPA for each item or service involved;

(2) If the QPA is based on a downcoded service code or modifier:

a. A statement that the service code or modifier billed by the provider or facility was downcoded;

b. An explanation of why the claim was downcoded, which shall include a description of which service codes were altered, if any, and a description of which modifiers were altered, added, or removed, if any; and

c. The amount that would have been the QPA had the service code or modifier not been downcoded.

(3) A certification by the health carrier or plan that:

a. The QPA applies for purposes of the recognized amount; and

b. Each QPA shared with the provider or facility was determined in compliance with this section;

(b) The following notices shall be provided to the nonparticipating provider or nonparticipating emergency facility with the initial payment:

(1) Under New Hampshire law, the provider or facility has the option to pursue either the state or the federal IDR process for determining the fair value of the services rendered when agreement cannot be reached;

(2) Both the state and the federal IDR process shall be preceded by the completion of an open negotiation period;

(3) The choice to pursue the state IDR process precludes access to the federal IDR process for determining the fair value of the specific services rendered and vice versa;

(4) The choice whether to pursue the state IDR process or the federal IDR process shall be made by the provider or facility before sending the notice of open negotiation to the health carrier or plan;

(5) If the provider or facility wishes to initiate an open negotiation period for purposes of determining the out-of-network rate under either the state or the federal IDR process, the provider or facility shall convey the notice of open negotiation to the appropriate person or office at the health carrier or plan within 30 business days of receiving the initial payment or notice of denial of payment;

(6) Under the state IDR process, after 20-business-days of open negotiation have elapsed without resulting in an agreement on the amount of payment, the provider or facility may initiate the state IDR process within 4 business days after the end of the 20th business day of open negotiation; and

(7) Contact information, including a telephone number and email address, for the appropriate person or office to initiate open negotiations for purposes of determining an amount of payment for such item or service, the legal business name of the health carrier or the legal business name of the plan sponsor, if applicable, and the registration number assigned under Ins 2706.24, as well as the registration number assigned under 45 CFR §149.530, if the health carrier or plan is registered under 45 CFR§149.530.

(c) Upon the request of the provider or facility, the health carrier or plan shall provide the following within 5 business days:

(1) Information about whether the QPA for items and services involved included contracted rates that were not on a fee-for-service basis for those specific items and services and whether the QPA for those items and services was determined using underlying fee schedule rates or a derived amount;

(2) Indicate whether a health carrier or plan uses an eligible database under 45 CFR§149.140(c)(3) to determine the QPA, information to identify which database was used;

(3) Indicate whether a related service code was used to determine the QPA for an item or service billed under a new service code under 45 CFR §149.140 (c)(4 (i) or (ii), information to identify the related service code; and

(4) Indicate whether the health carrier’s or plan’s contracted rates include risk-sharing, bonus, penalty, or other incentive-based or retrospective payments or payment adjustments for the items and services involved, as applicable, that were excluded for purposes of calculating the QPA.

(d) In the case of a health carrier or plan that, pursuant to this subpart, uses an eligible database to determine the QPA for an item or service, the health carrier or plan is responsible for any costs associated with accessing such database.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.08 Negotiation Period {#sec-ins-2706.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.08}

(a) The provider or facility may initiate an open negotiation period for purposes of determining the out-of-network rate for a qualified IDR item or service within 30 business days of the day the provider or facility receives an initial payment or notice of denial of payment regarding the item or service.

(b) To initiate the open negotiation period, the provider or facility shall submit a written open negotiation notice utilizing the open negotiation form developed by the commissioner to the other party. The open negotiation form shall include the following:

(1) Information sufficient to identify the provider or facility, including the name and current contact information, including the legal business name, email address, phone number, and mailing address, as provided with the claim form submitted by the provider or facility, and the National Provider Identifier (NPI);

(2) Information sufficient to identify the health carrier or plan, including the health carrier’s or plan's registration number under the state IDR registry, as well as the registration number under the federal IDR registry, if the health carrier or plan is federally registered, the legal business name of the health carrier or plan, as well as the current contact information, name, email address, phone number, and mailing address, of the health carrier or plan as provided with the initial payment or notice of denial of payment;

(3) The name and contact information, including the legal business name, email address, phone number, and mailing address, for any third party representing the party submitting the open negotiation notice, and an attestation that the third party has the authority to act on behalf of the party it represents in the open negotiation;

(4) Information sufficient to identify the item or service, including:

a. The date(s) the item or service was furnished and;

b. The date(s) that the provider or facility received the initial payment or notice of denial of payment for the item or service from the health carrier or plan;

c. The type of item or service, specifically, whether the item or service is an emergency service as defined in 45 CFR §149.110(c)(2)(i) or (ii), a non-emergency service as described in 45 CFR §149.120(b);

d. Whether the service is a professional service or facility-based service;

e. The state where the item or service was furnished;

f. The claim number;

g. The service code; and

h. Information to identify the location where the item or service was furnished such as, place of service code or bill type code;

(5) The initial payment amount including $0 if, for example, payment is denied;

(6) The QPA, if provided with the initial payment or notice of denial of payment;

(7) An offer of an out-of-network rate for each item or service;

(8) A statement that the items and services do not qualify for the notice and consent exception described at 45 CFR §149.410(b) or §149.420(c) through (i);

(9) A statement that the provider or facility was a nonparticipating provider or nonparticipating emergency facility on the date the item or service was furnished;

(10) A description of the open negotiation period and the state IDR process to include the purpose of the open negotiation period, state IDR process, and key deadlines in the open negotiation period and federal IDR process; and

(11) A copy of the initial payment or notice of denial of payment or other remittance advice that is required to include the disclosures under this section, with respect to the item or service.

(c) The 20 business-day open negotiation period shall begin on the day on which the provider or facility sends the open negotiation notice and the remittance advice documentation to the other party.

(d) The health carrier or health plan receiving the notice of open negotiation shall provide the provider or facility the response to the open negotiation form along with supporting documentation as soon as possible, but no later than the 10th business day of the 20 business day open negotiation period. The response to the open negotiation form shall include the following:

(3) The name and contact information, including the legal business name, email address, phone number, and mailing address, for any third party representing the party submitting the open negotiation response notice, and an attestation that the third party has the authority to act on behalf of the party it represents in the open negotiation;

(4) Information sufficient to identify the item or service included in the open negotiation notice, including the date(s) the item or service was furnished and the claim number;

(5) A statement as to whether the health carrier or plan agrees that:

a. The initial payment amount, including $0 if, for example, payment is denied, and the QPA reflected in the open negotiation notice accurately reflect the initial payment amount and QPA disclosed with the initial payment for the item or service;

b. If the open negotiation notice indicates that the initial payment amount or QPA was not communicated by the health carrier or plan with the initial payment or notice of denial of payment or other remittance advice, the initial payment amount, including $0 if, for example, payment is denied; and/or QPA it believes to be correct; and

c. Documentation to support the statement, for example, the remittance advice confirming the qualifying payment amount;

(6) The amount of cost sharing imposed for the item or service, if any;

(7) A counteroffer for an out-of-network rate for each item or service or an acceptance of the other party's offer;

(8) With respect to each item or service, either a statement and supporting documentation that explains why the item or service is not subject to the state IDR process or a statement agreeing that the item or service is subject to the state IDR process;

(9) A statement as to whether any of the information provided in the open negotiation notice is inaccurate and the basis for the statement, as well as supporting documentation; and

(10) A statement confirming that the initial payment or notice of denial of payment or other remittance advice provided by the provider or facility with the open negotiation notice is accurate, and if inaccurate, a copy of the accurate initial payment or notice of denial of payment or other remittance advice required to include the disclosures under this section, with respect to the item or service.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.09 Initiation of the State Independent Dispute Resolution Process {#sec-ins-2706.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.09}

(a) If the parties fail to reach an agreement during the open negotiation period, the provider or facility may initiate the state IDR process.

(b) To initiate the state IDR process, a provider or facility shall submit a written notice of IDR initiation using the standard form developed by the commissioner and shall deliver the notice to the health carrier or plan and to the commissioner. The notice of IDR initiation and supporting documentation shall be submitted to the commissioner by using the New Hampshire Independent Dispute Resolution Portal which may be found on the insurance department website. The notice of IDR initiation shall be accompanied by a copy of the open negotiation notice and the open negotiation response notice, and the open negotiation response form, if one was submitted. The notice of IDR initiation form shall include the following:

(1) Information sufficient to identify the provider or facility, including the legal business name, email address, phone number, mailing address, the NPI, and Tax Identification Number (TIN);

(2) Information sufficient to identify the health carrier or plan, including the carrier's or plan's registration number under the state IDR registry, as well as the registration number under the federal IDR registry under 45 CFR §149.530, if the health carrier or plan is federally registered, the legal business name of the health carrier or plan, as well as the current contact information including the name, email address, phone number, and mailing address of the health carrier or plan as provided with the initial payment or notice of denial of payment;

(3) The name and contact information including the legal business name, email address, phone number, and mailing address for any third party representing the provider or facility, and an attestation that the third party has the authority to act on behalf of the party it represents in the state IDR process;

(4) Information sufficient to identify whether the dispute being initiated includes batched or bundled qualified IDR items or services;

(5) Information sufficient to identify the qualified IDR item or service that is the subject of the notice of IDR initiation, including:

a. The date(s) the qualified IDR item or service was furnished;

b. The date(s) that the provider or facility received the initial payment or notice of denial of payment for such item or service from the health carrier or plan;

c. The date the open negotiation period began;

d. The type of item or service (specifically, whether the qualified IDR item or service is an emergency service as defined in 45 CFR §149.110(c)(2)(i) or (ii), a non-emergency service as described in 45 CFR §149.120(b);

e. Whether the service is a professional service or facility-based service;

f. The State where the item or service was furnished;

g. The claim number;

h. The service code; and

i. Information to identify the location the item or service was furnished, including place of service code or bill type code;

(6) The initial payment amount, including $0 if, for example, payment is denied;

(7) The QPA, if provided with the initial payment or notice of denial of payment;

(8) A statement that the items and services do not qualify for the notice and consent exception described at 45 CFR §149.410(b) or §149.420(c) through (i);

(9) A statement that the provider or facility was a nonparticipating provider or nonparticipating emergency facility, on the date the item or service was furnished;

(10) Attestation that the item or service under dispute is a qualified IDR item or service, and the basis for the attestation;

(11) A copy of the initial payment or notice of denial of payment or other remittance advice with respect to the item or service; and

(12) A statement describing the key aspects of the claim, such as patient acuity or level of training of the provider or facility that furnished the qualified IDR item or service, discussed by the parties during open negotiation that relate to the payment for the disputed claim, whether the reasons for initiating the state IDR process are different from the aspects of the claim discussed during the open negotiation period, and an explanation of why the party is initiating the state IDR process, including any of the permissible considerations that serve as the party's basis for initiating the state IDR process.

(c) The IDR initiation form and attachments shall be submitted within 4 business days beginning on the 21st business day after the start of the open negotiation period.

(d) The date of initiation of the state IDR process shall be the date of receipt of the notice of IDR initiation and attachments by the commissioner.

(e) The state IDR process is not available with respect to an item or service if the provider or facility provided notice and received consent under 45 CFR §149.410(b) or 45 CFR§149.420(c) through (i).

(f) Within 3 business days after the date of IDR initiation, a written IDR response form and supporting documentation shall be submitted by the health carrier or plan to the provider or facility and to the commissioner by using the New Hampshire Independent Dispute Resolution Portal which may be found on the Insurance Department website. The applicant shall provide the following on the form:

(1) Information sufficient to identify the provider or facility including the legal business name, email address, phone number, mailing address, and the NPI;

(2) Information sufficient to identify the health carrier or plan, including:

a. The carrier's or plan's registration number under the State IDR Registry;

b. The registration number under the federal IDR Registry under 45 CFR §149.530, if the health carrier or plan is federally registered, or an attestation that the health carrier or plan was not federally registered prior to the date that it submitted the notice;

c. The legal business name of the health carrier or plan, as well as the current contact information, name, email address, phone number, and mailing address, of the health carrier or plan as provided with the initial payment or notice of denial of payment;

d. The plan type, for example, self-insured or fully-insured; and

e. The TIN, or in the case of a plan that does not have a TIN, the TIN of the plan sponsor;

(3) The name and contact information, including the legal business name, email address, phone number, and mailing address for any third party representing the health carrier or plan, and an attestation that the third party has the authority to act on behalf of the party it represents in the state IDR process;

(4) Information sufficient to identify each item or service included in the notice of IDR initiation, including the date(s) the item or service was furnished, the date(s) that the initial payment or notice of denial of payment for such item or service was sent to the provider or facility by the health carrier or plan, and the claim number;

(5) A statement as to whether the health carrier or plan agrees that the initial payment, including $0 if, for example, payment is denied, and the QPA reflected in the notice of IDR initiation is accurate for the item or service that is the subject of the dispute, and if not, the initial payment amount, including $0 if, for example, payment is denied, or the QPA it believes to be correct, and documentation to support the statement, for example, the remittance advice confirming the QPA;

(6) The amount of cost sharing imposed for the item or service, if any;

(7) With respect to each item or service that is the subject of the dispute, either an attestation that the item or service is a qualified IDR item or service, or, for each item or service that the health carrier or plan asserts is not a qualified IDR item or service or is otherwise not eligible for resolution through the state IDR process, an explanation and documentation to support the statement;

(8) A statement confirming that the initial payment or notice of denial of payment or other remittance advice provided to the provider or facility is accurate, and if inaccurate, a copy of the accurate initial payment or notice of denial of payment or other remittance advice with respect to the item or service; and

(9) A statement as to whether any of the information provided in the notice of IDR initiation is inaccurate and the basis for the statement as well as any supporting documentation.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.10 Determination of Eligibility for IDR and Selection of Certified IDR Entity {#sec-ins-2706.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.10}

(a) Upon receipt of the notice of IDR initiation, the commissioner shall, within 5 business days of receipt of the notice, determine whether the dispute as to fair value of the out-of- network items or services is eligible for resolution through the state IDR process under RSA 420-J, RSA 417-F, RSA 417:4 XV(a)(15) and in accordance with the provisions of this part.

(b) If the dispute is not eligible for resolution under this part, the commissioner shall promptly notify the parties of this determination.

(c) If the dispute is determined to be eligible for resolution under RSA 420-J, RSA 417-F, RSA 417:4 XV(a)(15) and in accordance with the provisions of this part, the commissioner shall:

(1) Immediately notify the parties that the case has been accepted for state IDR review and that the parties shall have 3 business days to negotiate and agree upon a preferred certified IDR entity and notify the commissioner of the joint selection.

(2) Within one business day of receiving this notice of joint selection, the commissioner shall appoint the agreed upon certified IDR entity to the case and convey the case documentation to that entity.

(3) If no certified IDR entity is jointly selected within 3 business days of the commissioner’s notification to the parties that the case has been accepted for review under the state IDR process, the commissioner shall, on the first business day subsequent to the 3 business day period for joint selection, and using a randomized process, select and appoint a certified IDR entity to determine an out-of-network payment amount.

(4) Notify the IDR entity, conveying with the notice the case documentation to that entity, notify the health carrier or plan, and notify the provider or facility of the selection and appointment.

(5) The date of appointment of the certified IDR entity by the commissioner shall be treated as the date of initiation of the certified IDR entity review for purposes of the time periods in this section.

(d) The appointed certified IDR entity shall attest to the commissioner within 3 business days of the date of appointment that it meets the following requirements:

(1) The certified IDR entity does not have a conflict of interest as defined in 45 CFR§149.510(a)(2);

(2) The certified IDR entity will only assign personnel to a dispute and make decisions regarding hiring, compensation, termination, promotion, or other similar matters related to personnel assigned to the dispute in a manner that is not based upon the likelihood that the assigned personnel will support a particular party to the dispute; and

(3) The certified IDR entity will not assign any personnel to a dispute who would have any conflicts of interest, as defined at 45 CFR 149.510(a), regarding any party to the dispute or whose relationship with a party within the 1 year immediately preceding the assignment to the dispute would violate the restrictions on aiding or advising a former employer or principal in a manner similar to the restrictions set forth in 18 U.S.C. 207(b).

(e) If the certified IDR entity notifies the commissioner within 3 business days of the date of appointment of the certified IDR entity that it does not meet the eligibility requirements this section, or if the certified IDR entity does not respond within 3 business days after the date of appointment of the certified IDR entity:

(1) The commissioner shall randomly select another certified IDR entity consistent with the eligibility requirements of this section.

(2) The commissioner shall notify the parties of the new randomly selected certified IDR entity no later than 1 business day after the previously selected certified IDR entity notifies the commissioner that it has a conflict of interest or, if the previously selected certified IDR entity has failed to respond within 3 business days after the date of selection of the certified IDR entity, no later than 1 business day after the end of the 3- business-day period.

(3) The date of notification of the appointment of the new certified IDR entity shall be treated as the date of initiation of the certified IDR entity review for purposes of the time periods in this section.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.11 Request for Additional Information {#sec-ins-2706.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.11}

(a) The commissioner or the selected certified IDR entity may request additional information from either party to a dispute at any time, including for the purpose of assessing whether a conflict of interest exists, conducting an eligibility determination, or making a payment determination.

(b) Upon request, a party shall submit the additional information within 5 business days to the commissioner or the selected certified IDR entity, as applicable. Following a request for additional information, the time period for the applicable stage of the state IDR process shall be tolled until the earlier of the date either all of the requested information is provided or the 5-business-day period expires, and each subsequent timeframe in the state IDR process shall be determined based on the date of completion of the stage of the state IDR process that was tolled for provision of the requested information.

(c) If a party fails to submit the additional information as required, the related determination, including the eligibility determination, conflict-of-interest review, or payment determination will be made without the requested information unless a good-cause extension of the 5-business-day period, has been provided, and the party subsequently submits the additional information requested within the extended period.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.12 Authority to Continue Negotiations or Withdraw {#sec-ins-2706.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.12}

(a) If the parties to the state IDR process agree on an out-of-network rate for a qualified IDR item or service after assignment of the case to a certified IDR entity, but before the certified IDR entity has made its payment determination, the amount agreed to by the parties for the qualified IDR item or service shall be treated as the out-of-network rate for the qualified IDR item or service.

(b) To the extent the amount exceeds the initial payment amount and any cost sharing paid or required to be paid by the participant or beneficiary, or there was an initial denial of payment, payment shall be made directly by the health carrier or plan to the nonparticipating provider or facility not later than 30 business days after the agreement is reached.

(c) No party shall seek additional payment from the covered person or beneficiary, including instances in which the out-of-network rate exceeds the qualifying payment amount.

(d) The initiating party shall send a notification of withdrawal to the certified IDR entity and the commissioner as soon as possible, but no later than 3 business days after the date of the agreement. The notification shall include the dispute number, a statement of the out-of-network rate for the qualified IDR item or service, and signatures from authorized signatories for both parties.

(e) The certified IDR entity shall be entitled to retain the full fee that has been paid by the parties for any fair value dispute that has been assigned to the certified IDR entity and the dispute is withdrawn before the certified IDR entity has made its payment determination.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.13 Treatment of Batched Items and Services {#sec-ins-2706.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.13}

(a) In general, batched items and services may be submitted and considered jointly as part of one payment determination only if the qualified IDR items and services meet the following requirements:

(1) The qualified IDR items and services are billed by the same provider or group of providers or the same facility. Items and services are billed by the same provider or group of providers or the same facility, if the items or services are billed with the same NPI or TIN;

(2) Payment for the qualified IDR items and services is required to be made by the same health carrier or plan.

a. For group or individual health insurance coverage, this requirement is satisfied if the same health carrier or plan is required to make payment for the qualified IDR items and services, even if the qualified IDR items and services relate to claims from different group health plans or individual market policies;

b. For self-insured group health plans that have opted into the state IDR process, this requirement is satisfied if the same self-insured group health plan is required to make payment for the qualified IDR items and services, including when the plan makes payments through a third party administrator; and

c. The requirement is not satisfied if multiple self-insured group health plans are required to make payments for the qualified IDR items and services, even if those group health plans make payments through the same third party administrator;

(3) The qualified IDR items and services meet any of the following criteria under which multiple qualified IDR items and services relate to the treatment of a similar condition and therefore are permitted to be considered jointly as a single payment determination for purposes of encouraging efficiencies, including minimizing costs, in the state IDR process:

a. The qualified IDR items or services were furnished to a single patient during the same patient encounter. For purposes of this section, a “single patient encounter” means a patient encounter on one or more consecutive days during which the qualified IDR items or services were furnished to the same patient and billed on the same claim form;

b. The qualified IDR items and services were furnished to one or more patients and were billed under the same service code or a comparable code under a different procedural coding system, such as Current Procedural Terminology (CPT) codes with modifiers, if applicable, Healthcare Common Procedure Coding System (HCPCS) codes with modifiers, if applicable, or Diagnosis-Related Group (DRG) codes with modifiers, if applicable;

c. For anesthesiology, radiology, pathology, and laboratory qualified IDR items and services, the qualified IDR items and services were furnished to one or more patients and were billed under service codes belonging to the same Category I CPT code range, as specified in guidance published by the federal secretary of Health and Human Services; or

d. All the qualified IDR items and services were furnished within the same 30-business-day period.

(b) A certified IDR entity may consider up to 25 qualified IDR items and services jointly as batched items and services subject to a single fee. Batched items and services submitted and considered jointly shall be treated as a batched determination and subject to the fee schedule for batched determinations under this section. The fee for batched determinations may consist of a fixed batched fee for a batch of up to 25 line items and a fixed tiered fee for every additional 25 line items within a batched dispute beginning with the 26th line item.

(c) In the case of qualified IDR items and services billed by a provider or facility as part of a bundled payment arrangement relating to a single episode of care, or where a health carrier or plan makes or denies an initial payment as a bundled payment, the qualified IDR items and services may be submitted as part of one payment determination. Bundled payment arrangements submitted under this paragraph shall be subject to the rules for batched determinations and the certified IDR entity fee for single, batched determinations.

(d) Within 5 business days of the date of appointment, the appointed certified IDR entity shall review the information submitted in the notice of IDR initiation to determine whether qualified IDR items and services may properly be considered jointly as part of one payment determination as batched items and services or whether these items and services have been improperly batched under this section.

(e) If the certified IDR entity determines that items and services have been improperly batched, the entity shall notify the parties within the 5 business day review period, and the provider or facility shall have 5 business days to resubmit amended notice(s) of IDR initiation to the commissioner.

(f) The date of submission of the amended notice of IDR initiation to the commissioner shall be treated as the new IDR initiation date for purposes of the time periods in this part except that, upon determination by the commissioner that the amended notice of IDR initiation is eligible for resolution through the state IDR process under RSA 420-J, RSA 417-F, RSA 417:4 XV(a)(15) and in accordance with the provisions of this part, the commissioner shall immediately reassign the case to the IDR entity originally selected.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.14 Submission of Offers {#sec-ins-2706.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.14}

(a) The health carrier or plan and the provider or facility shall submit to the certified IDR entity their offers using the standard form developed by the commissioner no later than 10 business days after the date of appointment of the certified IDR entity.

(b) For providers and facilities, the offer shall include the following information:

(1) An offer of an out-of-network rate expressed as both a dollar amount and the corresponding percentage of the QPA represented by that dollar amount;

(2) Information on the size of the provider's practice or facility. Specifically, a provider shall specify whether the providers' practice has fewer than 20 employees, 20 to 50 employees, 51 to 100 employees, 101 to 500 employees, or more than 500 employees. For facilities, the facility shall specify whether the facility has 50 or fewer employees, 51 to 100 employees, 101 to 500 employees, or more than 500 employees;

(3) Information on the practice specialty or type;

(4) Any information relating to the offer that was submitted by either party, except that the information shall not include information on factors described in Ins 2706.15(d); and

(5) Information requested by the certified IDR entity relating to the offer.

(1) An offer of an out-of-network rate expressed as both a dollar amount and the corresponding percentage of the QPA represented by that dollar amount;

(2) Information on the coverage area of the health carrier or plan, the relevant geographic region for purposes of the QPA, whether the coverage is fully-insured or partially or fully self-insured;

(3) The QPA for the applicable year for the same or similar item or service as the qualified IDR item or service;

(4) Any information relating to the offer that was submitted by either party, except that the information shall not include information on factors described in Ins 2706.15(d); and

(5) Information requested by the certified IDR entity relating to the offer.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.15 Payment Determination for a Qualified IDR Item or Service {#sec-ins-2706.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.15}

(a) The certified IDR entity shall select the offer that the certified IDR entity determines best represents the fair value of the qualified IDR item or service as the out-of-network rate no later than 30 business days after the date of appointment of the certified IDR entity.

(b) In determining which offer to select, the certified IDR entity shall consider the qualifying payment amount(s) for the applicable year for the same or similar item or service. The certified IDR entity shall then consider information submitted by a party that relates to the following circumstances:

(1) The level of training, experience, and quality and outcomes measurements of the provider or facility that furnished the qualified IDR item or service, such as those endorsed by the consensus-based entity authorized in section 1890 of the Social Security Act;

(2) The market share held by the provider or facility or that of the health carrier or plan in the geographic region in which the qualified IDR item or service was provided;

(3) The acuity of the covered person or beneficiary receiving the qualified IDR item or service, or the complexity of furnishing the qualified IDR item or service to the covered person or beneficiary;

(4) The teaching status, case mix, and scope of services of the facility that furnished the qualified IDR item or service, if applicable;

(5) Demonstration of good faith efforts, or lack thereof, made by the provider or facility or the health carrier or plan to enter into network agreements with each other, and, if applicable, contracted rates between the provider or facility, as applicable, and the health carrier or plan, as applicable, during the previous 4 plan years;

(6) Information provided by a party in response to a request by the certified IDR entity; and

(7) Additional information submitted by a party that relates to the offer for the payment amount for the qualified IDR item or service that is the subject of the payment determination and that does not include information on factors described in paragraph (d) below.

(c) In weighing the considerations described in paragraph (b) above, the certified IDR entity shall evaluate whether the information is credible and relates to the offer submitted by either party for the payment amount for the qualified IDR item or service that is the subject of the payment determination. The certified IDR entity shall not give weight to information to the extent it is not credible, it does not relate to either party’s offer for the payment amount for the qualified IDR item or service, or it is already accounted for by the QPA under paragraph (b) above.

(d) In determining which offer to select, the certified IDR entity shall not consider:

(1) Usual and customary charges, including payment or reimbursement rates expressed as a proportion of usual and customary charges;

(2) The amount that would have been billed by the provider or facility with respect to the qualified IDR item or service had the provisions of RSA 358-T, 45 CFR149.410 and 149.420, as applicable, not applied; or

(3) The payment or reimbursement rate for items and services furnished by the provider or facility payable by a public payor, including:

a. Under the Medicare program under title XVIII of the Social Security Act;

b. The Medicaid program under title XIX of the Social Security Act;

c. The Children's Health Insurance Program under title XXI of the Social Security Act;

d. The TRICARE program under chapter 55 of title 10, United States Code;

e. Chapter 17 of title 38, United States Code; or

f. Demonstration projects under section 1115 of the Social Security Act.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.16 Written Decision {#sec-ins-2706.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.16}

(a) The certified IDR entity shall explain its determination in a written decision submitted to the parties and the commissioner.

(b) The written decision shall include an explanation of the determination, and shall include the following:

(1) Information the certified IDR entity determined demonstrated that the offer selected as the out-of-network rate is the offer that best represents the fair value of the qualified IDR item or service;

(2) The weight given to the qualifying payment amount and any additional credible information under Ins 2706.15 (b) (1)-(7);

(3) Whether the certified IDR entity relied on information described Ins 2706.15 (b)(1)-(7) above in selecting an offer; and

(4) If applicable, why the certified IDR entity concluded that the information described Ins 2706.15 (b)(1)-(7) was not already reflected in the qualifying payment amount.

(c) A determination made by a certified IDR entity is binding upon the parties, in the absence of fraud or evidence of intentional misrepresentation of material facts presented to the certified IDR entity regarding the claim.

(d) The decision shall be enforceable against the health carrier by the commissioner pursuant to the penalty provisions of RSA 420-J:14 and under the enforcement provisions of RSA 417.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.17 Payment {#sec-ins-2706.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.17}

(a) If the offer selected by the certified IDR entity is more than the sum of the initial payment, including any cost sharing paid or owed by the participant or beneficiary, the health carrier shall pay any additional amount due to the provider or facility not later than 30 calendar days after the determination by the certified IDR entity.

(b) If the offer selected by the certified IDR entity is less than the sum of the initial payment and any cost sharing paid by the participant or beneficiary, the provider or facility shall be liable to the health carrier or plan for the difference. The provider or facility shall pay the difference directly to the health carrier or plan not later than 30 calendar days after the determination by the certified IDR entity.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.18 Recordkeeping Requirements. {#sec-ins-2706.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.18}

The certified IDR entity shall maintain records of all claims and notices associated with the federal IDR process with respect to any determination for 6 years. The certified IDR entity shall make these records available for examination by the health carrier, plan, provider, or facility, or a state or federal oversight agency upon request, except to the extent the disclosure would violate either state or federal privacy law.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.19 Extension of Time Periods for Extenuating Circumstances {#sec-ins-2706.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.19}

(a) The time periods specified in this section, other than the time period for payment of the IDR entity fee and for payment by the health carrier or plan to the provider or facility, may be extended in extenuating circumstances at the commissioner's discretion if:

(1) With respect to a specific dispute, the commissioner determines that the parties or certified IDR entity cannot meet applicable timeframes due to matters beyond the control of one or both parties or the certified IDR entity, or for other good cause; or

(2) The commissioner determines that the parties or certified IDR entity cannot meet applicable timeframes due to systematic delays in processing disputes under the state IDR process, such as an unforeseen volume of disputes or state IDR system failures. Extensions provided due to systematic delays in processing disputes will be applied to the state IDR process timeframe(s) determined relevant by the commissioner. The commissioner shall post a public notice regarding any extensions of time periods pursuant to this paragraph.

(b) The certified IDR entity or either party may also submit a request for an extension due to extenuating circumstances to the commissioner. The requesting certified IDR entity or party shall attest that it will take prompt action to ensure that the certified IDR entity's payment determination under this section may be made as soon as administratively practicable under the circumstances.

(c) When an extension to a timeframe is granted, the time period for all applicable stages of the state IDR process shall be tolled until the extension period expires.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.20 Costs of the IDR Process {#sec-ins-2706.20 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.20}

(a) There shall be no administrative fee charged by the commissioner for the department’s administration of the state IDR process.

(1) If the state certified IDR entity is also federally certified, then the fees charged by the certified IDR entity shall be the same as the published fees that the entity currently charges under the federal IDR process as provided for in 45 CFR§149.510(e)(2)(vii) and (viii) for all single determinations, all batched determinations, and all tiered fees for every additional 25 line items within a batched dispute beginning with the 26th line item; and

(2) If the state certified IDR entity is not also a federally certified IDR entity, then the entity shall submit a proposed fee structure to the commissioner and the commissioner shall set a rate within the federal certified IDR entity fee ranges established under 45 CFR §149.510(e)(2)(vii) and (viii).

(b) Each party to an IDR process under this section shall submit to the selected IDR entity, together with its submission of an offer of an out-of-network rate, one half of the certified IDR entity’s fee.

(c) If any party does not timely submit its half of the certified IDR entity's fee, then the certified IDR entity shall promptly notify that party that, if the fee is not paid within 5 business days of the date of the notice, the IDR entity will, without further consideration, select the offer of the party that has paid its half of the fee as the out-of-network rate and notify the parties of its determination.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.21 Certification of IDR Entities Under the State IDR Process {#sec-ins-2706.21 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.21}

The commissioner shall certify any IDR entity for purposes of the state IDR process that demonstrates that it is certified as an IDR entity under the federal IDR process set out in 42 U.S.C. §300gg-111(c)(4) and as provided in 45 CFR §149.510 (e) or demonstrates to the satisfaction of the commissioner that it meets the requirements of 45 CFR §149.510 (e).

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.22 Revocation of Certification of a Certified IDR Entity. {#sec-ins-2706.22 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.22}

The commissioner shall revoke the certification of a certified IDR entity if, as a result of an audit or otherwise, the commissioner determines the following:

(a) The certified IDR entity has a pattern or practice of noncompliance with any requirements of this section;

(b) The certified IDR entity is operating in a manner that hinders the efficient and effective administration of the state IDR process;

(d) The certified IDR entity has committed or participated in fraudulent or abusive activities, including submission of false or fraudulent data to commissioner;

(e) The certified IDR entity lacks the financial viability to provide arbitration under the state IDR process;

(f) The certified IDR entity has failed to comply with requests from the commissioner made as part of an audit, including failing to submit all records of the certified IDR entity that pertain to its activities within the state IDR process; or

(g) The certified IDR entity is otherwise no longer fit or qualified to make determinations.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.23 Reporting of Information Relating to the State IDR Process {#sec-ins-2706.23 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.23}

Within 90 business days of the end of the calendar year, each certified IDR entity shall submit an annual report to the commissioner in a format as specified by the commissioner. The report shall include, but is not limited to, the following:

(a) The number of IDR cases appointed to the certified IDR entity by the commissioner during the preceding calendar year;

(b) The number of such cases where the case was withdrawn after being assigned to the IDR entity;

(c) The number of times during the year that the out-of-network rate determined, or agreed to, under this section has exceeded the QPA;

(d) With respect to each notice of IDR initiation for which such a determination was made, the following information:

(1) A description of the qualified IDR items and services included with respect to the notification, including the relevant billing and service codes and number of batched claims, if applicable;

(2) The amount of the offer submitted by the health carrier or plan and by the provider or facility expressed as a dollar amount and as a percentage of the QPA;

(3) Whether the offer selected by the certified IDR entity was the offer submitted by the health carrier or plan or by the provider or facility;

(4) The amount of the selected offer expressed as a dollar amount and as a percentage of the QPA;

(5) The practice specialty or type of each provider or facility, respectively, involved in furnishing each qualified IDR item or service;

(6) The number of business days elapsed between selection of the certified IDR entity and the determination of the out-of-network rate by the certified IDR entity; and

(7) The total amount of certified IDR entity fees paid to the certified IDR entity during the preceding calendar year.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.24 State IDR Registry of Health Carriers and Opting In Self-Funded Plans {#sec-ins-2706.24 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.24}

(a) The commissioner shall establish a state IDR registry consisting of the information described in paragraph below and shall assign a registration number for each health carrier or opting in self-funded plan. The information contained in the registry shall be made available to providers or facilities seeking to initiate an open negotiation or a fair value dispute through the state IDR process by posting the information on the department’s website.

(b) Each health carrier or opting in self-funded plan offering group or individual health insurance coverage subject to the state IDR process shall register with the state IDR registry. Initial registration shall be completed by the later of the date that is 30 business days after the 2026 effective date of the chapter or the date the health carrier or opting in self-funded plan begins offering a group health plan or individual health insurance coverage subject to the state IDR process.

(c) Health carriers or opting in self-funded plans offering group or individual health insurance coverage subject to the registration requirement shall include the following information with their registration:

(1) The legal business name, if any, of the health carrier or opting in self-funded plan and, if applicable, the legal business name of the group health plan sponsor;

(2) Whether the plan or coverage is a fully-insured group health plan, an opting in self-insured group health plan, individual health insurance coverage, or an FEHB plan that has adopted RSA 358-T as a specified state law;

(3) Contact information, including a telephone number and email address, for the appropriate person or office to initiate open negotiations for purposes of determining an amount of payment, including cost sharing, for such item or service;

(4) The 14-digit health insurance oversight system (HIOS) identifier, or if the 14-digit HIOS identifier has not been assigned, the 5-digit HIOS identifier, or if no HIOS identifier is available, the plan's or the plan sponsor's employer identification number (EIN) and the plan's plan number (PN), if a PN is available, or for FEHB carriers, the applicable contract number(s) and plan code(s); and

(5) Additional information needed to identify the health carrier or plan and the applicable federal and state requirements for determining appropriate out-of-network payment rates for items or services to which the protections against balance billing in RSA 358-T apply.

(d) A health carrier or opting in plan must timely report to the commissioner changes to the information required under this section within 30 business days after the information changes. A health carrier or opting in plan must confirm the accuracy of its registration annually in the fourth quarter of each calendar year.

(e) The requirements of paragraphs (c) (1) through (3) above may be performed by a third party administrator or service provider with authority to act on behalf of the health carrier or opting in plan offering group or individual health insurance coverage subject to the state IDR process. If the registration requirements are performed by such third party administrator or service provider, the health carrier or opting in plan offering group or individual health insurance coverage shall require that such third party administrator or service provider clearly delineate each health carrier or opting in plan offering group or individual health insurance coverage for which it has authority to act. If such third party administrator or service provider fails to provide the information in compliance with the requirements of paragraphs (c)(1) through (3) above, the plan or issuer shall be in violation of the requirements of this section.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.25 Option for Self-Funded Plans to Opt Into the State IDR Process. {#sec-ins-2706.25 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.25}

Self-funded group plans, government plans, and church plans not otherwise subject to this part shall have the opportunity to opt into the state IDR process and be subject to the provisions of this part. Plans wishing to opt in under this provision shall complete an opt in form and shall register under Ins 2706.24. Plans that have opted in under this provision may subsequently opt out by completing an opt out form.

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 2706.26 Waiver of Rules. {#sec-ins-2706.26 omnilex-key=us-nh-regs-official--agency-ins--Ins 2706.26}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) The commissioner shall report publicly any waiver granted on the department’s website at https://www.insurance.nh.gov.

APPENDIX

Rule

Specific State Statute the Rule Implements

Ins 2701.01

RSA 400-A:15, I; RSA 420-J:7, II; RSA 420-J:12

Ins 2701.02

RSA 400-A:15, I; RSA 420-J:7, II; RSA 420-J:12

Ins 2701.03

RSA 400-A:15, I; RSA 420-J:3; RSA 420-J:7, II

Ins 2701.04

RSA 400-A:15, I; RSA 420-J:7, II; RSA 420-J:12; 45 CFR 156.230

Ins 2701.05

RSA 400-A:15, I; RSA 420-J:7, II(b); 45 CFR 156.235

Ins 2701.06

RSA 400-A:15, I; RSA 420-J:7, II(c)

Ins 2701.07

RSA 400-A:15, I; RSA 420-J:7, II; RSA 420-J:12

Ins 2701.08

RSA 400-A:15, I; RSA 420-J:7, II; RSA 420-J:12

Ins 2701.09

RSA 400-A:15, I; RSA 420-J:7, II(a)

Ins 2701.10

RSA 400-A:15, I; RSA 420-J:7, II(b); RSA 420-J:12

Ins 2701.11

RSA 400-A:15, I; RSA 420-J:7 III and IV; RSA 420-J:12

Ins 2701.12

RSA 400-A:15, I; RSA 420-J:7, II; RSA 420-J:12

Ins 2701.13

RSA 400-A:15, I; RSA 420-J:7, II; RSA 420-J:12

Ins 2701.14

RSA 400-A:15, I; RSA 541-A:22, IV

Ins 2702.01

RSA 400-A:15, I; RSA 415:18-a, VIII; 29 USC 1185a (HR 1424-117)

Ins 2702.02

RSA 400-A:15, I; RSA 415:18-a, VIII; 29 USC 1185a (HR 1424-117)

Ins 2702.03

RSA 400-A:15, I; RSA 415:18-a, VIII; 29 USC 1185a (HR 1424-117)

Ins 2702.04

RSA 400-A:15, I; RSA 415:18-a, VIII; 29 USC 1185a (HR 1424-117)

Ins 2702.05

RSA 400-A:15, I; RSA 415:18-a, VIII; RSA 541-A:22, IV

Ins 2703.01

RSA 420-J:3; RSA 420-J:5-a through 5-e

Ins 2703.02

RSA 420-J:1; RSA 420-J:2; RSA 420-J:3, VIII

Ins 2703.03

RSA 420-J:5-a

Ins 2703.04

RSA 420-J:5

Ins 2703.05

RSA 420-J:5-b

Ins 2703.06

RSA 420-J:5-c

Ins 2703.07

RSA 420-J:5-d

Ins 2703.08

RSA 420-J:5-e

Ins 2703.09

RSA 420-J:5-e

Ins 2703.10

RSA 400-A:15, I; RSA 541-A:22, IV

Ins 2704.01

RSA 400-A:15, I; RSA 415:26; RSA 402-N:2; RSA 420-J:7-b, X;

RSA 420-J:12

Ins 2704.02

RSA 318:1, XI; RSA 318:2; RSA 400-A:15, I; RSA 402-N:1;

RSA 415:26; RSA 420-G:2, IX; RSA 420-J:3, XIX; RSA 420-J:7-b, X; RSA 420-J:12

Ins 2704.03

RSA 400-A:15, I; RSA 402-N:2

Ins 2704.04

RSA 400-A:15, I; RSA 402-N:2; RSA 402-N:6

Ins 2704.05

RSA 400-A:15, I; RSA 402-N:4; RSA 415:26; RSA 420-J:7-b, X;

RSA 420-J:8-a, IV; RSA 420-J:12

Ins 2704.06

RSA 400-A:15, I; RSA 400-A:16; RSA 402-N:5RSA 415:26;

RSA 420-J:7-b, X; RSA 420-J:12

Ins 2704.07

RSA 400-A:15, I; RSA 400-A:16; RSA 400-A:17-24; RSA 402-N:2;

RSA 415:26; RSA 417; RSA 420-J:7-b, X; RSA 420-J:12; RSA 420-J:14

Ins 2704.08

RSA 400-A:15, I; RSA 402-N:5, II; RSA 415:26; RSA 420:J:7-b, X;

RSA 420-J:12

Ins 2704.09

RSA 400-A:15, I; RSA 400-A:16, III; RSA 402-N:6, II; RSA 420-J:10-12

Ins 2704.10

RSA 400-A:15, I; RSA 400-A:37; RSA 402-N:2; RSA 402-N:7

Ins 2704.11

RSA 400-A:15, I; RSA 400-A:16, II; RSA 402-N:2

Ins 2704.12

RSA 400-A:15, I; RSA 541-A:22, IV

Ins 2705.01

RSA 400-A:15, I; 420-E:4-a, III; 420-J:7-b, IV-c (c)

Ins 2705.02

RSA 400-A:15, I; 420-E:4-a, III; 420-J:7-b, IV-c (c)

Ins 2705.03

RSA 400-A:15, I; 420-A:1; 420-B:1; 420-C:2; 420-E:4-a, II and III;

420-G:2; 420-J:7-b, IV-c (b) and (c)

Ins 2705.04

RSA 400-A:15, I; 420-E:4-a, III; 420-J:7-b, IV-c (c)

Ins 2705.05

RSA 400-A:15, I; 420-E:4-a, III; 420-J:7-b, IV-c

Ins 2705.06

RSA 400-A:15, I; 420-E:4-a, III; 420-J:7-b, IV-c ;

Pub. L. 104-191, Stat. 1936

Ins 2705.07

RSA 400-A:15, I; 420-E:4-a, III; 420-J:7-b, IV-c

Ins 2705.08

RSA 400-A:15, I

Ins 2705.09

RSA 400-A:15, I

Ins 2706.01

RSA 420-J; RSA 417-F; RSA 417:4 XV(a)(15); RSA 400-A:15; RSA 358-T:4

Ins 2706.02

RSA 420-J; RSA 417-F; RSA 417:4 XV(a)(15); RSA 400-A:15

Ins 2706.03

RSA 358-T:1; RSA 420-J:3; RSA 420-J:12; RSA 400-A:15

Ins 2706.04

RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.05

RSA 420-J:8-e; RSA 420-J:8-g; RSA 420-J:8-h; RSA 420-J:12; RSA 400-A:15

Ins 2706.06

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:8-g; RSA 420-J:8-h; RSA 420-J:12; RSA 400-A:15

Ins 2706.07

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:8-g; RSA 420-J:8-h; RSA 420-J:12; RSA 400-A:15

Ins 2706.08

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.09

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.10

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.11

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.12

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.13

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.14

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.15

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.16

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.17

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.18

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.19

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.20

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.21

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.22

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.23

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.24

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.25

RSA 420-J:3; RSA 420-J:8-e; RSA 420-J:12; RSA 400-A:15

Ins 2706.26

RSA 400-A:15, I; RSA 541-A:22, IV

History

#14559, eff 4-22-26, EXPIRES: 4-22-36

Chapter Ins 2800 Property and Casualty Rate and Supplementary Information Filings

Part Ins 2801 Advisory Organization

N.H. Code Admin. R. Ann. Ins 2801.01 Purpose, Applicability, and Scope {#sec-ins-2801.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2801.01}

(a) The purpose of this chapter is to set forth rules and procedural requirements which the commissioner deems necessary to carry out the provisions of RSA 412:16, II., III., V., VI.; RSA 412:23 and RSA 412:25 as to rate and supporting information filings of property and casualty insurers that adopt and incorporate in whole or in part approved prospective loss costs filings made by advisory organizations.

(b) Nothing in this chapter shall be construed to require insurers, advisory organizations or their participating insurers to change the current manner in which supplementary rating information is filed.

(c) Nothing in this chapter shall be construed to require advisory organizations or their participating insurers to immediately refile rates or premium charges in effect.

(d) This chapter shall apply to the type of insurance described in RSA 412 and to insurers making filings under RSA 412:16.

History

#5655, eff 7-1-93; ss by #6984, eff 5-1-99; ss by #8936, eff 8-1-07; ss by #10920, eff 9-1-15; ss by #14510, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 2801.02 Definitions {#sec-ins-2801.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2801.02}

(a) “Advisory organization” means “advisory organization” as defined in RSA 412:3, II.

(b) “Expenses” means “expenses” as defined in RSA 412:3, VIII.

(c) “Expense constant” means an additive component of a rate that is used to recognize a minimum cost associated with a policy regardless of its size.

(d) “Fixed expense” means a cost the value of which is independent of the size of the policy.

(e) "Investment income" means income derived from the insurer's invested assets attributed to policyholder supplied funds.

(f) “Loss cost multiplier” means a multiplicative factor applied to a prospective loss cost to develop a rate.

(g) “Prospective loss” costs means that portion of a rate that excludes profit and expenses except for loss adjustment expenses and is based on historical aggregate losses and loss adjustment expenses.

(h) “Rate” means “rate” as defined in RSA 412:3, XVIII.

(i) “Reference filing” as used in this chapter, means an advisory organization’s filing of prospective loss costs as defined in (g) above that insurers can adopt and incorporate in whole or in part in support of their own filings.

(j) “Supplementary rating information” means “supplementary rating information” as defined in RSA 412:3, XXII.

(k) “Underwriting contingencies” means the provisions included in the rate to account for risk exposure not foreseen as part of the development of expected loss or expense.

(l) “Underwriting profit” means the difference between the premium an insurer collects and the expected level of total losses, loss expenses, and all other expenses.

(m) A “variable expense” means a cost the value of which is dependent on the size of the policy.

History

#5655, eff 7-1-93; ss by #6984, eff 5-1-99; ss by #8936, eff 8-1-07; ss by #10920, eff 9-1-15; ss by #14510, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 2801.03 Advisory Organization Reference Filing of Advisory Prospective Loss Costs {#sec-ins-2801.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2801.03}

(a) Advisory organizations may develop and make reference filings containing advisory prospective loss costs. Such filing shall contain the statistical data and support for any calculations or assumptions underlying those prospective loss costs. The reference filings shall be filed and approved by the commissioner pursuant to the provisions of RSA 412:16, I, and in accordance with the provisions of RSA 412:15, RSA 412:19, RSA 412:23, and RSA 412:25.

(b) An insurer may adopt a referenced filing by:

(1) Becoming a participating insurer of the licensed advisory organization which made the reference filing of advisory prospective loss costs; and

(2) Filing with the commissioner the information required on reference adoption form RFF-1, as available in Appendix A.

(c) The insurer's rates shall be the approved prospective loss costs filed by the advisory organization which have been put into effect in accordance with the provisions of paragraph (a), combined with the insurer’s loss cost adjustments which are filed in form RFF-1 and approved by the commissioner pursuant to the provisions of RSA 412:16, and in accordance with the provisions of RSA 412:15 and RSA 412:19.

(d) To the extent that an insurer’s final rates are determined solely by applying its loss cost adjustments, as presented in form RFF-1, to the prospective loss costs contained in an advisory organization’s reference filing and printed in the advisory organization’s rating manual, the insurer shall not be required to develop or file its final rate pages with the commissioner. If an insurer chooses to print and distribute final rate pages for its own use, based solely upon the application of its filed loss costs adjustments to an advisory organization’s prospective loss costs, the insurer shall not be required to file those pages with the commissioner. If the advisory organization does not print the loss costs in its rating manual, the insurer shall submit its rates to the commissioner.

History

#5655, eff 7-1-93; ss by #6984, eff 5-1-99; ss by #8936, eff 8-1-07; ss by #10920, eff 9-1-15; ss by #14510, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 2801.04 Required Filing Documents {#sec-ins-2801.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2801.04}

Each insurer filing to adopt an advisory organization approved prospective loss cost reference filing shall include a completed copy of form RFF-1. Each insurer filing to revise the loss cost multiplier in effect shall likewise include a completed copy of form RFF-1.

History

#5655, eff 7-1-93; ss by #6984, eff 5-1-99; ss by #8936, eff 8-1-07; ss by #10920, eff 9-1-15; ss by #14510, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 2801.05 Underwriting and Rating Documentation {#sec-ins-2801.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2801.05}

Companies writing insurance in this state shall maintain all underwriting and rating documentation from which any premium charge is developed. Premium supporting records may be in physical or electronic format provided that these records are identical to the source document. Premium supporting records shall not be a summarization of facts and information from the source document from which they are made.

History

#5655, eff 7-1-93; ss by #6984, eff 5-1-99; ss by #8936, eff 8-1-07; ss by #10920, eff 9-1-15; ss by #14510, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 2801.06 Instructions for the Completion of Form RFF-1 {#sec-ins-2801.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 2801.06}

(a) On form RFF-1, as available in Appendix A, the insurer shall supply the following information:

(1) Insurer name and address, including the name of the person responsible for filing, their title and telephone number and the date of the filing;

(2) The National Association of Insurance Commissioner's identification number assigned to the insurer, and to the insurer’s group;

(3) The line of insurance to which the form applies;

(4) The name of the advisory organization;

(5) The filing reference number assigned to the approved prospective loss costs filing by the advisory organization, and that the insurer files to be deemed to have independently submitted as its own filing the prospective loss costs in the captioned referenced filing;

(6) A declaration that the insurer is a member, subscriber, or service purchaser of the named advisory organization for the line of insurance identified in (a)(3) above;

(7) The proposed percentage rate level change and effective date;

(8) The prior percentage rate level change and effective date;

(9) A declaration that the insurer will:

a. Either file to have its loss cost multipliers and, if utilized, expense constants be applicable to future revisions of the advisory organization's prospective loss costs for this line of insurance as identified in (a)(3) above, so that:

The insurer’s rates will be the combination of the advisory organization’s prospective loss costs and the insurer’s loss cost multipliers and, if utilized, expense constants specified in the attachments;
The rates will apply to policies written on or after the effective date of the advisory organization’s prospective loss costs; and
Authorization is effective until disapproved by the commissioner, or amended or withdrawn by the insurer; or

b. File to have its loss cost multipliers and, if utilized, expense constants be applicable only to the advisory organization reference filing identified in (a)(5) above.

(b) The following information shall be supplied if an expense constant is not used:

(1) The line of insurance, the subline of insurance, the coverage, the territory, and the classification the form will apply to;

(2) A declaration that the insurer will adopt the loss costs filing referenced in the adoption form:

a. Without modification; or

b. With modification, but if the filing is adopted with modification, the nature, percent, rationale, and supporting data shall be cited;

(3) The loss cost modification expressed as a multiplicative factor;

(4) The total production expense expressed as a percentage of premium;

(5) The general expense expressed as a percentage of premium;

(6) The taxes, licenses, and fees expressed as a percentage of premium;

(7) The underwriting profit and contingencies expressed as a percentage of premium;

(8) The offset for investment income expressed as a percentage of premium;

(9) The other expenses expressed as a percentage of premium;

(10) The total expenses, which shall be the sum of (4) above through (9) above, expressed as a percentage of premium;

(11) The expected loss ratio expressed in decimal form;

(12) The insurer’s calculated loss cost multiplier, which shall equal 1.00 divided by (b)(11) above;

(13) The insurer's selected loss cost multiplier which shall equal the modification in (b)(3) above divided by the insurer’s calculated lost cost multiplier in (b)(12); and

(14) The rate level change for the coverages that apply.

(1) The line of insurance, the subline of insurance, the coverage, the territory, and the classification the form will apply to;

(2) A declaration that the insurer will adopt the loss costs filing referenced in the adoption form:

a. Without modification; or

b. With modification, but if the filing is adopted with modification, the nature, percent, rationale and supporting data shall be cited;

(3) The loss cost modification expressed as a multiplicative factor;

(4) An explanation of how expenses are split between fixed and variable;

(5) The total production expense expressed as a percentage of premium and a breakdown of the expense between fixed and variable expense;

(6) The general expense expressed as a percentage of premium and a breakdown of the expense between fixed and variable expense;

(7) The taxes, licenses, and fees expressed as a percentage of premium and a breakdown of the expense between fixed and variable expense;

(8) The underwriting profit and contingencies expressed as a percentage of premium and a breakdown of the expense between fixed and variable expense;

(9) The offset for investment income expressed as a percentage of premium;

(10) The other expenses expressed as a percentage of premium and a breakdown of the expense between fixed and variable expense;

(11) The total expense, which shall be the sum of (5) through (10) above, expressed as a percentage of premium and a breakdown of the expense between fixed and variable expense;

(12) The expected loss ratio expressed in decimal form;

(13) The variable expense loss ratio expressed in decimal form;

(14) The formula expense constant calculated as follows:

a. The reciprocal of (c)(12) less the reciprocal of (c)(13);

b. The result of a. above times the average underlying loss costs;

(15) The selected expense constant;

(16) The formula variable loss cost multiplier, which shall be 1.00 divided by (c)(13) above;

(17) The selected variable loss cost multiplier which shall equal the modification in (c)(3) above divided by the insurer’s formula variable loss cost multiplier in (c)(16);

(18) An explanation of any differences between (14) above and (15) above; and

(19) The rate level change for the coverages that apply.

History

#5655, eff 7-1-93; ss by #6984, eff 5-1-99; ss by #8936, eff 8-1-07; ss by #10920, eff 9-1-15; ss by #14510, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 2801.07 Waiver of Rules. {#sec-ins-2801.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 2801.07}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX A

FORM RFF-1

Date:

PROSPECTIVE LOSS COSTS REFERENCE

FILING ADOPTION FORM

INSURER NAME _____________________________________________________________________

ADDRESS ____________________________________________________________

PERSON RESPONSIBLE FOR FILING ________________________________________________

TITLE ______________________TELEPHONE # ________________________________________

NAIC COMPANY # ______________________ NAIC GROUP #_____________________________
LINE OF INSURANCE _________________________________________________________________
ADVISORY ORGANIZATION ___________________________________________________________
ADVISORY ORGANIZATION REFERENCE FILING # _______________________________________
The above insurer hereby declares that it is a member, subscriber or service purchaser of the named advisory organization for this line of insurance. The insurer hereby files to be deemed to have independently submitted as its own filing the prospective loss costs in the captioned reference filing.

The insurer's rates will be the combination of the prospective loss costs and the loss cost multipliers and, if utilized, the expense constants specified in the attachments.

PROPOSED RATE LEVEL CHANGE ____% EFFECTIVE DATE ___________________
PRIOR RATE LEVEL CHANGE % EFFECTIVE DATE_____________________
CHECK ONE OF THE FOLLOWING:

______The insurer hereby files to have its loss cost multipliers and, if utilized, expense constants be applicable to future revisions of the advisory organization's prospective loss costs for this line of insurance. The insurer's rates will be the combination of the advisory organization's prospective loss costs and the insurer's loss cost multipliers and, if utilized, expense constants specified in the attachments. The rates will apply to policies written on or after the effective date of the advisory organization's prospective loss costs. This authorization is effective until disapproved by the commissioner, or amended or withdrawn by the insurer.

______The insurer hereby files to have its loss costs multipliers and, if utilized, expense constants be applicable only to the above advisory organization reference filing.

I. CALCULATION OF COMPANY LOSS COST MULTIPLIER WITHOUT EXPENSE CONSTANT

Line, subline, coverage, territory, class, etc. combination to which this page applies _____________

Loss Cost Modification:

A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing:

Without modification. (factor=1.000)

With the following modification: _________%

(Cite the nature of the modification, and attached supporting data and rationale.)

B. Loss Cost Modification Expressed as a Factor: __________

Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supporting information.

Selected Provisions

A. Total Production Expense ______________% (+)

B. General Expense ______________% (+)

C. Taxes, Licenses & Fees ______________% (+)

D. Underwriting Profit & Contingencies ______________% (+)

E. Investment Income ______________% (-)

F. Other (explain) ______________% (+)

G. TOTAL ______________%

A. Expected Loss Ratio: ELR:ELR=100%- 3G ______________%

B. ELR in decimal form = _____________

Calculated Loss Cost Multiplier (1.00/4B)= ______________%
Company Selected Loss Cost Multiplier = ______________

Any difference between 5 and 6 should be explained on line 2.

Rate level change for the coverages to which

this page applies. _____________%

II. CALCULATION OF COMPANY LOSS COST MULTIPLIER WITH EXPENSE CONSTANTS

Line, subline, coverage, territory, class, etc. combination to which this page applies __________

Loss Cost Modification:

A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing:

Without modification. (factor=1.000)

With the following modification: _________%

(Cite the nature of the modification, and attached supporting data and rationale.)

B. Loss Cost Modification Expressed as a Factor: ____________________________________

Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supporting information, including an explanation of the split between fixed and variable expenses.)

Selected Provisions

Overall Variable Fixed

A. Total Production Expense _______ _______ ________(+)

B. General Expense _______ _______ ________(+)

C. Taxes, Licenses & Fees _______ _______ ________(+)

D. Underwriting Profit & Contingencies _______ _______ ________(+)

E. Investment Income _______ _______ ________(-)

F. Other (explain) _______ ______ ________(+)

G. TOTAL _______ _______ _________

A. Expected Loss Ratio (ELR): 100% - Overall 3G. = _________

B. ELR in decimal form = _________

C. Variable Expected Loss Ratio (VELR): 100%-Variable 3.G = _________

D. VELR in decimal form = _________

A. Formula Expense Constant

(1.00/4B-1.00/4D) x Average Underlying Loss Cost = _________

B. Formula Variable Loss Cost Multiplier: (I.2.B ÷ III.2.D) = _________

C. Selected Expense Constant = _________

A. Formula Variable Loss Cost Multiplier: (1.00/4D)= _________

B. Selected Variable Loss Cost Multiplier (2B/6A) = _________

Explain any differences between 5A and 5B.

Any difference between 6A and 6B should be explained on line ________________________________________________________________________________

Rate level change for the coverages to which this page applies: ________%

APPENDIX B

Rule

Statute

Ins 2801.01

RSA 412:16, II, III, VI; RSA 412:25; RSA 412:43

Ins 2801.02

RSA 412:20

Ins 2801.03

RSA 412:15; RSA 412:16; RSA 412:19; RSA 412:23; RSA 412:25

Ins 2801.04

RSA 412:15; RSA 412:16

Ins 2801.05

RSA 412:16

Ins 2801.06

RSA 412:16

Ins 2801.07

RSA 400-A:15, I; RSA 541-A:22, IV

History

#14510, eff 2-7-26, EXPIRES: 2-7-36

Chapter Ins 2900 Hazardous Financial Conditions, Licensed Companies

Part Ins 2901 Regulation of Companies Deemed to Be in Hazardous Financial Condition

N.H. Code Admin. R. Ann. Ins 2901.01 Purpose {#sec-ins-2901.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 2901.01}

(a) The purpose of this chapter is to set forth the standards which the commissioner may use for identifying insurers found to be in such condition as to render the continuance of their business hazardous to their policyholders, creditors, or the general public.

(b) This chapter shall not be interpreted to limit the powers granted the commissioner by any laws or parts of laws of this state, nor shall this chapter be interpreted to supersede any laws or parts of laws of this state.

History

#5475, eff 9-21-92; ss by #5655, eff 7-1-93; ss by #7034, INTERIM, eff 7-1-99, EXPIRED: 10-29-99; ss by #7111, eff 10-29-99; ss by #8919, eff 7-1-07; ss by #9934, eff 6-1-11; ss by #12748, eff 6-1-19

N.H. Code Admin. R. Ann. Ins 2901.02 Standards {#sec-ins-2901.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 2901.02}

The following standards, either singly or a combination of two or more, may be considered by the commissioner to determine whether the continued operation of any insurer transacting an insurance business in this state might be deemed to be hazardous to its policyholders, creditors, or the general public. The commissioner may consider:

(a) Adverse findings reported in financial condition and market conduct examination reports, audit reports, and actuarial opinions, reports, or summaries;

(b) The National Association of Insurance Commissioners (NAIC) Insurance Regulatory Information System and its other financial analysis solvency tools and reports;

(c) Whether the insurer has made adequate provision, according to presently accepted actuarial standards of practice, for the anticipated cash flows required by the contractual obligations and related expenses of the insurer, when considered in light of the assets held by the insurer with respect to such reserves and related actuarial items including, but not limited to, the investment earnings on such assets, and the considerations anticipated to be received and retained under such policies and contracts;

(d) The ability of an assuming reinsurer to perform and whether the insurer's reinsurance program provides sufficient protection for the insurer's remaining surplus after taking into account the insurer's cash flow and the classes of business written as well as the financial condition of the assuming reinsurer;

(e) Whether the insurer's operating loss in the last 12 month period or any shorter period of time, including but not limited to net capital gain or loss, change in non-admitted assets, and cash dividends paid to shareholders, is greater than 50 percent of the insurer's remaining surplus as regards policyholders in excess of the minimum required;

(f) Whether the insurer's operating loss in the last 12 month period or any shorter period of time, excluding net capital gains, is greater than 20 percent of the insurer's remaining surplus as regards policyholders in excess of the minimum required;

(g) Whether a reinsurer, obligor, or any entity within the insurer's insurance holding company system is insolvent, threatened with insolvency, or delinquent in payment of its monetary or other obligations, and which in the opinion of the commissioner may affect the solvency of the insurer;

(h) Contingent liabilities, pledges, or guarantees which either individually or collectively involve a total amount which in the opinion of the commissioner may affect the solvency of the insurer;

(i) Whether any "controlling person" of an insurer is delinquent in the transmitting to, or payment of, net premiums to the insurer;

(j) The age and collectability of receivables;

(k) Whether the management of an insurer, including officers, directors, or any other person who directly or indirectly controls the operation of the insurer, fails to possess and demonstrate the competence, fitness, and reputation deemed necessary to serve the insurer in such position;

(l) Whether the management of an insurer has failed to respond to inquiries relative to the condition of the insurer or has furnished false and misleading information concerning an inquiry;

(m) Whether the insurer has failed to meet financial and holding company filing requirements in the absence of a reason satisfactory to the commissioner;

(n) Whether management of an insurer either has filed any false or misleading sworn financial statement, or has released any false or misleading financial statement to lending institutions or to the general public, or has made a false or misleading entry, or has omitted an entry of material amount in the books of the insurer;

(o) Whether the insurer has grown so rapidly and to such an extent that it lacks adequate financial and administrative capacity to meets its obligations in a timely manner;

(p) Whether the insurer has experienced or will experience in the foreseeable future cash flow or liquidity problems;

(q) Whether management has established reserves that do not comply with minimum standards established by state insurance laws, regulations, statutory accounting standards, sound actuarial principles, and standards of practice;

(r) Whether management persistently engages in material under reserving that results in adverse development;

(s) Whether transactions among affiliates, subsidiaries or controlling persons for which the insurer receives assets or capital gains, or both, do not provide sufficient value, liquidity, or diversity to assure the insurer's ability to meet its outstanding obligations as they mature; and

(t) Any other finding determined by the commissioner to be hazardous to the insurer's policyholders, creditors, or general public.

History

#5475, eff 9-21-92; ss by #5655, eff 7-1-93; ss by #7034, INTERIM, eff 7-1-99, EXPIRED: 10-29-99; ss by #7111, eff 10-29-99; ss by #8919, eff 7-1-07; ss by #9934, eff 6-1-11; ss by #12748, eff 6-1-19

N.H. Code Admin. R. Ann. Ins 2901.03 Commissioner's Authority {#sec-ins-2901.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 2901.03}

(a) For the purposes of making a determination of an insurer's financial condition under this chapter, the commissioner may:

(1) Disregard any credit or amount receivable resulting from transactions with a reinsurer that is insolvent, impaired, or otherwise subject to a delinquency proceeding;

(2) Make appropriate adjustments including disallowance to asset values attributable to investments in or transactions with parents, subsidiaries, or affiliates consistent with the NAIC Accounting Practices and Procedures Manual, state laws, and regulations;

(3) Refuse to recognize the stated value of accounts receivable if the ability to collect receivables is highly speculative in view of the age of the account or the financial condition of the debtor; and

(4) Increase the insurer's liability in an amount equal to any contingent liability, pledge, or guarantee not otherwise included if there is a substantial risk that the insurer will be called upon to meet the obligation undertaken within the next 12 month period.

(b) If the commissioner determines that the continued operation of the insurer licensed to transact business in this state may be hazardous to the policyholders, creditors, or the general public, then the commissioner may, upon a determination, issue an order requiring the insurer to:

(1) Reduce the total amount of present and potential liability for policy benefits by reinsurance;

(2) Reduce, suspend, or limit the volume of business being accepted or renewed;

(3) Reduce general insurance and commission expenses by specified methods;

(4) Increase the insurer's capital and surplus;

(5) Suspend or limit the declaration and payment of dividend by an insurer to its stockholders or to its policyholders;

(6) File reports in a form acceptable to the commissioner concerning the market value of an insurer's assets;

(7) Limit or withdraw from certain investments or discontinue certain investment practices to the extent the commissioner deems necessary;

(8) Document the adequacy of premium rates in relation to the risks insured;

(9) File, in addition to regular annual statements, interim financial reports pursuant to RSA 400-A:36, III;

(10) Correct corporate governance practice deficiencies, and adopt and utilize governance practices acceptable to the commissioner;

(11) Provide a business plan to the commissioner in order to continue to transact business in the state; and

(12) Notwithstanding any other provision of law limiting the frequency or amount of premium rate adjustments, adjust rates for any non-life insurance product written by the insurer that the commissioner considers necessary to improve the financial condition of the insurer.

If the insurer is a foreign insurer the commissioner's order may be limited to the extent provided by statute.

(c) An insurer subject to an order under (b) above may request a hearing to review that order. The notice of hearing shall be served upon the insurer pursuant to RSA 400-A:18. The notice of hearing shall state the time and place of hearing, and the conduct, condition or ground upon which the commissioner based the order. Unless mutually agreed between the commissioner and the insurer, the hearing shall occur not less than 10 days nor more than 30 days after notice is served and shall be conducted at the insurance department. The commissioner shall hold all hearings under this subsection privately, unless the insurer requests a public hearing in which case the hearing shall be public.

History

#5475, eff 9-21-92; ss by #5655, eff 7-1-93; ss by #7034, INTERIM, eff 7-1-99, EXPIRED: 10-29-99; ss by #7111, eff 10-29-99; ss by #8919, eff 7-1-07; ss by #9934, eff 6-1-11; ss by #12748, eff 6-1-19

N.H. Code Admin. R. Ann. Ins 2901.04 Judicial Review {#sec-ins-2901.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 2901.04}

Any order or decision of the commissioner shall be subject to review in accordance with RSA 541 at the instance of any party to the proceedings whose interests are substantially affected.

History

#8919, eff 7-1-07; ss by #9934, eff 6-1-11; ss by #12748, eff 6-1-19

N.H. Code Admin. R. Ann. Ins 2901.05 Waiver of Rules {#sec-ins-2901.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 2901.05}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX

Rule

Specific State Statute the Rule Implements

Ins 2901.01

RSA 400-A:15, I; RSA 400-A:36-a; RSA 400-A:37; RSA 401-B; RSA 402-C; RSA 403-C

Ins 2901.02

RSA 400-A:15, I; RSA 400-A:36-a; RSA 400-A:37; RSA 401-B; RSA 402-C; RSA 403-C

Ins 2901.03

RSA 400-A:15, I; RSA 400-A:18; RSA 400-A:19; RSA 400-A:36-a; RSA 400-A:37;

RSA 401-B; RSA 402-C; RSA 403-C

Ins 2901.04

RSA 400-A:15, I; RSA 400-A:17; RSA 400-A:18; RSA 400-A:19; RSA 401-B:15; RSA 541

Ins 2901.05

RSA 400-A:15, I; RSA 541-A:22, IV

History

#12748, eff 6-1-19

Chapter Ins 3000 Privacy of Consumer Financial and Health Information

Part Ins 3001 Nonpublic Personal Health and Financial Information

N.H. Code Admin. R. Ann. Ins 3001.01 Purpose {#sec-ins-3001.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3001.01}

(a) This rule governs the treatment of nonpublic personal health information and nonpublic personal financial information about individuals by all licensees of the state insurance department. This rule:

(1) Requires a licensee to provide notice to individuals about its privacy policies and practices;

(2) Describes the conditions under which a licensee may disclose nonpublic personal health information and nonpublic personal financial information about individuals to affiliates and nonaffiliated third parties; and

(3) Provides methods for individuals to prevent a licensee from disclosing that information.

History

#7500, eff 7-1-01, EXIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3001.02 Scope {#sec-ins-3001.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3001.02}

(a) This rule applies to:

(1) Nonpublic personal financial information about individuals who obtain or are claimants or beneficiaries of products or services primarily for personal, family, or household purposes from licensees. This rule does not apply to information about companies or about individuals who obtain products or services for business, commercial, or agricultural purposes; and

(2) All nonpublic personal health information.

(b) Compliance. A licensee domiciled in this state that is in compliance with this rule in a state that has not enacted laws or regulations that meet the requirements of Title V of the Gramm-Leach-Bliley Act (PL 102-106) may nonetheless be deemed to be in compliance with Title V of the Gramm-Leach-Bliley Act in the other state.

History

#7500, eff 7-1-01, EXIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3001.03 Rule of Construction {#sec-ins-3001.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3001.03}

The examples in this rule and the sample clauses in Appendix A and the Federal Model Privacy Form in Appendix B of this rule are not exclusive. Compliance with an example or use of a sample clause or the Federal Privacy Model Form, to the extent applicable, constitutes compliance with this rule. Licensees may rely on use of the Federal Privacy Form in Appendix B, consistent with the attached instructions, as a safe harbor of compliance with the privacy notice content requirements of this regulation. Use of the Federal Model Privacy Form is not required. Licensees may continue to use other types of privacy notices, including notices that contain the examples in this regulation and/or the sample clauses in Appendix A, provided that such notices accurately describe the Licensee’s privacy practices and otherwise meet the notice content requirements of this regulation. However, while Licensees may continue to use privacy notices that contain the examples in this regulation and/or the sample clauses in Appendix A, Licensees may not rely on use of privacy notices with the sample clauses in Appendix A as a safe harbor of compliance with the notice content requirements of this regulation after July 1, 2019.

History

#7500, eff 7-1-01, EXIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3001.04 Definitions {#sec-ins-3001.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3001.04}

As used in this rule, unless the context requires otherwise:

(a) “Affiliate” means any company that controls, is controlled by, or is under common control with another company.

(b) (1) “Clear and conspicuous” means that a notice is reasonably understandable and designed to call attention to the nature and significance of the information in the notice; and

(2) Examples:

a. Reasonably understandable. A licensee makes its notice reasonably understandable if it:

Presents the information in the notice in clear, concise sentences, paragraphs, and sections;
Uses short explanatory sentences or bullet lists whenever possible;
Uses definite, concrete, everyday words and active voice whenever possible;
Avoids multiple negatives;
Avoids legal and highly technical business terminology whenever possible; and
Avoids explanations that are imprecise and readily subject to different interpretations;

b. Designed to call attention. A licensee designs its notice to call attention to the nature and significance of the information in it if the licensee:

Uses a plain-language heading to call attention to the notice;
Uses a typeface and type size that are easy to read;
Provides wide margins and ample line spacing;
Uses boldface or italics for key words; and
In a form that combines the licensee’s notice with other information, uses distinctive type size, style, and graphic devices, such as shading or sidebars; and

c. Notices on web sites. If a licensee provides a notice on a web page, the licensee designs its notice to call attention to the nature and significance of the information in it if the licensee uses text or visual cues to encourage scrolling down the page if necessary to view the entire notice and ensure that other elements on the web site (such as text, graphics, hyperlinks, or sound) do not distract attention from the notice, and the licensee either:

Places the notice on a screen that consumers frequently access, such as a page on which transactions are conducted; or
Places a link on a screen that consumers frequently access, such as a page on which transactions are conducted, that connects directly to the notice and is labeled appropriately to convey the importance, nature, and relevance of the notice.

(c) “Collect” means to obtain information that the licensee organizes or can retrieve by the name of an individual or by identifying number, symbol, or other identifying particular assigned to the individual, irrespective of the source of the underlying information.

(d) “Commissioner” means the insurance commissioner of the state.

(e) “Company” means corporation, limited liability company, business trust, general or limited partnership, association, sole proprietorship, or similar organization.

(f) (1) “Consumer” means an individual who seeks to obtain, obtains or has obtained an insurance product or service from a licensee that is to be used primarily for personal, family, or household purposes, and about whom the licensee has nonpublic personal information, or that individual’s legal representative; and

(2) Examples:

a. An individual who provides nonpublic personal information to a licensee in connection with obtaining or seeking to obtain financial, investment or economic advisory services relating to an insurance product or service is a consumer regardless of whether the licensee establishes an ongoing advisory relationship;

b. An applicant for insurance prior to the inception of insurance coverage is a licensee’s consumer;

c. An individual who is a consumer of another financial institution is not a licensee’s consumer solely because the licensee is acting as agent for, or provides processing or other services to, that financial institution;

d. An individual is a licensee’s consumer if:

The individual is a beneficiary of a life insurance policy underwritten by the licensee;
The individual is a claimant under an insurance policy issued by the licensee;
The individual is an insured or an annuitant under an insurance policy or an annuity, respectively, issued by the licensee; or
The individual is a mortgagor of a mortgage covered under a mortgage insurance policy; and
The licensee discloses nonpublic personal financial information about the individual to a nonaffiliated third party other than as permitted under Ins 3004.01, Ins 3004.02 and Ins 3004.03;

e. Provided that the licensee provides the initial, annual and revised notices under Ins 3002.01, Ins 3002.02, and Ins 3002.05 to the plan sponsor, group or blanket insurance policyholder or group annuity contractholder, or workers’ compensation policyholder, and further provided that the licensee does not disclose to a nonaffiliated third party nonpublic personal financial information about an individual described in 1., 2., and 3. below, other than as permitted under Ins 3004.01, Ins 3004.02, and Ins 3004.03, such an individual is not the consumer of the licensee solely because he or she is:

A participant or a beneficiary of an employee benefit plan that the licensee administers or sponsors or for which the licensee acts as a trustee, insurer or fiduciary;
Covered under a group or blanket insurance policy or group annuity contract issued by the licensee; or
A claimant covered by a workers’ compensation plan;

f. 1. The individuals described in subparagraphs e.1. through 3. above are consumers of a licensee if the licensee does not meet all the conditions of subparagraph e. above;

In no event shall the individuals, solely by virtue of the status described in subparagraphs e.1. through 3. above, be deemed to be customers for purposes of this rule;

g. An individual is not a licensee’s consumer solely because he or she is a beneficiary of a trust for which the licensee is a trustee; and

h. An individual is not a licensee’s consumer solely because he or she has designated the licensee as trustee for a trust.

(g) “Consumer reporting agency” has the same meaning as in Section 603(f) of the federal Fair Credit Reporting Act (15 U.S.C. 1681a(f)).

(h) “Control” means:

(1) Ownership, control, or power to vote 25 percent or more of the outstanding shares of any class of voting security of the company, directly or indirectly, or acting through one or more other persons;

(2) Control in any manner over the election of a majority of the directors, trustees, or general partners (or individuals exercising similar functions) of the company; or

(3) The power to exercise, directly or indirectly, a controlling influence over the management of policies of the company, as the commissioner determines.

(i) “Customer” means a consumer who has a customer relationship with a licensee.

(j) (1) “Customer relationship” means a continuing relationship between a consumer and a licensee under which the licensee provides one or more insurance products or services to the consumer that are to be used primarily for personal, family, or household purposes; and

(2) Examples:

a. A consumer has a continuing relationship with a licensee if:

The consumer is a current policyholder of an insurance product issued by or through the licensee; or
The consumer obtains financial, investment, or economic advisory services relating to an insurance product or service from the licensee for a fee; and

b. A consumer does not have a continuing relationship with a licensee if:

The consumer applies for insurance but does not purchase the insurance;
The licensee sells the consumer airline travel insurance in an isolated transaction;
The individual is no longer a current policyholder of an insurance product or obtains insurance services with or through the licensee;
The consumer is a beneficiary or claimant under a policy and has submitted a claim under a policy choosing a settlement option involving an ongoing relationship with the licensee;
The consumer is a beneficiary or a claimant under a policy and has submitted a claim under that policy choosing a lump sum settlement option;
The customer’s policy is lapsed, expired, or otherwise inactive or dormant under the licensee’s business practices, and the licensee has not communicated with the customer about the relationship for a period of 12 consecutive months, other than annual privacy notices, material required by law or regulation, communication at the direction of a state or federal authority, or promotional materials;
The individual is an insured or an annuitant under an insurance policy or annuity, respectively, but is not the policyholder or owner of the insurance policy or annuity; or
For the purposes of this rule, the individual’s last known address according to the licensee’s records is deemed invalid. An address of record is deemed invalid if mail sent to that address by the licensee has been returned by the postal authorities as undeliverable and if subsequent attempts by the licensee to obtain a current valid address for the individual have been unsuccessful.

(k) (1) “Financial institution” means any institution the business of which is engaging in activities that are financial in nature or incidental to such financial activities as described in Section 4(k) of the Bank Holding Company Act of 1956 (12 U.S.C. 1843 (k)).

(2) Financial institution does not include:

a. Any person or entity with respect to any financial activity that is subject to the jurisdiction of the Commodity Futures Trading Commission under the Commodity Exchange Act (7 U.S.C. 1 et seq.);

b. The Federal Agricultural Mortgage Corporation or any entity charged and operating under the Farm Credit Act of 1971 (12 U.S.C. 2001 et seq.); or

c. Institutions chartered by Congress specifically to engage in securitizations, secondary market sales (including sales of servicing rights) or similar transactions related to a transaction of a consumer, as long as the institutions do not sell or transfer nonpublic personal information to a nonaffiliated third party.

(l) (1) “Financial product or service” means any product or service that a financial holding company could offer by engaging in an activity that is financial in nature or incidental to such a financial activity under Section 4(k) of the Bank Holding Company Act of 1956 (12 U.S.C. 1843 (k)); and

(2) Financial service includes a financial institution’s evaluation or brokerage of information that the financial institution collects in connection with a request or an application from a consumer for a financial product or service.

(m) “Health care” means:

(1) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, services, procedures, tests, or counseling that:

a. Relates to the physical, mental, or behavioral condition of an individual; or

b. Affects the structure or function of the human body or any part of the human body, including the banking of blood, sperm, organs, or any other tissues; or

(2) Prescribing, dispensing, or furnishing to an individual drugs or biologicals, or medical devices or health care equipment and supplies.

(n) “Health care provider” means a physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with state law or a health care facility.

(o) “Health information” means any information or data except age or gender, whether oral or recorded in any form or medium, created by or derived from a health care provider or the consumer that relates to:

(1) The past, present or future physical, mental or behavioral health or condition of an individual;

(2) The provision of health care to an individual; or

(3) Payment for the provisions of health care to an individual.

(p) (1) “Insurance product or service” means any product or service that is offered by a licensee pursuant to the insurance laws of this state; and

(2) “Insurance services” includes a licensee’s evaluation, brokerage, or distribution of information that the licensee collects in connection with a request or an application from a consumer for an insurance product or service.

(q) (1) “Licensee” means all licensed insurers, producers and other persons licensed or required to be licensed or authorized or required to be authorized, or registered or required to be registered pursuant to the provisions of Title XXXVII;

(2) A licensee is not subject to the notice and opt out requirements for nonpublic personal financial information set forth in Ins 3001, Ins 3002, Ins 3003 and Ins 3004 of this rule if the licensee is an employee, agent or other representative of another licensee (“the principal”) and:

a. The principal otherwise complies with, and provides the notices required by, the provisions of this rule; and

b. The licensee does not disclose any nonpublic personal information to any person other than the principal or its affiliates in a manner permitted by this rule; and

(3) a. Subject to b. below, “licensee” shall also include an unauthorized insurer that accepts business placed through a licensed excess lines broker in this state, but only in regard to the excess lines placements placed pursuant to RSA 405:24 through RSA 405:31 and RSA 405-A; and

b. An excess lines broker or excess lines insurer shall be deemed to be in compliance with the notice and opt out requirements for nonpublic personal financial information set forth in Ins 3001, Ins 3002, Ins 3003, and Ins 3004 of this regulation provided:

The broker or insurer does not disclose nonpublic personal information of a consumer or a customer to nonaffiliated third parties for any purpose, including joint servicing or marketing under Ins 3004.01 of this rule, except as permitted by Ins 3004.02 and Ins 3004.03 of this rule; and
The broker or insurer delivers a notice to the consumer at the time a customer relationship is established on which the following is printed in 16-point type:

PRIVACY NOTICE

“NEITHER THE U.S. BROKERS THAT HANDLED THIS INSURANCE

NOR THE INSURERS THAT HAVE UNDERWRITTEN THIS INSURANCE

WILL DISCLOSE NONPUBLIC PERSONAL INFORMATION CONCERNING

THE BUYER TO NONAFFILIATES OF THE BROKERS OR INSURERS EXCEPT AS PERMITTED BY LAW.

(r) (1) Nonaffiliated third party” means any person except:

a. A licensee’s affiliate; or

b. A person employed jointly by a licensee and any company that is not the licensee’s affiliate (but nonaffiliated third party includes the other company that jointly employs the person); and

(2) Nonaffiliated third party includes any company that is an affiliate solely by virtue of the direct or indirect ownership or control of the company by the licensee or its affiliate in conducting merchant banking or investment banking activities of the type described in section 4(k)(4)(H) or insurance company investment activities of the type described in section 4(k)(4)(I) of the federal Bank Holding Company Act (12 U.S.C. 1843(k)(4)(H) and (I)).

(s) “Nonpublic personal information” means nonpublic personal financial information and nonpublic personal health information.

(t) (1) “Nonpublic personal financial information” means:

a. Personally identifiable financial information; and

b. Any list, description, or other grouping of consumers (and publicly available information pertaining to them) that is derived using any personally identifiable financial information that is not publicly available; and

(2) Nonpublic personal financial information does not include:

a. Health information;

b. Publicly available information, except as included on a list described in paragraph (t) (1)b. above; or

c. Any list, description, or other grouping of consumers (and publicly available information pertaining to them) that is derived without using any personally identifiable financial information that is not publicly available; and

(3) Examples of lists:

a. Nonpublic personal financial information includes any list of individuals’ name and street addresses that is derived in whole or in part using personally identifiable financial information that is not publicly available, such as account numbers; and

b. Nonpublic personal financial information does not include any list of individuals’ names and addresses that contains only publicly available information, is not derived in whole or in part using personally identifiable financial information that is not publicly available, and is not disclosed in a manner that indicates that any of the individuals on the list is a consumer of a financial institution.

(u) “Nonpublic personal health information” means health information:

(1) That identifies an individual who is the subject of the information; or

(2) With respect to which there is a reasonable basis to believe that the information could be used to identify an individual.

(v) (1) “Personally identifiable financial information” means any information:

a. A consumer provides to a licensee to obtain an insurance product or service from the licensee;

b. About a consumer resulting from transaction involving an insurance product or service between a licensee and a consumer; or

c. The licensee otherwise obtains about a consumer in connection with providing an insurance product or service to that consumer; and

(2) Examples:

a. Information included. Personally identifiable financial information includes:

Information a consumer provides to a licensee on an application to obtain an insurance product or service;
Account balance information and payment history;
The fact that an individual is or has been one of the licensee’s customers or has obtained an insurance product or service from the licensee;
Any information about the licensee’s consumer if it is disclosed in a manner that indicates that the individual is or has been the licensee’s consumer;
Any information that a consumer provides to a licensee or that the licensee or its agent otherwise obtains in connection with collecting on a loan or servicing a loan;
Any information the licensee collects through an Internet “cookie” (an information collecting device from a web server); and
Information from a consumer report; and

b. Information not included. Personally identifiable financial information does not include:

Health information;
A list of names and addresses of customers of an entity that is not a financial institution; and
Information that does not identify a consumer, such as aggregate information or blind data that does not contain personal identifiers such as account numbers, names, or addresses.

(w) (1) “Publicly available information” means any information that a licensee has a reasonable basis to believe is lawfully made available to the general public from:

a. Federal, state or local government records;

b. Widely distributed media; or

c. Disclosures to the general public that are required to be made by federal, state or local law;

(2) Reasonable basis. A licensee has a reasonable basis to believe that information is lawfully made available to the general public if the licensee has taken steps to determine:

a. That the information is of the type that is available to the general public; and

b. Whether an individual can direct that the information not be made available to the general public and, if so, that the licensee’s consumer has not done so; and

(3) Examples:

a. Government records. Publicly available information in government records includes information in government real estate records and security interest filings;

b. Widely distributed media. Publicly available information from widely distributed media includes information from a telephone book, a television or radio program, a newspaper, or a web site that is available to the general public on an unrestricted basis. A web site is not restricted merely because an Internet service provider or a site operator requires a fee or a password, so long as access is available to the general public;

c. Reasonable basis:

A licensee has a reasonable basis to believe that mortgage information is lawfully made available to the general public if the licensee has determined that the information is of the type included on the public record in the jurisdiction where the mortgage would be recorded; and
A licensee has a reasonable basis to believe that an individual’s telephone number is lawfully made available to the general public if the licensee has located the telephone number in the telephone book or the consumer has informed you that the telephone number is not unlisted.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

Part Ins 3002 Privacy, and Opt Out Notices for Financial Information

N.H. Code Admin. R. Ann. Ins 3002.01 Initial Privacy Notice to Consumers Required {#sec-ins-3002.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3002.01}

(a) Initial notice requirement. A licensee shall provide a clear and conspicuous notice that accurately reflects its privacy policies and practices to:

(1) Customer. An individual who becomes the licensee’s customer, not later than when the licensee establishes a customer relationship, except as provided in (e) below; and

(2) Consumer. A consumer, before the licensee discloses any nonpublic personal financial information about the consumer to any nonaffiliated third party, if the licensee makes a disclosure other than as authorized by Ins 3004.02 and Ins 3004.03.

(b) When initial notice to a consumer is not required. A licensee is not required to provide an initial notice to a consumer under (a)(2) above if:

(1) The licensee does not disclose any nonpublic personal financial information about the consumer to any nonaffiliated third party, other than as authorized by Ins 3004.02 and Ins 3004.03, and the licensee does not have a customer relationship with the consumer; or

(2) A notice has been provided by an affiliated licensee, as long as the notice clearly identifies all licensees to whom the notice applies and is accurate with respect to the licensee and the other institutions.

(1) General rule. A licensee establishes a customer relationship at the time the licensee and the consumer enter into a continuing relationship;

(2) Examples of establishing customer relationship. A licensee establishes a customer relationship when the consumer:

a. Becomes a policyholder of a licensee that is an insurer when the insurer delivers an insurance policy or contract to the consumer, or in the case of a licensee that is an insurance producer or insurance broker, obtains insurance through that licensee; or

b. Agrees to obtain financial, economic or investment advisory services relating to insurance products or services for a fee from the licensee.

(d) Existing customers. When an existing customer obtains a new insurance product or service from a licensee that is to be used primarily for personal, family or household purposes, the licensee satisfies the initial notice requirements of (a) above as follows:

(1) The licensee may provide a revised policy notice, under Ins 3002.05, that covers the customer’s new insurance product or service; or

(2) If the initial, revised, or annual notice that the licensee most recently provided to that customer was accurate with respect to the new insurance product or service, the licensee does not need to provide a new privacy notice under (a) above.

(e) Exceptions to allow subsequent delivery of notice:

(1) A licensee may provide the initial notice required by (a) above within a reasonable time after the licensee establishes a customer relationship if:

a. Establishing the customer relationship is not at the customer’s election; or

b. Providing notice not later than when the licensee establishes a customer relationship would substantially delay the customer’s transaction and the customer agrees to receive the notice at a later time; and

(2) Examples of exceptions:

a. Not at customer’s election. Establishing a customer relationship is not at the customer’s election if a licensee acquires or is assigned a customer’s policy from another financial institution or residual market mechanism and the customer does not have a choice about the licensee’s acquisition or assignment;

b. Substantial delay of customer’s transaction. Providing notice not later than when a licensee establishes a customer relationship would substantially delay the customer’s transaction when the licensee and the individual agree over the telephone to enter into a customer relationship involving prompt delivery of the insurance product or service; and

c. No substantial delay of customers transaction. Providing notice not later than when a licensee establishes a customer relationship would not substantially delay the customer’s transaction when the relationship is initiated in person at the licensee’s office or through other means by which the customer may view the notice, such as on a web site.

(f) Delivery. When a licensee is required to deliver an initial privacy notice by this section, the licensee shall deliver it according to Ins 3002.06. If the licensee uses a short-form initial notice for non-customers according to Ins 3002.03(d), the licensee may deliver its privacy notice according to Ins 3002.03(d)(3).

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3002.02 Annual Privacy Notice to Customers Required {#sec-ins-3002.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3002.02}

(a) (1) General rule. A licensee shall provide a clear and conspicuous notice to customers that accurately reflects its privacy policies and practices not less than annually during the continuation of the customer relationship. Annually means at least once in any period of 12 consecutive months during which that relationship exists. A licensee may define the 12-consecutive-month period, but the licensee shall apply it to the customer on a consistent basis; and

(2) Example: A licensee provides a notice annually if it defines the 12-consecutive-month period as a calendar year and provides the annual notice to the customer once in each calendar year following the calendar year in which the licensee provided the initial notice. For example, if a customer opens an account on any day of year 1, the licensee shall provide an annual notice to that customer by December 31 of year 2.

(b) Exception to general rule. A licensee that provides nonpublic personal information to nonaffiliated third parties only in accordance with Ins 3004.01, Ins 3004.02, or Ins 3004.03 and has not changed its policies and practices with regard to disclosing nonpublic personal information from the policies and practices that were disclosed in the most recent disclosure sent to consumers in accordance with this section or Ins 3002.01 shall not be required to provide an annual disclosure under this section until such time as the licensee fails to comply with any criteria described in this paragraph.

(c) (1) Termination of customer relationship. A licensee is not required to provide an annual notice to a former customer. A former customer is an individual with whom a licensee no longer has a continuing relationship; and

(2) Examples:

a. A licensee no longer has a continuing relationship with an individual if the individual no longer is a current policyholder of an insurance product or no longer obtains insurance services with or through the licensee;

b. A licensee no longer has a continuing relationship with an individual if the individual’s policy is lapsed, expired, paid up or otherwise inactive or dormant under the licensee’s business practices, and the licensee has not communicated with the customer about the relationship for a period of 12 consecutive months, other than annual privacy notices, material required by law or regulation, or promotional materials;

c. For the purposes of this rule, a licensee no longer has a continuing relationship with an individual if the individual’s last known address according to the licensee’s records is deemed invalid. An address of record is deemed invalid if mail sent to that address by the licensee has been returned by the postal authorities as undeliverable and if subsequent attempts by the licensee to obtain a current valid address for the individual have been unsuccessful; and

d. A licensee no longer has a continuing relationship with a customer, in the case of providing real estate settlement services, at the time the customer completes execution of all documents related to the real estate closing, payment for those services has been received, or the licensee has completed all of its responsibilities with respect to the settlement, including filing documents on the public record, whichever is later.

(d) Delivery. When a licensee is required by this section to deliver an annual privacy notice, the licensee shall deliver it according to Ins 3002.06.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3002.03 Information to be Included in Privacy Notices {#sec-ins-3002.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3002.03}

(a) General rule. The initial, annual and revised privacy notices that a licensee provides under Ins 3002.01, Ins 3002.02, and Ins 3002.05 shall include each of the following items of information, in addition to any other information the licensee wishes to provide, that applies to the licensee and to the consumers to whom the licensee sends it privacy notice:

(1) The categories of nonpublic personal financial information that the licensee collects;

(2) The categories of nonpublic personal financial information that the licensee discloses;

(3) The categories of affiliates and nonaffiliated third parties to whom the licensee discloses nonpublic personal financial information, other than those parties to whom the licensee discloses information under Ins 3004.02 and Ins 3004.03;

(4) The categories of nonpublic personal financial information about the licensee’s former customers that the licensee discloses and the categories of affiliates and nonaffiliated third parties to whom the licensee discloses nonpublic personal financial information about the licensee’s former customers, other than those parties to whom the licensee discloses information under Ins 3004.02 and Ins 3004.03;

(5) If a licensee discloses nonpublic personal financial information to a nonaffiliated third party under Ins 3004.01 (and no other exception in Ins 3004.02 and Ins 3004.03 applies to that disclosure), a separate description of the categories of information the licensee discloses and the categories of third parties with whom the licensee has contracted;

(6) An explanation of the consumer’s rights under Ins 3003.01(a) to opt out of the disclosure of nonpublic personal financial information to nonaffiliated third parties, including the method(s) by which the consumer may exercise that right at that time;

(7) Any disclosures that the licensee makes under Section 603(d)(2)(A)(iii) of the federal Fair Credit Reporting Act (15 U.S.C. 1681a(d)(2)(A)(iii)) (that is, notices regarding the ability to opt out of disclosures of information among affiliates);

(8) The licensee’s policies and practices with respect to protecting the confidentiality and security of nonpublic personal information; and

(9) Any disclosure that the licensee makes under (b) below.

(b) Description of parties subject to exceptions. If a licensee discloses nonpublic personal financial information as authorized under Ins 3004.02 and Ins 3004.03, the licensee is not required to list those exceptions in the initial or annual privacy notices required by Ins 3002.01 and Ins 3002.02. When describing the categories of parties to whom disclosure is made, the licensee is required to state only that it makes disclosures to other affiliated or nonaffiliated third parties, as applicable, as permitted by law.

(1) Categories of nonpublic personal financial information that the licensee collects. A licensee satisfies the requirement to categorize nonpublic personal financial information it collects if the licensee categorizes it according to the source of the information, as applicable:

a. Information from the consumer;

b. Information about the consumer’s transactions with the licensee or its affiliates;

c. Information about the consumer’s transactions with nonaffiliated third parties; and

d. Information from a consumer reporting agency;

(2) Categories of nonpublic personal financial information a licensee discloses.

a. A licensee satisfies the requirement to categorize nonpublic personal financial information it discloses if the licensee categorizes the information according to source, as described in (c)(1) above, as applicable, and provides a few examples to illustrate the types of information in each category. These might include:

Information from the consumer, including application information, such as assets and income and identifying information, such as name, address, and social security number;
Transaction information, such as information about balances, payment history, and parties to the transaction; and
Information from consumer reports, such as a consumer’s creditworthiness and credit history;

b. A licensee does not adequately categorize the information that it discloses if the licensee uses only general terms, such as transaction information about the consumer; and

c. If a licensee reserves the right to disclose all of the nonpublic personal financial information about consumers that it collects, the licensee may simply state that fact without describing the categories or examples of nonpublic personal information that the licensee discloses;

(3) Categories of affiliates and nonaffiliated third parties to whom the licensee discloses.

a. A licensee satisfies the requirement to categorize the affiliates and nonaffiliated third parties to which the licensee discloses nonpublic personal financial information about consumers if the licensee identifies the types of businesses in which they engage;

b. Types of businesses may be described by general terms only if the licensee uses a few illustrative examples of significant lines of business. For example, a licensee may use the term financial products or services if it includes appropriate examples of significant lines of businesses, such as life insurer, automobile insurer, consumer banking or securities brokerage; and

c. A licensee also may categorize the affiliates and nonaffiliated third parties to which it discloses nonpublic personal financial information about consumers using more detailed categories;

(4) Disclosures under exception for service providers and joint marketers. If a licensee discloses nonpublic personal financial information under the exception in Ins 3004.01 to a nonaffiliated third party to market products or services that it offers alone or jointly with another financial institution, the licensee satisfies the disclosure requirement of (a)(5) above if it:

a. Lists the categories of nonpublic personal financial information it discloses, using the same categories and examples the licensee used to meet the requirements of (a)(2) above, as applicable; and

b. States whether the third party is:

A service provider that performs marketing services on the licensee’s behalf or on behalf of the licensee and another financial institution; or
A financial institution with whom the licensee has a joint marketing agreement;

(5) Simplified notices. If a licensee does not disclose, and does not wish to reserve the right to disclose, nonpublic personal financial information about customers or former customers to affiliates or nonaffiliated third parties except as authorized under Ins 3004.02 and Ins 3004.03, the licensee may simply state that fact, in addition to the information it shall provide under (a)(1), (a)(8), (a)(9) and (b) above; and

(6) Confidentiality and security. A licensee describes its policies and practices with respect to protecting the confidentiality and security of nonpublic personal financial information if it does both of the following:

a. Describes in general terms who is authorized to have access to the information; and

b. States whether the licensee has security practices and procedures in place to ensure the confidentiality of the information in accordance with the licensee’s policy. The licensee is not required to describe technical information about the safeguards it uses.

(d) Short-form initial notice with opt out notice for non-customers:

(1) A licensee may satisfy the initial notice requirements in Ins 3002.01(a)(2) and Ins 3002.04(d) for a consumer who is not a customer by providing a short-form initial notice at the same time as the licensee delivers an opt out notice as required in Ins 3002.04;

(2) A short-form initial notice shall:

a. Be clear and conspicuous;

b. State that the licensee’s privacy notice is available upon request; and

c. Explain a reasonable means by which the consumer may obtain that notice;

(3) The licensee shall deliver its short-form initial notice according to Ins 3002.06. The licensee is not required to deliver its privacy notice with its short-form initial notice. The licensee instead may simply provide the consumer a reasonable means to obtain its privacy notice. If a consumer who receives the licensee’s short-form notice requests the licensee’s privacy notice, the licensee shall deliver its privacy notice according to Ins 3002.06; and

(4) Examples of obtaining privacy notice. The licensee provides a reasonable means by which a consumer may obtain a copy of its privacy notice if the licensee:

a. Provides a toll-free telephone number that the consumer may call to request the notice; or

b. For a consumer who conducts business in person at the licensee’s office, maintains copies of the notice on hand that the licensee provides to the consumer immediately upon request.

(e) Future disclosures. The licensee’s notice may include:

(1) Categories of nonpublic personal financial information that the licensee reserves the right to disclose in the future, but does not currently disclose; and

(2) Categories of affiliates or nonaffiliated third parties to whom the licensee reserves the right in the future to disclose, but to whom the licensee does not currently disclose, nonpublic personal financial information.

(f) Sample clauses and Federal Model Privacy Form. Sample clauses illustrating some of the notice content required by this section and the Federal Model Privacy Form are included in Appendix A and Appendix B, respectively, of this rule.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3002.04 Form of Opt Out Notice to Consumers and Opt Out Methods {#sec-ins-3002.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3002.04}

(a) (1) Form of opt out notice. If a licensee is required to provide an opt out notice under Ins 3003.01(a), it shall provide a clear and conspicuous notice to each of its consumers that accurately explains the right to opt out under that section. The notice shall state:

a. That the licensee discloses or reserves the right to disclose nonpublic personal financial information about its consumer to a nonaffiliated third party;

b. That the consumer has the right to opt out of that disclosure; and

c. A reasonable means by which the consumer may exercise the opt out right; and

(2) Examples:

a. Adequate opt out notice. A licensee provides adequate notice that the consumer can opt out of the disclosure of nonpublic personal financial information to a nonaffiliated third party if the licensee:

Identifies all of the categories of nonpublic personal financial information that it discloses or reserves the right to disclose, and all of the categories of nonaffiliated third parties to which the licensee discloses the information, as described in Ins 3002.03(a)(2) and (3) above, and states that the consumer can opt out of the disclosure of that information; and
Identifies the insurance products or services that the consumer obtains from the licensee, either singly or jointly, to which the opt out direction would apply;

b. Reasonable opt out means. A licensee provides a reasonable means to exercise an opt out right if it:

Designates check-off boxes in a prominent position on the relevant forms with the opt out notice;
Includes a reply form together with the opt out notice;
Provides an electronic means to opt out, such as a form that can be sent via electronic mail or a process at the licensee’s web site, if the consumer agrees to the electronic delivery of information; or
Provides a toll-free telephone number that consumers may call to opt out;

c. Unreasonable opt out means. A licensee does not provide a reasonable means of opting out if:

The only means of opting out is for the consumer to write his or her own letter to exercise that opt out right; or
The only means of opting out as described in any notice subsequent to the initial notice is to use a check-off box that the licensee provided with the initial notice but did not include with the subsequent notice; and

d. Specific opt out means. A licensee may require each consumer to opt out through a specific means, as long as that means is reasonable for that consumer.

(b) Same form as initial notice permitted. A licensee may provide the opt out notice together with or on the same written or electronic form as the initial notice the licensee provides in accordance with Ins 3002.01.

(c) Initial notice required when opt out notice delivered subsequent to initial notice. If a licensee provides the opt out notice later than required for the initial notice in accordance with Ins 3002.01, the licensee shall also include a copy of the initial notice with the opt out notice in writing or, if the consumer agrees, electronically.

(d) Joint relationships:

(1) If 2 or more consumers jointly obtain an insurance product or service from a licensee, the licensee may provide a single opt out notice. The licensee’s opt out notice shall explain how the licensee will treat an opt out direction by a joint consumer (as explained in paragraph (5) below);

(2) Any of the joint consumers may exercise the right to opt out. The licensee may either:

a. Treat an opt out direction by a joint consumer as applying to all of the associated joint consumers; or

b. Permit each joint consumer to opt out separately;

(3) If a licensee permits each joint consumer to opt out separately, the licensee shall permit one of the joint consumers to opt out on behalf of all of the joint consumers;

(4) A licensee may not require all joint consumers to opt out before it implements any opt out direction;

(5) Example. If John and Mary are both named policyholders on a homeowner’s insurance policy issued by a licensee and the licensee sends policy statements to John’s address, the licensee may do any of the following, but it shall explain in its opt out notice which opt out policy the licensee will follow:

a. Send a single opt out notice to John’s address, but the licensee shall accept an opt out direction from either John or Mary;

b. Treat an opt out direction by either John or Mary as applying to the entire policy. If the licensee does so and John opts out, the licensee may not require Mary to opt out as well before implementing John’s opt out direction; and

c. Permit John and Mary to make different opt out directions. If the licensee does so:

It shall permit John and Mary to opt out for each other;
If both opt out, the licensee shall permit both of them to notify it in a single response (such as on a form or through a telephone call); and
If John opts out and Mary does not, the licensee may only disclose nonpublic personal financial information about Mary, but not about John and not about John and Mary jointly.

(e) Time to comply with opt out. A licensee shall comply with a consumer’s opt out direction as soon as reasonably practicable after the licensee receives it.

(f) Continuing right to opt out. A consumer may exercise the right to opt out at any time.

(g) Duration of consumer’s opt out direction:

(1) A consumer’s direction to opt out under this section is effective until the consumer revokes it in writing or, if the consumer agrees, electronically; and

(2) When a customer relationship terminates, the customer’s opt out direction continues to apply to the nonpublic personal financial information that the licensee collected during or related to that relationship. If the individual subsequently establishes a new customer relationship with the licensee, the opt out direction that applied to the former relationship does not apply to the new relationship.

(h) Delivery. When a licensee is required to deliver an opt out notice by this section, the licensee shall deliver it according to Ins 3002.06.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3002.05 Revised Privacy Notices {#sec-ins-3002.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3002.05}

(a) General rule. Except as otherwise authorized in this rule, a licensee shall not, directly or through an affiliate, disclose any nonpublic personal financial information about a consumer to a nonaffiliated third party other than as described in the initial notice that the licensee provided to that consumer under Ins 3002.01, unless:

(1) The licensee has provided to the consumer a clear and conspicuous revised notice that accurately describes its policies and practices;

(2) The licensee has provided to the consumer a new opt out notice;

(3) The licensee has given the consumer a reasonable opportunity, before the licensee discloses the information to the nonaffiliated third party, to opt out of the disclosure; and

(4) The consumer does not opt out.

(b) Examples:

(1) Except as otherwise permitted by Ins 3004.01, Ins 3004.02, and Ins 3004.03, a licensee shall provide a revised notice before it:

a. Discloses a new category of nonpublic personal financial information to any nonaffiliated third party;

b. Discloses nonpublic personal financial information to a new category of nonaffiliated third party; or

c. Discloses nonpublic personal financial information about a former customer to a nonaffiliated third party, if that former customer has not had the opportunity to exercise an opt out right regarding that disclosure; and

(2) A revised notice is not required if the licensee discloses nonpublic personal financial information to a new nonaffiliated third party that the licensee adequately described in its prior notice.

(c) Delivery. When a licensee is required to deliver a revised privacy notice by this section, the licensee shall deliver it according to Ins 3002.06.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3002.06 Privacy Notices to Group Policyholders {#sec-ins-3002.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3002.06}

Unless a licensee is providing privacy notices directly to covered individuals described in Ins 3001.04 (f)(2)e.1., 2., or 3., a licensee shall provide initial, annual and revised notices to the plan sponsor, group or blanket insurance policyholder or group annuity contractholder, or workers’ compensation policyholder, in the manner described in Ins 3001.05 through Ins 3002.05, describing the licensee’s privacy practices with respect to nonpublic personal information about individuals covered under the policies, contracts or plans.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3002.07 Delivery {#sec-ins-3002.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3002.07}

(a) How to provide notices. A licensee shall provide any notices that this rule requires so that each consumer can reasonably be expected to receive actual notice in writing or, if the consumer agrees, electronically.

(b) (1) Examples of reasonable expectation of actual notice. A licensee may reasonably expect that a consumer will receive actual notice if the licensee:

a. Hand-delivers a printed copy of the notice to the consumer;

b. Mails a printed copy of the notice to the last known address of the consumer separately or in a policy, billing, or other written communication;

c. For a consumer who conducts transactions electronically, posts the notice on the electronic site and requires the consumer to acknowledge receipt of the notice as a necessary step to obtaining a particular insurance product or service; and

d. For an isolated transaction with a consumer, such as the licensee providing an insurance quote or selling the consumer travel insurance, posts the notice and requires the consumer to acknowledge receipt of the notice as a necessary step to obtaining the particular insurance product or service; and

(2) Examples of unreasonable expectation of actual notice. A licensee may not, however, reasonably expect that a consumer will receive actual notice of its privacy policies and practices if it:

a. Only posts a sign in its office or generally publishes advertisements of its privacy policies and practices; or

b. Sends the notice via electronic mail to a consumer who does not obtain an insurance product or service from the licensee electronically.

(c) Annual notices only. A licensee may reasonably expect that a customer will receive actual notice of the licensee’s annual privacy notice if:

(1) The customer uses the licensee’s web site to access insurance products and services electronically and agrees to receive notices at the web site and the licensee posts its current privacy notice continuously in a clear and conspicuous manner on the web site; or

(2) The customer has requested that the licensee refrain from sending any information regarding the customer relationship and the licensee’s current privacy notice remains available to the customer upon request.

(d) Oral description of notice insufficient. A licensee may not provide any notice required by this rule solely by orally explaining the notice, either in person or over the telephone.

(e) Retention or accessibility of notices for customers:

(1) For customers only, a licensee shall provide the initial notice required by Ins 3002.01(a)(1), the annual notice required by Ins 3002.02(a), and the revised notice required by Ins 3002.05 so that the customer can retain them or obtain them later in writing or, if the customer agrees, electronically; and

(2) Examples of retention or accessibility: A licensee provides a privacy notice to the customer so that the customer can retain it or obtain it later if the licensee:

a. Hand-delivers a printed copy of the notice to the customer;

b. Mails a printed copy of the notice to the last known address of the customer; or

c. Makes its current privacy notice available on a web site (or a link to another web site) for the customer who obtains an insurance product or service electronically and agrees to receive the notice at the web site.

(f) Joint notice with other financial institutions. A licensee may provide a joint notice from the licensee and one or more of its affiliates or other financial institutions, as identified in the notice, as long as the notice is accurate with respect to the licensee and the other institutions. A licensee also may provide a notice on behalf of another financial institution.

(g) Joint relationships. If 2 or more consumers jointly obtain an insurance product or service from a licensee, the licensee may satisfy the initial, annual, and revised notice requirements of Ins 3002.01(a), Ins 3002.02(a), and Ins 3002.05(a), respectively, by providing one notice to those consumers jointly.

History

#9922, eff 5-6-11 (from Ins 3002.06); ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3003.01 Limits on Disclosure of Nonpublic Personal Financial Information to Nonaffiliated Third Parties {#sec-ins-3003.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3003.01}

(a) (1) Conditions for disclosure. Except as otherwise authorized in this rule, a licensee may not, directly or through any affiliate, disclose any nonpublic personal financial information about a consumer to a nonaffiliated third party unless:

a. The licensee has provided to the consumer an initial notice as required under Ins 3002.01;

b. The licensee has provided to the consumer an opt out notice as required in Ins 3002.04;

c. The licensee has given the consumer a reasonable opportunity, before it discloses the information to the nonaffiliated third party, to opt out of the disclosure; and

d. The consumer does not opt out;

(2) Opt out definition: Opt out means a direction by the consumer that the licensee not disclose nonpublic personal financial information about that consumer to a nonaffiliated third party, other than as permitted by Ins 3004.01, Ins 3004.02, and Ins 3004.03; and

(3) Examples of reasonable opportunity to opt out: A licensee provides a consumer with a reasonable opportunity to opt out if:

a. By mail. The licensee mails the notices required in (a)(1) above to the consumer and allows the consumer to opt out by mailing a form, calling a toll-free telephone number, or any other reasonable means within 30 days from the date the licensee mailed the notices;

b. By electronic means. A customer opens an on-line account with a licensee and agrees to receive the notices required in (a)(1) above electronically, and the licensee allows the customer to opt out by any reasonable means within 30 days after the date that the customer acknowledges receipt of the notices in conjunction with opening the account; and

c. Isolated transaction with consumer. For an isolated transaction such as providing the consumer with an insurance quote, a licensee provides the consumer with a reasonable opportunity to opt out if the licensee provides the notices required in (a)(1) above at the time of the transaction and requests that the consumer decide, as a necessary part of the transaction, whether to opt out before completing the transaction.

(b) Application of opt out to all consumers and all nonpublic personal financial information:

(1) A licensee shall comply with this section, regardless of whether the licensee and the consumer have established a customer relationship; and

(2) Unless a licensee complies with this section, the licensee may not, directly or through any affiliate, disclose any nonpublic personal financial information about a consumer that the licensee has collected, regardless of whether the licensee collected it before or after receiving the direction to opt out from the consumer.

(c) Partial opt out. A licensee may allow a consumer to select certain nonpublic personal financial information or certain nonaffiliated third parties with respect to which the consumer wishes to opt out.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3003.02 Limits on Redisclosure and Reuse of Nonpublic Personal Financial Information {#sec-ins-3003.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3003.02}

(a) (1) Information the licensee receives under an exception. If a licensee receives nonpublic personal financial information from a nonaffiliated financial institution under an exception in Ins 3004.02 or Ins 3004.03 of this rule, the licensee’s disclosure and use of that information is limited as follows:

a. The licensee may disclose the information to the affiliates of the financial institution from which the licensee received the information;

b. The licensee may disclose the information to its affiliates, but the licensee’s affiliates may, in turn, disclose and use the information only to the extent that the licensee may disclose and use the information; and

c. The licensee may disclose and use the information pursuant to an exception in Ins 3004.02 or Ins 3004.03 of this rule in the ordinary course of business to carry out the activity covered by the exception under which the licensee received the information; and

(2) Example: If a licensee receives information from a nonaffiliated financial institution for claims settlement purposes, the licensee may disclose the information for fraud prevention or in response to a properly authorized subpoena. The licensee may not disclose that information to a third party for marketing purposes or use that information for its own marketing purposes.

(b) (1) Information a licensee receives outside of an exception. If a licensee receives nonpublic personal financial information from a nonaffiliated financial institution other than under an exception in Ins 3004.02 or Ins 3004.03 of this rule, the licensee may disclose the information only:

a. To the affiliates of the financial institution from which the licensee received the information;

b. To its affiliates, but its affiliates may, in turn, disclose the information only to the extent that the licensee may disclose the information; and

c. To any other person, if the disclosure would be lawful if made directly to that person by the financial institution from which the licensee received the information; and

(2) Example: If a licensee obtains a customer list from a nonaffiliated financial institution outside of the exceptions in Ins 3004.02 or Ins 3004.03:

a. The licensee may use that list for its own purposes; and

b. The licensee may disclose that list to another nonaffiliated third party only if the financial institution from which the licensee purchased the list could have lawfully disclosed the list to that third party. That is, the licensee may disclose the list in accordance with the privacy policy of the financial institution from which the licensee received the list, as limited by the opt out direction of each consumer whose nonpublic personal financial information the licensee intends to disclose, and the licensee may disclose the list in accordance with an exception in Ins 3004.02 or Ins 3004.03, such as to the licensee’s attorneys or accountants.

(c) Information a licensee discloses under an exception. If a licensee discloses nonpublic personal information to a nonaffiliated third party under an exception in Ins 3004.02 or Ins 3004.03 of this rule, the third party may disclose and use that information only as follows:

(1) The third party may disclose the information to the licensee’s affiliates;

(2) The third party may disclose the information to its affiliates, but its affiliates may, in turn, disclose and use the information only to the extent that the third party may disclose and use the information; and

(3) The third party may disclose and use the information pursuant to an exception in Ins 3004.02 or Ins 3004.03 in the ordinary course of business to carry out the activity covered by the exception under which it received the information.

(d) Information a licensee discloses outside of an exception. If a licensee discloses nonpublic personal financial information to a nonaffiliated third party other than under an exception in Ins 3004.02 or Ins 3004.03 of this rule, the third party may disclose the information only:

(1) To the licensee’s affiliates;

(2) To the third party’s affiliates, but the third party’s affiliates, in turn, may disclose the information only to the extent the third party can disclose the information; and

(3) To any other person, if the disclosure would be lawful if the licensee made it directly to that person.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

(a) General prohibition on disclosure of account numbers. A licensee shall not, directly or through an affiliate, disclose, other than to a consumer reporting agency, a policy number or similar form of access number or access code for a consumer’s policy or transaction account to any nonaffiliated third party for use in telemarketing, direct mail marketing, or other marketing through electronic mail to the consumer.

(b) Exceptions. Subsection (a) above does not apply if a licensee discloses a policy number or similar form of access number or access code:

(1) To the licensee’s service provider solely in order to perform marketing for the licensee’s own products or services, as long as the service provider is not authorized to directly initiate charges to the account;

(2) To a licensee who is a producer solely in order to perform marketing for the licensee’s own products or services; or

(3) To a participant in an affinity or similar program where the participants in the program are identified to the customer when the customer enters into the program.

(1) Policy number. A policy number, or similar form of access number or access code, does not include a number or code in an encrypted form, as long as the licensee does not provide the recipient with a means to decode the number or code; and

(2) Policy or transaction account. For the purposes of this section, a policy or transaction account is an account other than a deposit account or a credit card account. A policy or transaction account does not include an account to which third parties cannot initiate charges.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

Part Ins 3004 Exceptions to Limits on Disclosures of Financial Information

N.H. Code Admin. R. Ann. Ins 3004.01 Exception to Opt Out Requirements for Disclosure of Nonpublic Personal Financial Information for Service Providers and Joint Marketing {#sec-ins-3004.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3004.01}

(a) General rule:

(1) The opt out requirements in Ins 3002.04 and Ins 3003.01 do not apply when a licensee provides nonpublic personal financial information to a nonaffiliated third party to perform services for the licensee or functions on the licensee’s behalf, if the licensee:

a. Provides the initial notice in accordance with Ins 3002.01; and

b. Enters into a contractual agreement with the third party that prohibits the third party from disclosing or using the information other than to carry out the purposes for which the licensee disclosed the information, including use under an exception in Ins 3004.02 or Ins 3004.03, in the ordinary course of business to carry out those purposes; and

(2) Example. If a licensee discloses nonpublic personal financial information under this section to a financial institution with which the licensee performs joint marketing, the licensee’s contractual agreement with that institution meets the requirements of (a)(1) b. above, if it prohibits the institution from disclosing or using the nonpublic personal financial information except as necessary to carry out the joint marketing or under an exception in Ins 3004.02 or Ins 3004.03 in the ordinary course of business to carry out that joint marketing.

(b) Service may include joint marketing. The services a nonaffiliated third party performs for a licensee under subsection (a) above may include marketing of the licensee’s own products or services or marketing of financial products or services offered pursuant to joint agreements between the licensee and one or more financial institutions.

(c) Definition of “joint agreement”. For purposes of this section, “joint agreement” means a written contract pursuant to which a licensee and one or more financial institutions jointly offer, endorse or sponsor a financial product or service.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3004.02 Exceptions to Notice and Opt Out Requirements for Disclosure of Nonpublic Personal Financial Information for Processing and Servicing Transactions {#sec-ins-3004.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3004.02}

(a) Exceptions for processing transactions at consumer’s request. The requirements for initial notice in Ins 3002.01(a)(2), the opt out in Ins 3002.04 and Ins 3003.01 and service providers and joint marketing in Ins 3004.01 do not apply if the licensee discloses nonpublic personal financial information as necessary to effect, administer or enforce a transaction that a consumer requests or authorizes, or in connection with:

(1) Servicing or processing an insurance product or service that a consumer requests or authorizes;

(2) Maintaining or servicing the consumer’s account with a licensee, or with another entity as part of a private label credit card program or other extension of credit on behalf of such entity;

(3) A proposed or actual securitization, secondary market sale (including sales of servicing rights) or similar transaction related to a transaction of the consumer; or

(4) Reinsurance or stop loss or excess loss insurance.

(b) “Necessary to effect, administer or enforce a transaction” means that the disclosure is:

(1) Required, or is one of the lawful or appropriate methods, to enforce the licensee’s rights or the rights of other persons engaged in carrying out the financial transaction or providing the product or service; or

(2) Required, or is a usual, appropriate, or acceptable method:

a. To carry out the transaction or the product or service business of which the transaction is a part, and record, service, or maintain the consumer’s account in the ordinary course of providing the insurance product or service;

b. To administer or service benefits or claims relating to the transaction or the product or service business of which it is a part;

c. To provide a confirmation, statement or other record of the transaction, or information on the status or value of the insurance product or service to the consumer or the consumer’s agent or broker;

d. To accrue or recognize incentives or bonuses associated with the transaction that are provided by a licensee or any other party;

e. To underwrite insurance at the consumer’s request or for any of the following purposes as they relate to a consumer’s insurance: account administration, reporting, investigating, or preventing fraud or material misrepresentation, processing premium payments, processing insurance claims, administering insurance benefits (including utilization review activities), participating in research projects, or as otherwise required or specifically permitted by federal or state law; or

f. In connection with:

The authorization, settlement, billing, processing, clearing, transferring, reconciling, or collection of amounts charged, debited or otherwise paid using a debit, credit, or other payment card, check or account number, or by other payment means;
The transfer of receivables, accounts or interests therein; or
The audit of debit, credit, or other payment information.

History

#7500, eff 7-1-01, EXPIRED: 701-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3004.03 Other Exceptions to Notice and Opt Out Requirements for Disclosure of Nonpublic Personal Financial Information {#sec-ins-3004.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3004.03}

(a) Exceptions to opt out requirements. The requirements for initial notice to consumers in Ins 3002.01(a)(2), the opt out in Ins 3002.04 and Ins 3003.01, and service providers and joint marketing in Ins 3004.01 do not apply when a licensee discloses nonpublic personal financial information:

(1) With the consent or at the direction of the consumer, provided that the consumer has not revoked the consent or direction;

(2) a. To protect the confidentiality or security of a licensee’s records pertaining to the consumer, service, product, or transaction;

b. To protect against or prevent actual or potential fraud or unauthorized transactions;

c. For required institutional risk control or for resolving consumer disputes or inquiries;

d. To persons holding a legal or beneficial interest relating to the consumer; or

e. To persons acting in a fiduciary or representative capacity on behalf of the consumer;

(3) To provide information to insurance rate advisory organizations, guaranty funds or agencies, agencies that are rating a licensee, persons that are assessing the licensee’s compliance with industry standards, and the licensee’s attorneys, accountants, and auditors;

(4) To the extent specifically permitted or required under other provisions of law and in accordance with the federal Right to Financial Privacy Act of 1978 (12 U.S.C. 3401 et seq.), to law enforcement agencies [including the Federal Reserve Board, Office of the Comptroller of the Currency, Federal Deposit Insurance Corporation, Office of Thrift Supervision, National Credit Union Administration, the Securities and Exchange Commission, the Secretary of the Treasury, with respect to 31 U.S. C. Chapter 53, Subchapter II (Records and Reports on Monetary Instruments and Transactions) and 12 U.S.C. Chapter 21 (Financial Recordkeeping), a state insurance authority, and the Federal Trade Commission], self-regulatory organizations, or for an investigation on a matter related to public safety;

(5) a. To a consumer reporting agency in accordance with the federal Fair Credit Reporting Act (15 U.S.C. 1681 et seq.); or

b. From a consumer report reported by a consumer reporting agency;

(6) In connection with a proposed or actual sale, merger, transfer or exchange of all or a portion of a business or operating unit if the disclosure of nonpublic personal financial information concerns solely consumers of the business or unit;

(7) a. To comply with federal, state or local laws, rules and other applicable legal requirements;

b. To comply with a properly authorized civil, criminal or regulatory investigation, or subpoena or summons by federal, state or local authorities; or

c. To respond to judicial process or government regulatory authorities having jurisdiction over a licensee for examination, compliance, or other purposes as authorized by law; or

(8) For purposes related to the replacement of a group benefit plan, a group health plan, a group welfare plan or a workers’ compensation plan.

(b) Examples of revocation of consent. A consumer may revoke consent by subsequently exercising the right to opt out of future disclosures of nonpublic personal information as permitted under Ins 3002.04(g).

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

Part Ins 3005 Rules for Health Information

N.H. Code Admin. R. Ann. Ins 3005.01 When Authorization Required for Disclosure of Nonpublic Personal Health Information {#sec-ins-3005.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3005.01}

(a) A licensee shall not disclose nonpublic personal health information about a consumer or customer unless an authorization is obtained from the consumer or customer whose nonpublic personal health information is sought to be disclosed.

(b) Nothing in this section shall prohibit, restrict, or require an authorization for the disclosure of nonpublic personal health information by a licensee for the performance of the following insurance functions by or on behalf of the licensee: claims administration; claims adjustment and management; detection, investigation, or reporting of actual or potential fraud, misrepresentation, or criminal activity; underwriting; policy placement or issuance; loss control; ratemaking and guaranty fund functions; reinsurance and excess loss insurance; risk management; case management; disease management; quality assurance; quality improvement; performance evaluation; provider credentialing verification; utilization review; peer review activities; actuarial, scientific, medical, or public policy research; grievance procedures; internal administration of compliance, managerial, and information systems; policyholder service functions; auditing; reporting; database security; administration of consumer disputes and inquiries; external accreditation standards; the replacement of a group benefit plan or workers’ compensation policy or program; activities in connection with a sale, merger, transfer, or exchange of all or part of a business or operating unit; any activity that permits disclosure without authorization pursuant to the federal Health Insurance Portability and Accountability Act privacy rules promulgated by the U.S. Department of Health and Human Services; disclosure that is required, or is one of the lawful or appropriate methods, to enforce the licensee’s rights or the rights of other persons engaged in carrying out a transaction or providing a product or service that a consumer requests or authorizes; and any activity otherwise permitted by law, required pursuant to governmental reporting authority, or to comply with legal process. Additional insurance functions may be added with the approval of the commissioner to the extent they are necessary for appropriate performance of insurance functions and are fair and reasonable to the interest of consumers.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3005.02 Authorizations {#sec-ins-3005.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3005.02}

(a) A valid authorization to disclose nonpublic personal health information pursuant to this section shall be in written or electronic form and shall contain all of the following:

(1) The identity of the consumer or customer who is the subject of the nonpublic personal health information;

(2) A general description of the types of nonpublic personal health information to be disclosed;

(3) General descriptions of the parties to whom the licensee discloses nonpublic personal health information, the purpose of the disclosure and how the information will be used;

(4) The signature of the consumer or customer who is the subject of the nonpublic personal health information or the individual who is legally empowered to grant authority and the date signed; and

(5) Notice of the length of time for which the authorization is valid and that the consumer or customer may revoke the authorization at any time and the procedure for making a revocation.

(b) An authorization for the purposes of this section shall specify a length of time for which the authorization shall remain valid, which in no event shall be for more than 24 months.

(c) A consumer or customer who is the subject of nonpublic personal health information may revoke an authorization provided pursuant to this section at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation.

(d) A licensee shall retain the authorization or a copy thereof in the record of the individual who is the subject of nonpublic personal health information.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3005.03 Authorization Request Delivery {#sec-ins-3005.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3005.03}

A request for authorization and an authorization form may be delivered to a consumer or a customer as part of an opt-out notice pursuant to Ins 3002.06, provided that the request and the authorization form are clear and conspicuous. An authorization form is not required to be delivered to the consumer or customer or included in any other notices unless the licensee intends to disclose protected health information pursuant to Ins 3005.01.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3005.04 Relationship to Federal Rules {#sec-ins-3005.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3005.04}

Irrespective of whether a licensee is subject to the federal Health Insurance Portability and Accountability Act privacy rule as promulgated by the U.S. Department of Health and Human Services (the “federal rule”), if a licensee complies with all requirements of the federal rule except for its effective date provision, the licensee shall not be subject to the provisions of this section.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3005.05 Relationship to State Laws {#sec-ins-3005.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3005.05}

Nothing in this subpart shall preempt or supersede existing state law related to medical records, health or insurance information privacy.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

Part Ins 3006 Additional Provisions

N.H. Code Admin. R. Ann. Ins 3006.01 Protection of Fair Credit Reporting Act {#sec-ins-3006.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3006.01}

Nothing in this rule shall be construed to modify, limit, or supersede the operation of the federal Fair Credit Reporting Act (15 U.S.C. 1681 et seq.), and no inference shall be drawn on the basis of the provisions of this rule regarding whether information is transaction or experience information under Section 603 of that Act.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3006.02 Nondiscrimination {#sec-ins-3006.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3006.02}

(a) A licensee shall not unfairly discriminate against any consumer or customer because that consumer or customer has opted out from the disclosure of his or her nonpublic personal financial information pursuant to the provisions of this rule.

(b) A licensee shall not unfairly discriminate against a consumer or customer because that consumer or customer has not granted authorization for the disclosure of his or her nonpublic personal health information pursuant to the provisions of this rule.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

N.H. Code Admin. R. Ann. Ins 3006.03 Violation {#sec-ins-3006.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3006.03}

A violation of this rule shall be subject to the penalty provisions of RSA 400-A:15, III and RSA 417:13.

History

#7500, eff 7-1-01, EXPIRED: 7-1-09
#12749, eff 5-6-19
#9922, eff 5-6-11; ss by #12749, eff 5-6-19

Part Ins 3007 Waiver of Rules

N.H. Code Admin. R. Ann. Ins 3007.01 Waiver of Rules {#sec-ins-3007.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3007.01}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule

provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX A - SAMPLE CLAUSES

Licensees, including a group of financial holding company affiliates that use a common privacy notice, may use the following sample clauses, if the clause is accurate for each institution that uses the notice. (Note that disclosure of certain information, such as assets, income, and information from a consumer reporting agency, may give rise to obligations under the federal Fair Credit Reporting Act, such as a requirement to permit a consumer to opt out of disclosures to affiliates or designation as a consumer reporting agency if disclosures are made to nonaffiliated third parties.)

A-1-Categories of information a licensee collects (all institutions)

A licensee may use this clause, as applicable, to meet the requirement of Ins 3002.03 to describe the categories of nonpublic personal information the licensee collects.

Sample Clause A-1:

We collect nonpublic personal information about you from the following sources:

· Information we receive from you on applications or other forms;

· Information about your transactions with us, our affiliates or others; and

· Information we receive from a consumer reporting agency.

A-2-Categories of information a licensee discloses (institutions that disclose outside of the exceptions)

A licensee may use one of these clauses, as applicable, to meet the requirement of Ins 3002.03 to describe the categories of nonpublic personal information the licensee discloses. The licensee may use these clauses if it discloses nonpublic personal information other than as permitted by the exceptions in Ins 3004.01, Ins 3004.02 and Ins 3004.03.

Sample Clause A-2, Alternative 1:

We may disclose the following kinds of nonpublic personal information about you:

· Information we receive from you on applications or other forms, such as [provide illustrative examples, such as “your name, address, social security number, assets, income, and beneficiaries”];

· Information about your transactions with us, our affiliates or others, such as [provide illustrative examples, such as “your policy coverage, premiums, and payment history”]; and

· Information we receive from a consumer reporting agency, such as [provide illustrative examples, such as “your creditworthiness and credit history”].

Sample Clause A-2, Alternative 2:

We may disclose all of the information that we collect, as described [describe location in the notice, such as “above” or “below”].

A-3-Categories of information a licensee discloses and parties to whom the licensee discloses (institutions that do not disclose outside of the exceptions)

A licensee may use this clause, as applicable, to meet the requirements of Ins 3002.03 to describe the categories of nonpublic personal information about customers and former customers that the licensee discloses and the categories of affiliates and nonaffiliated third parties to whom the licensee discloses. A licensee may use this clause if the licensee does not disclose nonpublic personal information to any party, other than as permitted by the exceptions in Ins 3004.02 and Ins 3004.03.

Sample Clause A-3:

We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted by law.

A-4-Categories of parties to whom a licensee discloses (institutions that disclose outside of the exceptions)

A licensee may use this clause, as applicable, to meet the requirement of Ins 3002.03 to describe the categories of affiliates and nonaffiliated third parties to whom the licensee discloses nonpublic personal information. This clause may be used if the licensee discloses nonpublic personal information other than as permitted by the exceptions in Ins 3004.01, Ins 3004.02 and Ins 3004.03, as well as when permitted by the exceptions in Ins 3004.02 and Ins 3004.03.

Sample Clause A-4:

We may disclose nonpublic personal information about you to the following types of third parties:

· Financial service providers, such as [provide illustrative examples, such as “life insurers, automobile insurers, mortgage bankers, securities broker-dealers, and insurance agents”];

· Non-financial companies, such as [provide illustrative examples, such as “retailers, direct marketers, airlines, and publishers”]; and

· Others, such as [provide illustrative examples, such as “nonprofit organizations”].

We may also disclose nonpublic personal information about you to nonaffiliated third parties as permitted by law.

A-5-Service provider/joint marketing exception

A licensee may use one of these clauses, as applicable, to meet the requirements of Ins 3002.03 related to the exception for service providers and joint marketers in Ins 3004.01. If a licensee discloses nonpublic personal information under this exception, the licensee shall describe the categories of nonpublic personal information the licensee discloses and the categories of third parties with whom the licensee has contracted.

Sample Clause A-5, Alternative 1:

We may disclose the following information to companies that perform marketing services on our behalf or to other financial institutions with whom we have joint marketing agreements:

· Information we receive from you on applications or other forms, such as [provide illustrative examples, such as “your name, address, social security number, assets, income and beneficiaries”];

· Information about your transactions with us, our affiliates or others, such as [provide illustrative examples, such as “your policy coverage, premium, and payment history”]; and

· Information we receive from a consumer reporting agency, such as [provide illustrative examples, such as “your creditworthiness and credit history”].

Sample Clause A-5, Alternative 2:

We may disclose all of the information we collect, as described [describe location in the notice, such as “above” or “below”] to companies that perform marketing services on our behalf or to other financial institutions with whom we have joint marketing agreements.

A-6-Explanation of opt out right (institutions that disclose outside of the exceptions)

A licensee may use this clause, as applicable, to meet the requirement of Ins 3002.03 to provide an explanation of the consumer’s right to opt out of the disclosure of nonpublic personal information to nonaffiliated third parties, including the method(s) by which the consumer may exercise that right. The licensee may use this clause if the licensee discloses nonpublic personal information other than permitted by the exceptions in Ins 3004.01, Ins 3004.02 and Ins 3004.03.

Sample Clause A-6:

If you prefer that we do not disclose nonpublic personal information about you to nonaffiliated third parties, you may opt out of those disclosures, that is, you may direct us not to make those disclosures (other than disclosures permitted by law). If you wish to opt out of disclosures to nonaffiliated third parties, you may [describe a reasonable means of opting out, such as “call the following toll-free number: (insert number)”].

A-7-Confidentiality and security (all institutions)

A licensee may use this clause, as applicable, to meet the requirement of Ins 3002.03 to describe its policies and practices with respect to protecting the confidentiality and security of nonpublic personal information.

Sample Clause A-7:

We restrict access to nonpublic personal information about you to [provide an appropriate description, such as “those employees who need to know that information to provide products or services to you”]. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

APPENDIX B – FEDERAL MODEL PRIVACY FORM

Licensees, including a group of financial holding company affiliates that use a common privacy notice, may use the Federal Model Privacy Form, if the Form is accurate for each institution that uses the Form. (Note that disclosure of certain information, such as assets, income, and information from a consumer reporting agency, may give rise to obligations under the federal Fair Credit Reporting Act, such as a requirement to permit a consumer to opt of disclosures to affiliates or designation as a consumer reporting agency if disclosures are made to nonaffiliated third parties.)

A. General Instructions

How the Model Privacy Form is used.

(a) The Model Form may be used, at the option of a “licensee”, including a group of licensees or other financial institutions that use a common privacy notice, to meet the content requirements of the privacy notice and opt-out notice set forth in Ins 3002.03 and Ins 3002.04.

(b) The Model Form is a standardized form, including page layout, content, format, style, pagination, and shading. Licensees seeking to obtain the safe harbor through use of the Model Form may modify it only as described in these Instructions.

(c) Note that disclosure of certain information, such as assets, income, and information from a consumer reporting agency, may give rise to obligations under the federal Fair Credit Reporting Act (FCRA), codified at 15 U.S.C. §§ 1681-1681x, such as a requirement to permit a consumer to opt out of disclosures to affiliates, or designation as a consumer reporting agency if disclosures are made to nonaffiliated third parties.

(d) The word “customer” may be replaced by the word “member,” whenever it appears in the Model Form, as appropriate.

The Contents of the Model Privacy Form

The Model Form consists of two pages, which may be printed on both sides of a single sheet of paper or may appear on two separate pages. Where a licensee provides a long list of licensees or financial institutions at the end of the Model Form in accordance with Instruction B3(a)(i), or provides additional information in accordance with Instruction B3(c) and such list or additional information exceeds the space available on Page Two of the Model Form, such list or additional information may extend to a third page.

(a) Page One. The first page consists of the following components:

(1) Date last revised (upper right-hand corner)

(2) Title

(3) Key frame (Why? What? How?)

(4) Disclosure table (“Reasons we can share your personal information”)

(5) “To limit our sharing” box, as needed, for the licensee’s opt-out information

(6) “Questions” box, for customer service contact information

(7) Mail-in opt-out form, as needed

(b) Page Two. The second page consists of the following components:

(1) Heading (Page 2)

(2) Frequently Asked Questions (“Who we are” and “What we do”)

(3) Definitions

(4) “Other important information” box, as needed

The format of the Model Privacy Form.

The format of the Model Form may be modified only as described below.

(a) Easily readable type font. Licensees that use the Model Form must use an easily readable type font. While a number of factors together produce easily readable font, licensees are required to use a minimum of 10- point font (unless otherwise expressly permitted in these Instructions) and sufficient spacing between lines.

(b) Logo. A licensee may include a corporate logo on any page of the notice, so long as it does not interfere with the readability of the Model Form or the space constraints of each page.

(c) Page size and orientation. Each page of the Model Form must be printed in portrait orientation, the size of which must be sufficient to meet the layout and minimum font size requirements, with sufficient white space on the top, bottom, and sides of the content.

(d) Color. The Model Form must be printed on white or light color paper (such as cream) with black or other contrasting ink color. Spot color may be used to achieve visual interest, so long as the color contrast is distinctive and the color does not detract from the readability of the Model Form. Logos may also be printed in color.

(e) Languages. The Model Form may be translated into languages other than English.

B. Information Required in the Model Privacy Form

The information in the Model Form may be modified only as described below:

Name of licensee or group of affiliated licensees or institutions providing the notice

Insert the name of the licensee providing the notice, or a common identity of the affiliated licensees or financial institutions jointly providing the notice on the form, wherever [name of licensee] appears.

Page One

(a) Last revised date. The licensee must insert in the upper right-hand corner the date on which the notice was last revised. The information shall appear in minimum 8-point font as “rev. [month/year]” using either the name or number of the month, such as “rev. July 2016” or “rev. 7/16.”

(b) General instructions for the “What?” box

(i) The bulleted list identifies the types of personal information that the licensee collects and shares. All licensees must use the term “Social Security Number” in the first bullet.

(ii) A licensee must use five (5) of the following terms, to complete the bulleted list: income; account balances; payment history; transaction history; transaction or loss history; credit history; credit scores; assets; investment experience; credit-based insurance scores; insurance claim history; medical information; overdraft history; purchase history; account transactions; risk tolerance; medical-related debts; credit card or other debt; mortgage rates and payments; retirement assets; checking account information; employment information; wire transfer instructions.

(c) General instructions for the disclosure table. The left column lists reasons for sharing or using personal information. Each reason correlates to a specific legal provision described in Paragraph 2(d) of this Instruction. In the middle column, each licensee must provide a “Yes” or “No” response that accurately reflects its information-sharing policies and practices with respect to the reason listed on the left. In the right column, each licensee must provide in each box one of the following three (3) responses, as applicable, that reflects whether a consumer can limit such sharing:

“Yes,” if it is required to or voluntarily provides an opt-out; “No,” if it does not provide an opt-out; or

“We don’t share,” if it answers “No” in the middle column.

Only the sixth row (“For our affiliates to market to you”) may be omitted at the option of the licensee. See Paragraph 2(d)(6) of this instruction.

(d) Specific disclosures and corresponding legal provisions

(i) For our everyday business purposes. This reason incorporates sharing information under Ins 3004.02 and Ins 3004.03 and with service providers pursuant to Ins 3004.01 other than the disclosures described in Paragraphs (2)(d)(ii) or (2)(d)(iii) of this instruction.

(ii) For our marketing purposes. This reason incorporates sharing information with service providers by a licensee for its own marketing pursuant to Ins 3004.01. A licensee that shares for this reason may choose to provide an opt-out.

(iii) For joint marketing with other financial companies. This reason incorporates sharing information under joint marketing agreements between 2 or more licensees or financial institutions and with any service provider used in conjunction with such agreement pursuant to Ins 3004.01. A licensee that shares for this reason may choose to provide an opt-out.

(iv) For our affiliates’ everyday business purposes – information about transactions and experiences. This reason incorporates sharing information specified in Sections 603(d)(2)(A)(i) and (ii) of the FCRA. A licensee that shares information for this reason may choose to provide an opt-out.

(v) For our affiliates’ everyday business purposes – information about creditworthiness. This reason incorporates sharing information pursuant to Section 603(d)(2)(A)(iii) of the FCRA. A licensee that shares information for this reason must provide an opt-out.

(vi) For our affiliates to market to you. This reason incorporates sharing information specified in Section 624 of the FCRA. This reason may be omitted from the disclosure table when: the licensee does not have affiliates (or does not disclose personal information to its affiliates); the licensee’s affiliates do not use personal information in a manner that requires an opt-out; or the licensee provides the affiliate marketing notice separately. Licensees that include this reason must provide an opt-out of indefinite duration. A licensee that is required to provide an affiliate marketing opt-out, but does not include that opt-out in the Model Form under this part, must comply with Section 624 of the FCRA and Ins 3000, with respect to the initial notice and opt-out and any subsequent renewal notice and opt-out. A licensee not required to provide an opt-out under this subparagraph may elect to include this reason in the Model Form.

(vii) For nonaffiliates to market to you. This reason incorporates sharing described in Ins 3002.04 and Ins 3003.01(a). A licensee that shares personal information for this reason must provide an opt-out.

(e) To limit our sharing. A licensee must include this section of the Model Form only if it provides an opt-out. The word “choice” may be written in either the singular or plural, as appropriate. Licensees must select one or more of the applicable opt-out methods described: telephone, such as by a toll-free number; a web site; or use of a mail-in opt-out form. Licensees may include the word “toll-free” before telephone, as appropriate. A licensee that allows consumers to opt out online must provide either a specific web address that takes consumers directly to the opt-out page or a general web address that provides a clear and conspicuous direct link to the opt-out page. The opt-out choices made available to the consumer who contacts the licensee through these methods must correspond accurately to the “Yes” responses in the third column of the disclosure table. In the part entitled “Please note,” licensees may insert a number that is 30 days or greater in the space marked “[30].” Instructions on voluntary or state privacy law opt-out information are in Paragraph 2(g)(v) of these Instructions.

(f) Questions box. Customer service contact information must be inserted as appropriate where [phone number] or [web site] appear. Licensees may elect to provide either a phone number, such as a toll-free number, or a web address, or both. Licensees may include the words “toll-free” before the telephone number, as appropriate.

(g) Mail-in opt-out form. Licensees must include this mail-in form only if they state in the “To limit our sharing” box that consumers can opt out by mail. The mail-in form must provide opt-out options that correspond accurately to the “Yes” responses in the third column of the disclosure table. Licensees that require consumers to provide only name and address may omit the section identified as “[account #].” Licensees that require additional or different information, such as a random opt-out number or a truncated account number to implement an opt-out election should modify the “[account #]” reference accordingly. This includes licensees that require customers with multiple accounts to identify each account to which the opt-out should apply. A licensee must enter its opt-out mailing address in the far right of this form (see version 3); or below the form (see version 4). The reverse side of the mail-in opt-out form must not include any content of the Model Form.

(i) Joint accountholder. Only licensees that provide their joint accountholders the choice to opt out for only one accountholder, in accordance with Paragraph 3(a)(5) of these Instructions, must include in the far left column of the mail-in form the following statement:

If you have a joint account, your choice(s) will apply to everyone on your account unless you mark below.

□ Apply my choice(s) only to me.

The word “choice” may be written in either the singular or plural, as appropriate. Licensees that provide insurance products or services, provide this option, and elect to use the Model Form may substitute the word “policy” for “account” in this statement. Licensees that do not provide this option may eliminate this left column from the mail-in form.

(ii) FCRA Section 603(d)(2)(A)(iii) opt-out. If the licensee shares personal information pursuant to Section 603(d)(2)(A)(iii) of the FCRA, it must include in the mail-in opt-out form the following statement:

□ Do not share information about my creditworthiness with your affiliates for their everyday business purposes.

(iii) FCRA Section 624 opt-out. If the licensee uses Section 624 of the FCRA, in accord with paragraph 2(d)(6) of these Instructions, it must include in the mail-in opt-out form the following statement:

□ Do not allow your affiliates to use my personal information to market to me.

(iv) Nonaffiliate opt-out. If the licensee shares personal information pursuant to Ins 3003.01(a), it must include in the mail-in opt-out form the following statement:

□ Do not share my personal information with nonaffiliates to market their products and services to me.

(v) Additional opt-outs. Licensees that use the disclosure table to provide opt-out options beyond those required by Federal law must provide those opt-outs in this section of the Model Form. A licensee that chooses to offer an opt-out for its own marketing in the mail-in opt-out form must include one of the two following statements:

□ Do not share my personal information to market to me. or

□ Do not use my personal information to market to me.

A licensee that chooses to offer an opt-out for joint marketing must include the following statement:

□ Do not share my personal information with other financial institutions to jointly market to me.

(h) Barcodes. A licensee may elect to include a barcode and/or “tagline” (an internal identifier) in 6-point type at the bottom of page one, as needed for information internal to the licensee, so long as these do not interfere with the clarity or text of the form.

Page Two

(a) General Instructions for the Questions. Certain Questions on the Model Form may be customized as follows:

(i) “Who is providing this notice?” This question may be omitted where only one licensee provides the Model Form and that licensee is clearly identified in the title on Page One. Two or more licensees or financial institutions that jointly provide the Model Form must use this question to identify themselves as required by Ins 3002.07(f). Where the list of licensees or financial institutions exceeds four (4) lines, the licensee must describe in the response to this question the general types of licensees or financial institutions jointly providing the notice and must separately identify those licensees or financial institutions, in minimum 8-point font, directly following the “Other important information” box, or, if that box is not included in the licensee’s form, directly following the “Definitions.” The list may appear in a multi- column format.

(ii) “How does [name of licensee] protect my personal information?” The licensee may only provide additional information pertaining to its safeguards practices following the designated response to this question. Such information may include information about the licensee’s use of cookies or other measures it uses to safeguard personal information. Licensees are limited to a maximum of 30 additional words.

(iii) “How does [name of licensee] collect my personal information?” Licensees must use five (5) of the following terms to complete the bulleted list for this question: open an account; deposit money; pay your bills; apply for a loan; use your credit or debit card; seek financial or tax advice; apply for insurance; pay insurance premiums; file an insurance claim; seek advice about your investments; buy securities from us; sell securities to us; direct us to buy securities; direct us to sell your securities; make deposits or withdrawals from your account; enter into an investment advisory contract; give us your income information; provide employment information; give us your employment history; tell us about your investment or retirement portfolio; tell us about your investment or retirement earnings; apply for financing; apply for a lease; provide account information; give us your contact information; pay us by check; give us your wage statements; provide your mortgage information; make a wire transfer; tell us who receives the money; tell us where to send the money; show your government-issued ID; show your driver’s license; order a commodity futures or option trade.

Licensees that collect personal information from their affiliates and/or credit bureaus must include the following statement after the bulleted list: “We also collect your personal information from others, such as credit bureaus, affiliates, or other companies.” Licensees that do not collect personal information from their affiliates or credit bureaus but do collect information from other companies must include the following statement instead: “We also collect your personal information from other companies.” Only licensees that do not collect any personal information from affiliates, credit bureaus, or other companies can omit both statements.

(iv) “Why can’t I limit all sharing?” Licensees that describe state privacy law provisions in the “Other important information” box must use the bracketed sentence: “See below for more on your rights under state law.” Other licensees must omit this sentence.

(v) “What happens when I limit sharing for an account I hold jointly with someone else?” Only licensees that provide opt-out options must use this question. Other licensees must omit this question. Licensees must choose one of the following two statements to respond to this question: “Your choices will apply to everyone on your account.” or “Your choices will apply to everyone on your account-unless you tell us otherwise.” Licensees may substitute the word “policy” for “account” in these statements.

(b) General Instructions for the Definitions. The licensee must customize the space below the responses to the three definitions in this section. This specific information must be in italicized lettering to set off the information from the standardized definitions.

(i) Affiliates. As required by Ins 3002.03(a)(3), where [affiliate information] appears, the licensee must:

a. If it has no affiliates, state: “[name of licensee] has no affiliates”;

b. If it has affiliates but does not share personal information with them, state: “[name of licensee] does not share with our affiliates”; or

c. If it shares with its affiliates, state, as applicable: “Our affiliates include companies with a [common corporate identity of licensee] name; financial companies such as [insert illustrative list of companies]; nonfinancial companies, such as [insert illustrative list of companies]; and others, such as [insert illustrative list].”

(ii) Nonaffiliates. As required by Ins 3002.03(c)(3), where [nonaffiliate information] appears, the licensee must:

a. If it does not share with nonaffiliated third parties, state: “[name of licensee] does not share with nonaffiliates so they can market to you”; or

b. If it shares with nonaffiliated third parties, state, as applicable: “Nonaffiliates we share with can include [list categories of companies such as mortgage companies, insurance companies, direct marketing companies, and nonprofit organizations].”

(iii) Joint Marketing. As required by Ins 3004.01, where [joint marketing] appears, the licensee must:

a. If it does not engage in joint marketing, state: “[name of licensee] doesn’t jointly market”; or

b. If it shares personal information for joint marketing, state, as applicable: “Our joint marketing partners include [list categories of companies such as credit card companies].”

(c) General instructions for the “Other important information” box. This box is optional. The space provided for information in this box is not limited, and an additional page may be used if necessary. Only the following types of information can appear in this box:

(i) State and/or international privacy law information; and/or

(ii) A form by which the consumer may acknowledge receipt of the notice.

APPENDIX I

Rule

Specific State Statute the Rule Implements

Ins 3001.01

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3001.02

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3001.03

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3001.04

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3002.01

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3002.02

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3002.03

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3002.04

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3002.05

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3002.06

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3002.07

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3003.01

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3003.02

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3003.03

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3004.01

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3004.02

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3004.03

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3005.01

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3005.02

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3005.03

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3005.04

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3005.05

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3006.01

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3006.02

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16

Ins 3006.03

RSA 400-A:15, I; RSA 406-C:9; RSA 406-C:16; RSA 417:13

Ins 3007.01

RSA 400-A:15, I; RSA 406-C:16; RSA 541-A:22, IV

Appendix A

RSA 400-A:15, I

Appendix B

RSA 400-A:15, I

History

#12749, eff 5-6-19

Chapter Ins 3100 Electronic Filings

Part Ins 3101 Electronic Filing Standards

N.H. Code Admin. R. Ann. Ins 3101.01 Purpose {#sec-ins-3101.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3101.01}

The purpose of this part is to require insurers, advisory organizations, nonprofit service organizations, health maintenance organizations, fraternal benefit societies, or their authorized filing agent(s) or representative(s), to submit all rates, forms, rule submissions or filings, and all applicable fees to the insurance department using the NAIC system for electronic rate and form filing (SERFF).

History

#5651, eff 7-1-93; ss by #6968, eff 3-26-99, EXPIRED: 3-26-07
#9282, eff 10-1-08; ss by #11147, eff 10-1-16

N.H. Code Admin. R. Ann. Ins 3101.02 Applicability and Scope {#sec-ins-3101.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3101.02}

This part shall apply to all submissions or filings of insurance forms, rules, rates, including property and casualty loss costs, and experience reports, including accident and health actuarial certifications, policy experience exhibits and credit insurance experience reports, required by statute or rule to be provided to the insurance department by or on behalf of insurers, advisory organizations, nonprofit service organizations, health maintenance organizations, or fraternal benefit societies.

History

#5651, eff 7-1-93; ss by #6968, eff 3-26-99, EXPIRED: 3-26-07
#9282, eff 10-1-08; ss by #11147, eff 10-1-16

N.H. Code Admin. R. Ann. Ins 3101.03 Definitions {#sec-ins-3101.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3101.03}

(a) "EFT" means electronic funds transfer.

(b) "NAIC" means the national association of insurance commissioners.

History

#5651, eff 7-1-93; ss by #6968, eff 3-26-99, EXPIRED: 3-26-07
#9282, eff 10-1-08; ss by #11147, eff 10-1-16

N.H. Code Admin. R. Ann. Ins 3101.04 Procedural Requirements {#sec-ins-3101.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3101.04}

(a) All insurance companies submitting rate, loss costs, and form filings submissions shall comply with the New Hampshire insurance department's requirements for the type of insurance for which the companies are submitting.

(b) All life, accident, and health submissions or filings shall comply with Ins 401.14 Forms Filing, Review and Inventory Procedures.

(d) Insurance companies submitting rate and form filing materials shall provide all fees via EFT if domiciled in a state or country where the state insurance department or comparable agency requires foreign or alien insurers to pay any fees for the filing or examination of policy forms. The materials submitted shall include payment of the retaliatory fee due to the state of New Hampshire pursuant to RSA 400-A:35.

(e) Insurers, advisory organizations, nonprofit service organizations, health maintenance organizations, and fraternal benefit societies shall use SERFF for all correspondence related to any submission or filing.

History

#5651, eff 7-1-93; ss by #6968, eff 3-26-99, EXPIRED: 3-26-07
#9282, eff 10-1-08; ss by #11147, eff 10-1-16; ss by #13071, eff 7-22-20

N.H. Code Admin. R. Ann. Ins 3101.05 Waiver of Rules {#sec-ins-3101.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3101.05}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX

Rule

Statute

Ins 3101.01

RSA 400-A:15,I; 412:5; 412:7; 412:16; 412:28; 415:1; 415-D:2; 418:15;

420-A:8; 420-B:8; 420-F:4; 408; 408-A; 408-D:5; 408-E:3,IV; 416-A:17-a

Ins 3101.02

RSA 400-A:15,I; 412:5; 412:7; 412:16; 412:28; 415:1; 415-D:2; 415-H:4;418:15; 420-A:8; 420-B:8; 420-F:4; 408; 408-A; 408-D:5; 408-E:3,IV; 416-A:17-a; 420-G:12

Ins 3101.03

RSA 400-A:15,I; 412:5; 412:7; 412:16; 412:28; 415:1; 415-D:2; 418:15;

420-A:8; 420-B:8; 420-F:4; 408; 408-A; 408-D:5; 408-E:3,IV; 416-A:17-a

Ins 3101.04

RSA 400-A:15,I; 412:5; 412:7; 412:16; 412:28; 415:1; 415-D:2; 418:15;

420-A:8; 420-B:8; 420-F:4; 408; 408-A; 408-D:5; 408-E:3,IV; 416-A:17-a

Ins 3101.04

RSA 400-A:15,I; RSA 408; RSA 408-A; RSA 408-D:5; RSA 408-E:3,IV; RSA 412:5; RSA 412:7; RSA 412:16; RSA 412:28; RSA 415:1; RSA 416-A:3; RSA 416-A:17-a; RSA 418:18; RSA 420-A:8; RSA 420-B:8; RSA 420-F:4; RSA 420-G:12 & 13

Ins 3101.05

RSA 400-A:15,I; RSA 541-A:22, IV

History

#13071, eff 7-22-20

Chapter Ins 3200 Sales of Insurance by Financial Institutions

Part Ins 3201 General Information

N.H. Code Admin. R. Ann. Ins 3201.01 Purpose {#sec-ins-3201.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3201.01}

The purpose of this rule is to authorize and regulate the solicitation and sales of insurance products and services by financial institutions, protect the insurance buying public, and, maintain parity between state and federally chartered financial institutions as provided for by RSA 406-C.

History

#7064, eff 7-24-99; ss by #7540, eff 8-1-01

Part Ins 3202 Licensing Requirements

N.H. Code Admin. R. Ann. Ins 3202.01 License Required {#sec-ins-3202.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3202.01}

(a) A financial institution or individual shall apply for a license to engage in one or more of the following:

(1) Soliciting individuals to purchase insurance. Soliciting means recommending or selling specific insurance products or services. Soliciting shall not include the clerical or ministerial acts involved in:

a. Making a general referral to a licensed insurance agent;

b. The dissemination of sales literature prepared by the agency; and

c. The scheduling of appointments with licensed insurance agents.

(2) Collecting premiums for insurance sold by the financial institution;

(3) Transmitting an application for a policy of insurance;

(4) Negotiating for, or placing, risks;

(5) Delivering policies; or

(6) Other than in a clerical or ministerial manner, aiding in the transaction of the insurance business.

(b) If the individual performs clerical tasks only, a license shall not be required for that individual.

(c) A financial institution shall obtain a corporate agent’s license under RSA 406-C:5 if it directly receives insurance commissions, is compensated based on the volume of insurance sales, or if it recommends or sponsors specific insurance products. At least one officer of the organization shall also obtain an agent’s license for the appropriate lines of insurance and shall be responsible for the financial institution’s insurance sales activities.

(d) All insurance sales transactions shall be conducted by individually licensed agents. The financial institution officer responsible for the financial institution’s insurance sales activities shall ensure that all employees are made aware that the conduct of the sale of insurance by unlicensed financial institution employees is prohibited under New Hampshire law.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3202.02 Financial Institution License Application {#sec-ins-3202.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3202.02}

(a) A financial institution shall apply for a license on the insurance department application form.

(b) Along with the application, the applicant shall provide the following:

(1) A certified copy of its charter;

(2) An officer’s certification of a board resolution authorizing the financial institution to engage in the sale of insurance and to make appropriate application to the Department;

(3) A list of the financial institution officers directly involved in insurance sales; and

History

#7064, eff 7-24-99; amd by #7540, eff 8-1-01

N.H. Code Admin. R. Ann. Ins 3202.03 Authorized or Approved Carriers {#sec-ins-3202.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3202.03}

Financial institutions shall offer only insurance products of insurance companies licensed and authorized or approved to do business in New Hampshire.

History

#7064, eff 7-24-99

Part Ins 3203 Procedures for Authority to Sell Insurance

N.H. Code Admin. R. Ann. Ins 3203.01 Insurance Sales Relationships. {#sec-ins-3203.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3203.01}

(a) A licensed financial institution may directly employ a licensed insurance agent or own a subsidiary, all or part of which is an insurance agency.

(b) The financial institution may contract with third parties to assist the financial institution agency’s sales activities.

(c) A financial institution’s licensed employees or agents shall hold the appropriate license for the lines of insurance which they are actively selling.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3203.02 Special Requirements for Depository Institutions {#sec-ins-3203.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3203.02}

(a) A financial institution may apply for a license to sell insurance if the financial institution and employees actively engage in the business of insurance and have complied with all the licensing requirements of the insurance department.

(b) A licensed financial institution that directly, or through a subsidiary as defined by applicable federal and state banking law, may establish an insurance agency.

(1) Collecting commissions from insurance carriers and paying commissions to its licensed sales staff; and

(2) Processing insurance applications, delivering insurance policies and collecting premiums, where consistent with procedures of the relevant insurance carriers.

(d) Business records of the agency, including copies of customer application(s) and policy information, customer complaints, licensing and all other compliance records, shall be available. A licensed financial institution which shares in commissions only, shall maintain business records commensurate with its active participation in the sale of insurance which shall, at a minimum, include information regarding customer complaints, licensing and all other compliance records and information on commissions received by the financial institution. In the alternative, the required business records of the agency shall be maintained and available at the agency in electronic form, with the original hard copy kept in off-site storage.

(e) A financial institution that establishes a networking arrangement with a third party marketer shall obtain a corporate agent’s license to share in commissions. The third party marketer shall be properly licensed in New Hampshire. If the financial institution contracts with third parties to assist it with insurance sales activities, the location of the third party activities shall be consistent with Ins 3204.07.

(f) The following principles shall be applied to financial institutions when acting as insurance agents in determining the scope of solicitation and sales activities so long as such solicitation and sales activities otherwise comply with RSA 406-C and the other provisions of this chapter:

(1) Contacts and meetings with customers and solicitation sales of insurance by licensed agents of the financial institution agency may be held;

(2) Mailings to advertise and sell as well as brochures, leaflets and other literature alerting potential customers to the financial institution’s insurance activities may be distributed;

(3) Personnel of bank branches may make referrals to the bank’s insurance agency; and

(4) Telephone and cybermarketing may be used.

History

#7064, eff 7-24-99; amd by #7540, eff 8-1-01

N.H. Code Admin. R. Ann. Ins 3203.03 Qualifications and Training {#sec-ins-3203.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3203.03}

(a) A financial institution shall have experienced and qualified personnel to conduct the insurance sales program in a manner that provides customers with proper advice and accurate information.

(b) Licensed employees shall satisfy the continuing education requirements in Ins 1300.

(c) To aid in distinguishing between insurance and non-insurance products, financial institutions shall develop written policies consistent with the provisions of RSA 406-C and this chapter specifying who may sell and recommend insurance products and how individuals selling and recommending insurance products identify themselves and their sales roles.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3203.04 Independent Agent or Agency {#sec-ins-3203.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3203.04}

(a) An independent agent or insurance agency may lease, rent, or otherwise occupy space in an unlicensed financial institution subject to the following conditions:

(1) The dollar amount of rent shall be fixed and shall not be based on a percentage of premium income or otherwise tied to the transaction of insurance;

(2) The lease shall contain:

a. A clause expressly negating a partnership or joint venture;

b. A clause stipulating that the landlord has no right to exercise control over the tenant insurance agency except for collection of rent or other common and usual landlord/tenant activities and relationships; and

(3) The lease shall contain a clause requiring the insurance agency to comply with the separation of activities and disclosure requirements of RSA Chapter 406-C.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3203.05 Commissions {#sec-ins-3203.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3203.05}

(a) Commissions shall not be paid to, or shared with, an individual or business entity, including but not limited to a financial institution, which is not licensed as an insurance agent or broker in New Hampshire.

(b) Non-licensed individuals or business entities shall not be awarded a portion of the insurance revenue.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3203.06 Referral Fees {#sec-ins-3203.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3203.06}

Only licensed employees of a financial institution shall, directly or indirectly receive any compensation or consideration from an insurance agent or broker, insurance agency, insurance company, or a financial institution, based upon referral of potential insurance purchases to, or making appointments with, a licensed insurance agent or broker. However, an employee of a financial institution who is not licensed to sell insurance may refer a party to a person who is licensed to sell insurance if the employee making such referral is compensated for such referral in an amount that does not exceed a nominal amount and such amount is not based on or related to the party’s purchase of insurance.

History

#7064, eff 7-24-99; ss by #7540, eff 8-1-01

N.H. Code Admin. R. Ann. Ins 3203.07 Inducements or Rebating {#sec-ins-3203.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3203.07}

A financial institution shall not offer special benefits, such as rebates or discounts on insurance in violation of RSA 417:4, IX(a), RSA 402:39, or RSA 402:40 or any other provisions of law.

History

#7064, eff 7-24-99

Part Ins 3204 Consumer Protection

N.H. Code Admin. R. Ann. Ins 3204.01 Statutory Requirements {#sec-ins-3204.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.01}

(a) Financial institutions selling insurance shall be subject to all consumer protection provisions of New Hampshire law, including RSA Chapter 417, the Unfair Trade Practices Act, and applicable state statutes and laws regarding privacy and confidential information.

(b) Financial institutions selling insurance shall also be subject to the federal anti-tying provisions of 12 U.S.C.A. §1972, and the applicable disclosure provisions of the February 15, 1994 Interagency Statement on Retail Sales of Non-deposit Investment Products, issued jointly by federal bank regulatory agencies as well as Ban 520.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3204.02 Disclosures {#sec-ins-3204.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.02}

To avoid customer confusion, in addition to the disclosures specifically required by the insurance laws of New Hampshire and the rules of the department, advertising, promotional material and solicitation shall include the disclosures required by RSA 406-C:8 to be delivered to the customer at or before the time of sale of an insurance product.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3204.03 Disclosures When Insurance is Required as a Condition of Obtaining a Loan. {#sec-ins-3204.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.03}

(a) When a financial institution requires a customer to obtain insurance in connection with a loan the financial institution may inform customers that insurance is available from the financial institution, its subsidiary or an affiliate.

(b) To avoid the impression that a connection exists between the financial institution’s credit decision and the customer’s choice of insurance seller, when insurance is available through the financial institution, a customer applying for a loan or an extension of credit shall be informed by the financial institution that:

(1) The customer shall not be required to purchase insurance from the financial institution, a subsidiary or an affiliate; and,

(2) The purchase of insurance from an agent of the customer’s choice shall not affect current or future credit decisions.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3204.04 Tying of Non-Insurance Products with Insurance Products Prohibited {#sec-ins-3204.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.04}

(a) A financial institution’s non-insurance products shall not be tied in with insurance products in a manner that violates 12 U.S.C. § 1972 or any other applicable state statute, including RSA 402:39, RSA 402:40 and RSA Chapter 417, the Unfair Trade Practices Act. Financial institutions shall not require the purchase of insurance from the financial institution or from a designated insurer or agent as a condition of other financial institution transactions. A financial institution shall have written policies and procedures in place to prevent impermissible tying.

(b) Such measures required by (a) above shall include:

(1) Monitoring sales activity to detect coercion when offering customers multiple products or services;

(2) Training bank employees about tying prohibitions, including providing examples of prohibited practices and sensitizing employees to the concerns raised by tying;

(3) Involving management in reviewing training, audit, and compliance programs, and updating any policies and procedures to reflect changes in products, services, or applicable law;

(4) Reviewing customer files to determine whether any extension of credit is conditioned on obtaining an insurance product from the bank or its affiliates; and

(5) Responding to any customer allegations of prohibited tying arrangements.

(c) The tying prohibitions shall not prevent financial institution sales personnel from informing a customer that insurance is required in order to obtain a loan or that loan approval is contingent on the customer obtaining acceptable insurance. In such circumstances, sales personnel shall comply with Ins 3204.03.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3204.05 Discrimination Against Nonaffiliated Companies or Agents Prohibited {#sec-ins-3204.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.05}

(a) A financial institution shall not:

(1) Condition the provision or terms of any other service upon acquisition of insurance through a particular insurer, agent or broker;

(2) Reject a required policy solely because the policy was sold by a person who is not associated with the financial institution; or

(3) Impose a requirement on any agent or broker not associated with the financial institution that is not imposed on any agent who is associated with the financial institution.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3204.06 Affirmative Statement Signed by Insurance Customer {#sec-ins-3204.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.06}

The financial institution shall obtain a written affirmative statement at the time that a customer applying for a loan or an extension of credit is first informed that insurance is available through the financial institution, which acknowledges that the customer applying for credit has received the disclosure required by Ins 3204.03.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3204.07 Separation from Deposit and Loan Activities {#sec-ins-3204.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.07}

(a) Sales of insurance shall, to the extent practicable, take place in a location that is distinct from the area where retail deposits or credit transactions are being conducted. Where physical space will allow, signs or other means shall be used to distinguish any established insurance sales area from any established retail deposit taking or lending areas.

(b) When the staffing level, size or design of a particular facility of a financial institution prevent sales from being conducted in a location distinct from the retail area, the financial institution shall submit a plan to the department for approval. The plan shall show the content and physical placement of signage within the retail area. Placement of signage shall minimize customer confusion. In no event shall the sale of insurance products be conducted at the retail deposit-taking stations of a financial institution.

(c) A financial institution shall establish written procedures to demarcate the conclusion of a deposit or loan transaction conducted in the same physical space as a subsequent insurance solicitation.

(d) Signs or other means shall be used to distinguish the insurance sales area from an established retail deposit taking area such as a teller line.

(e) Signs shall:

(1) Be clearly visible to customers and distinguish insurance products from non-insurance products;

(2) Identify insurance agencies and producers who are affiliated with the institution and who are providing insurance products within the retail area; and

(3) Be posted in areas where insurance is sold and shall clarify that insurance sold is not a deposit or obligation of the financial institution, is not guaranteed by the financial institution and is not insured by the Federal Deposit Insurance Corporation (FDIC), the National Credit Union Administration (NCUA), or their successors as applicable to the licensed financial institution.

(f) Tellers and other employees behind the teller line, while conducting retail deposit or credit transactions, shall not:

(1) Unless in response to a question, inform a customer that insurance products are sold at the financial institution;

(2) Make general or specific investment recommendations regarding insurance products;

(3) Qualify a customer as eligible to purchase the products;

(4) Accept orders for the products, even if unsolicited; or

(5) Perform other activities that involve the sale of an insurance product so as to trigger the licensing requirements of Ins 3202.01.

(g) Solicitation for the purchase or sale of insurance by a financial institution’s licensed employee who also exercises authority over credit transactions shall include:

(1) The disclosures required in Ins 3204.02 to address the potential for customer confusion and possible coercion; and

(2) A written and oral disclosure that the purchase of insurance from the licensed employee shall not enhance or affect current or future credit decisions of the financial institution.

(h) Signage, informational materials, and sales literature concerning the availability of insurance products sold through the financial institution shall be displayed so as to distinguish any established insurance sales area from any established retail deposit or credit area and shall comply with applicable requirements of Ins 2600 and Ins 3204.09.

(i) A financial institution shall maintain a file for a 3 year period of any written customer complaint received with respect to insurance solicitations made by licensed employees of the financial institution.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3204.08 Customer Privacy {#sec-ins-3204.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.08}

(a) Consistent with the provisions of RSA 406-C:9 a financial institution shall not use any non-public customer information, other than information pertaining solely to insurance transactions between a customer and the financial institution or its affiliate or subsidiary, or provide such non-public customer information to a third party for the purpose of selling or soliciting the purchase of insurance unless the customer has provided a written consent to use such non-public customer information for insurance solicitation and it is clearly and conspicuously disclosed to the customer that the non-public customer information may be so used.

(b) All completed insurance applications shall be returned only to the licensed insurance agent and under no circumstances shall the financial institution indicate that such applications be returned to an unlicensed financial institution.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3204.09 Advertising of Insurance by a Financial Institution {#sec-ins-3204.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 3204.09}

(a) Advertisements directed to prospective or existing insurance purchasers shall be from a licensed financial institution, agent or insurer.

(b) If insurance advertisements directed to prospective purchasers are included in mailings of bank statements or other documents generated by the financial institution relating to products or services provided by the financial institution, the mailings shall clearly identify the separate sources of the materials.

(c) Notices of cancellation or non-renewal, or other similar communications relating to in-force insurance shall originate with a licensed financial institution, agent, insurance company, insurance agency, or third party administrator, if any, and shall be distinct from deposit account communications or any other financial institution communication.

(d) Insurance statements may include information regarding checking, savings or trust accounts, certificates of deposit, or other banking products or services if the insurance information is segregated from other banking information and if the disclosure requirements of RSA 406-C:8 are otherwise satisfied.

(e) Terminology used in connection with the solicitation and sales of insurance products and services shall be sufficiently different from that used in connection with traditional banking products and services so as to avoid confusion.

(f) Promotional material shall clearly distinguish insured deposit products from uninsured insurance products such that an individual of ordinary intelligence would immediately recognize that the insurance material offered by a licensed insurance agent or insurer is separate from the financial institution’s insured deposit product material. In addition, an insurance product shall not have a name which is misleadingly similar to the name of a financial institution so as to reasonably create customer confusion.

History

#7064, eff 7-24-99

Part Ins 3205 Compliance, Enforcement and Penalty Provisions

N.H. Code Admin. R. Ann. Ins 3205.01 Compliance {#sec-ins-3205.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3205.01}

Financial institutions shall develop and implement policies and procedures to ensure that sales activities are conducted in compliance with applicable laws and rules and in a manner consistent with this chapter. Compliance procedures shall identify potential conflicts of interest and how conflicts shall be addressed. The compliance procedures shall also provide for a system to monitor customer complaints and their resolution. The compliance function shall be conducted independently of insurance and annuity product sales and management activities.

History

#7064, eff 7-24-99

N.H. Code Admin. R. Ann. Ins 3205.02 Penalties {#sec-ins-3205.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3205.02}

(a) A violation of Ins 3202.01 through Ins 3205.01, shall result in an enforcement action under RSA 406-C. The department shall specify which sections, including specific subsections if any, of RSA 406-C are alleged violated in any enforcement action brought under this section.

(b) In addition to any other penalties provided by the laws of this state, a financial institution or individual who violates a requirement of the administrative rules sections cited in (a) above shall, after notice and hearing in accordance with the procedures set forth in Ins 201 through Ins 204, be subject to suspension, revocation or fine pursuant to RSA 406-C:18 unless in instances of an administrative fine the financial institution or individual requests no fine as set forth in (d) below.

(c) After appropriate notice and hearing, an administrative fine of $2,500 shall be levied for each finding of violation of a provision of the sections cited in (a) above as set forth in RSA 406-C. The financial institution or individual may request a reduced fine or no fine.

(d) The financial institution or individual may request no fine as set forth in (d) below, or a reduced fine as set forth in (c) above through demonstration by the financial institution or individual that:

(1) There is no or minimal damage or costs to consumers, the State or other licensed entities as a result of the violation;

(2) The financial institution or individual has not committed multiple or repeated violations;

(3) The act or omission in issue was not knowing, intentional, or committed in bad faith; and

(4) The requested reduced fine represents an appropriate penalty based on the nature and severity of the resultant harm.

(e) Financial institutions or individuals shall additionally be subject to suspension pursuant to RSA 406-C:18 when the violation of the sections noted in (a) above is ongoing or there is a high probability the violation will be repeated based on findings of record.

(f) Financial institutions or individuals shall be subject to revocation pursuant to RSA 406-C:18 if:

(1) The act or omission was knowing, intentional or committed in bad faith; or

(2) There was significant damage or cost to consumers, the State or other licensed entities as a result of the violation.

(g) A knowing violation of a section other than those cited in (a) above shall result in an enforcement action under RSA 400-A:15, III, subject to the requirements therein.

(h) After appropriate notice and hearing, an administrative fine of $2,500 shall be levied for each finding of violation of RSA 400-A:15, III if the penalty of suspension or revocation as specified below is not appropriate.

(i) The financial institution or individual may request at hearing a reduced fine or no fine imposed under (h) above through successful demonstration that:

(1) There is no or minimal damage or costs to consumers, the State or other licensed entities as a result of the violation;

(2) The financial institution or individual has not committed multiple or repeated violations; and

(3) The requested reduced fine represents an appropriate penalty based on the nature and severity of the resultant harm.

(j) Financial institutions or individuals shall be subject to suspension pursuant to RSA 400-A:15, III if one of the following occurs:

(1) The violation is continuing; or

(2) There is a high probability the violation will be repeated, based on findings of record; and

(3) Imposition of a penalty other than suspension, such as a fine, will not be a sufficient deterrent.

(k) Financial institutions or individuals shall be subject to revocation pursuant to RSA 400-A:15, III if:

(1) The violative act or omission was intentional or committed in bad faith; or

(2) There was significant damage or cost to consumers, the State or other licensed entities as a result of the violation.

(l) Repeated or multiple violations of this part shall constitute separate violations subject to penalty.

Appendix

Rule

Specific State or Federal Statutes or Regulations which the Rule Implements

Ins 3201.01

RSA 406-C:1

Ins 3202.01

RSA 406-C:3, 4, 5

Ins 3202.02

RSA 406-C:3; 402:16

Ins 3202.03

RSA 405:32; 406-C:6

Ins 3203.01

RSA 406-C:5, 6

Ins 3203.02

RSA 406-C:1

Ins 3203.03

RSA 406-C:12

Ins 3203.04

RSA 406-C:12

Ins 3203.05

RSA 417:4 IX; 402:39; 402:40

Ins 3203.06

RSA 417:4 IX; 402:39; 402:40

Ins 3203.07

RSA 417:4 IX; 402:39; 402:40

Ins 3204.01

RSA 417:4

Ins 3204.02

RSA 406-C:8

Ins 3204.03

RSA 406-C:8

Ins 3204.04

RSA 406-C:10

Ins 3204.05

RSA 406-C:11

Ins 3204.06

RSA 406-C:9

Ins 3204.07

RSA 406-C:7

Ins 3204.08

RSA 406-C:9, 13

Ins 3204.09

RSA 406-C:12

Ins 3205.01

RSA 406-C:17

Ins 3205.02

RSA 406-C:17, 406-C:18; 400-A:15, III

History

#7064, eff 7-24-99; ss by #7300, eff 7-1-00; amd by #7540, eff 8-1-01

Chapter Ins 3300 Insurance Scores

Part Ins 3301 Use of Insurance Scores

N.H. Code Admin. R. Ann. Ins 3301.01 Purpose {#sec-ins-3301.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3301.01}

The purpose of this chapter is to specify:

(a) The conditions that are required to be met before insurers may use insurance scores or information from consumer reports to determine underwriting eligibility or in rating and pricing of private passenger automobile or homeowners insurance; and

(b) The obligations of insurers with respect to providing information and assistance to consumers.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

N.H. Code Admin. R. Ann. Ins 3301.02 Scope {#sec-ins-3301.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3301.02}

(a) This chapter shall apply to any property and casualty insurer that is:

(1) Licensed to write private passenger automobile and homeowners insurance;

(2) Required to submit rate, rule, and policy form filings to the commissioner; and

(3) Using an insurance score or information obtained from a consumer report for underwriting purposes, including declinations, or rating purposes.

(b) For the purposes of this chapter, homeowners insurance shall include dwelling insurance for owner occupied one-family to 4-family buildings.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

N.H. Code Admin. R. Ann. Ins 3301.03 Definitions {#sec-ins-3301.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3301.03}

(a) “Adverse action” means:

(1) A denial of, refusal to renew, or cancellation of any private passenger automobile or homeowners insurance policy;

(2) Charging an initial rate that is higher than the rate the consumer would have received if the company had not taken credit information into account; or

(3) An increase in any premium charge for, or a reduction of, or other adverse or unfavorable change in the terms of coverage or amount of, any private passenger or homeowners insurance.

(b) “Affiliated insurer” means an insurer that directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with another insurer.

(c) “Applicant” means an individual who seeks to obtain a private passenger automobile or homeowners insurance policy with an insurer.

(d) “Consumer” means an individual who in this state seeks to obtain, obtains, or has obtained private passenger automobile or homeowners insurance.

(e) “Consumer report’ means a credit report or any other communication of any information by a consumer reporting agency that:

(1) Bears on a consumer's creditworthiness, credit standing, or credit capacity; and

(2) Is used or collected or expected to be used or expected to be collected as a factor in establishing the consumer's underwriting eligibility or rating for private passenger automobiles or homeowners insurance.

(f) “Consumer reporting agency” means any person or entity that, for monetary fees, dues, or on a cooperative non-profit basis, regularly engages in whole or in part in the practice of assembling or evaluating consumer credit information or other information for the purpose of furnishing a consumer report to third parties.

(g) “Control” means the direct or indirect possession of the power to direct, or cause the direction of, the management and business policies of an insurer, regardless of whether the power is exercised by:

(1) Ownership of voting securities or of securities convertible into voting securities;

(2) Contract, other than a commercial contract for goods or non-management services; or

(3) Any other means.

(h) “Credit information” means information related to a consumer's credit contained in a consumer report, credit report, or other document.

(i) “Credit report” means a report issued by a consumer reporting agency bearing on the consumer's creditworthiness, credit standing, or credit capacity.

(j) “Insurance score” means a score that is derived by utilizing data from an individual’s consumer report in an algorithm, computer program, model, or other process that reduces the data to a numeric or alphabetical, or similar coding.

(k) “Private passenger automobile insurance” means a policy of insurance sold to eligible risks as defined in Ins 1402.02(c) covering motor vehicles as defined in Ins 1402.02(h).

(l) “Producer” means a person or business entity licensed under RSA 402-J.

(m) “Rating” means the establishment of base rates, classification factors, modifications to rates or factors, or tier placement, and any other factors used to determine the premium or price charged to the consumer for the insurance coverage requested.

(n) “Tier” means a rating or underwriting category within a single insurer or group of affiliated insurers into which consumers with similar risk characteristics are placed for purposes of determining a premium or rate.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

N.H. Code Admin. R. Ann. Ins 3301.04 Waiver of Rules {#sec-ins-3301.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3301.04}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule

provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

History

#12599, eff 8-3-18

Part Ins 3302 Written Standards on Obtaining an Insurance Score or a Consumer Report

N.H. Code Admin. R. Ann. Ins 3302.01 Written Standards {#sec-ins-3302.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3302.01}

(a) If an insurance score or information from a consumer report is used in determining the underwriting eligibility or in the rating of private passenger automobile or homeowners insurance, the insurer shall establish written standards for determining when to obtain an insurance score or consumer report.

(b) Such standards shall include provisions which state that the insurer shall not obtain an insurance score or consumer report based in whole or in part on:

(1) Any attribute enumerated in RSA 417:4, VIII(e);

(2) The following attributes not enumerated in RSA 417:4, VIII(e):

a. Income;

b. Sexual orientation;

c. Gender;

d. Religion;

e. Blindness; or

f. Any other physical handicap or disability.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3303 Use of Insurance Scores and Consumer Report Information in Underwriting

N.H. Code Admin. R. Ann. Ins 3303.01 Use in Underwriting {#sec-ins-3303.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3303.01}

(a) If an insurer uses insurance scores or information from consumer reports for the purpose of underwriting private passenger automobile or homeowners insurance, the insurance score shall be established and used in a manner that:

(1) Is not contrary to the provisions of RSA 417-A and RSA 417-B;

(2) Is not contrary to the provisions of RSA 417:4, VIII(e) or based in whole or in part on:

a. Income;

b. Sexual orientation;

c. Gender;

d. Religion;

e. Blindness; or

f. Any other physical handicap or disability;

(3) Is in accordance with the company's filed underwriting guidelines; and

(4) Otherwise complies with this chapter, RSA 412 and RSA 417.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3304 Use of Insurance Scores and Consumer Report Information in Ratemaking

N.H. Code Admin. R. Ann. Ins 3304.01 Ratemaking Use {#sec-ins-3304.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3304.01}

(a) The use of an insurance score or information from consumer reports in rating private passenger automobile or homeowners insurance shall:

(1) Not result in rates that are excessive, inadequate, or unfairly discriminatory; and

(2) Otherwise comply with this rule and RSA 412:15, III and RSA 417:4, VIII(g).

(b) If an insurer uses an insurance score or information from consumer reports in rating private passenger automobile or homeowners insurance, the insurer shall update the insurance score or consumer report with current credit information at least once every 36 months from the last time the insurer obtained current credit information for the consumer, provided however, no insurer need obtain current credit related information for a consumer, if one of the following applies:

(1) The consumer is in the most favorably-priced tier of the insurer, or if the policy is issued from an insurer within a group of affiliated insurers, then the most favorably-priced tier within that group of affiliated insurers. However, the insurer shall have the discretion to order such report, if consistent with its filed underwriting guidelines;

(2) Information from a consumer report was not used for underwriting eligibility or rating such consumer when the policy was initially written. However, the insurer shall have the discretion to use information from a consumer report for underwriting eligibility or rating such consumer upon renewal, if consistent with its filed underwriting guidelines;

(3) The insurer re-evaluates the consumer beginning no later than 36 months after inception and thereafter based upon other underwriting eligibility or rating factors, excluding credit information; or

(4) The insurer is otherwise treating the consumer in accordance with written standards and procedures which have been filed and approved by the commissioner, including those which include a phase-out of the use of credit information after initial issuance of a policy.

(1) The insured has corrected information on their consumer report; or

(2) The insurer uses insurance scores based on credit information or consumer reports to establish renewal premium, the request is made prior to the renewal offer, and only once every 12 months.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3305 Prohibited Use of Certain Credit Factors in Rating or Underwriting

N.H. Code Admin. R. Ann. Ins 3305.01 Prohibited Factors {#sec-ins-3305.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3305.01}

(a) No insurer, as part of their underwriting or rating of homeowners or private passenger automobile insurance policies, shall use any of the following in any insurance scoring methodology, or in reviewing the consumer report of any consumer:

(1) Credit inquiries not initiated by the consumer, including inquiries associated with unsolicited promotional offers for credit cards or other financial instruments and services;

(2) Inquiries requested by the consumer for his or her own credit information;

(3) Credit inquiries related to insurance coverage, if so identified on the records of the consumer reporting agency;

(4) The dollar amount of a consumer's available credit, unless this amount is being considered in the calculation of the consumer's ratio of debt to total available line of credit;

(5) Collection accounts with medical industry code, if so identified on the records of the consumer reporting agency;

(6) Accounts or transactions that have been identified as associated with an unresolved or confirmed case of identity theft;

(7) Multiple lender inquiries, if coded by the consumer reporting agency on the consumer's credit report as being from the home mortgage industry and made within 30 days of one another, unless only one inquiry is considered; and

(8) Multiple lender inquiries, if coded by the consumer reporting agency on the consumer's credit report as being from the automobile lending industry and made within 30 days of one another, unless only one inquiry is considered.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

N.H. Code Admin. R. Ann. Ins 3305.02 Extraordinary Life Circumstances {#sec-ins-3305.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3305.02}

(a) Notwithstanding any other law or rule, an insurer that uses credit information shall, on written request from an applicant for insurance coverage or an insured, provide reasonable exceptions to the insurer's rates, rating classification, company or tier placement, or underwriting rules or guidelines for a consumer who has experienced and whose credit information has been directly influenced by any of the following events:

(1) Catastrophic event, as declared by the federal or state government;

(2) Serious illness or injury, or serious illness or injury to an immediate family member;

(3) Death of a spouse, child, or parent;

(4) Divorce or involuntary interruption of legally-owed alimony or support payments;

(5) Identity theft;

(6) Temporary loss of employment for a period of 3 months or more, if it results from involuntary termination;

(7) Military deployment overseas; or

(8) Other events, as determined by the insurer.

(b) If an applicant or insured submits a request for an exception as set forth in Ins 3305.02 (a), an insurer may, in its sole discretion:

(1) Require the consumer to provide reasonable, written, and independently verifiable documentation of the event;

(2) Require the consumer to demonstrate that the event had direct and meaningful impact on the consumer's credit information;

(3) Require such request be made no more than 60 days from the date of the application for insurance or the policy renewal;

(4) Grant an exception despite the consumer not providing the initial request for an exception in writing; or

(5) Grant an exception where the consumer asks for consideration of repeated events or the insurer has considered this event previously.

(c) An insurer is not out of compliance with any law or rule relating to underwriting, rating, or rate filing as a result of granting an exception under this section. Nothing in this section shall be construed to provide a consumer or other insured with a course of action that does not exist in the absence of this section.

(d) The insurer shall provide notice to consumers that reasonable exceptions are available and information about how the consumer may inquire further.

(e) Within 30 days of the insurer's receipt of sufficient documentation of an event described in Ins 3305.02(a), the insurer shall inform the consumer of the outcome of their request for a reasonable exception. Such communication shall be in writing or provided to an applicant in the same medium as the request.

History

#9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3306 Filing of Underwriting Models

N.H. Code Admin. R. Ann. Ins 3306.01 Underwriting Filing Required {#sec-ins-3306.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3306.01}

(a) If an insurer uses insurance scores or information from consumer reports to underwrite new or renewal private passenger automobile or homeowners insurance business, its underwriting models shall be filed with the commissioner in accordance with RSA 412:15, III and RSA 412:16.

(b) The filing shall include:

(1) The characteristics or factors of insurance scores or consumer reports used in the underwriting process; and

(2) The underwriting eligibility guidelines specifically related to the use of insurance scores or information from consumer reports by the insurer.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by 9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3307 Filing of Rates

N.H. Code Admin. R. Ann. Ins 3307.01 Rate Filing Required {#sec-ins-3307.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3307.01}

(a) If an insurer uses an insurance score or information from consumer reports in rating new or renewal private passenger automobile or homeowners insurance business, its rates and related rating rules shall be filed with the commissioner in accordance with RSA 412:15, III and RSA 412:16.

(b) The filing shall include:

(1) The insurance score or consumer report criteria or parameters used in any rate calculation; and

(2) The numerical rating factors corresponding to (1) above.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by 9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3308 Filings Required for Insurance Scoring Models and Use of Consumer Report Information

N.H. Code Admin. R. Ann. Ins 3308.01 Submission of Basis for Insurance Score or Use of Consumer Report Information {#sec-ins-3308.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3308.01}

(a) Every model, algorithm, computer program, or other process used to establish an insurance score which in turn is used in the underwriting or rating of an insurance policy shall be submitted to the commissioner by the insurer or any entity acting on behalf of an insurer. Such submission shall be made separately from the filing of underwriting or rating criteria.

(b) If an insurer or any other entity acting on behalf of such insurer intends to make use of information obtained from consumer reports, but not in connection with the model, algorithm, computer program, or other process submitted under Ins 3308.01 (a), such insurer or other entity acting on behalf of such insurer, shall submit to the commissioner a detailed explanation of how it will use this information. Such submission shall be made separately from the filing of underwriting or rating criteria.

(c) In order to meet the requirements of (a) or (b) above, any filing pursuant to this chapter shall include, in addition to the statistical validation or other explanation:

(1) The insurance score or consumer report criteria or parameters used in any rate calculation; and

(2) The numerical rating factors corresponding to (1) above.

(d) No model, algorithm, computer program, or other process submitted under Ins 3308.01 (a), or other use of information obtained from consumer reports, shall be:

(1) Contrary to any provision of RSA 417-A or RSA 417-B;

(2) Contrary to the provisions of RSA 417:4, VIII(e) or based in whole or in part on:

a. Income;

b. Sexual orientation;

c. Gender;

d. Religion;

e. Blindness; or

f. Any other physical handicap or disability; or

(3) In violation of this chapter or RSA 417:4, VIII(g).

(e) The submissions, and accompanying supporting information, required in accordance with (a) and (b) above shall be filed with the commissioner and approved in accordance with RSA 412:15, III and RSA 412:16.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

N.H. Code Admin. R. Ann. Ins 3308.02 Confidentiality of Submission {#sec-ins-3308.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3308.02}

Information submitted pursuant to Ins 3308.01 that is not part of the public rate filing pursuant to RSA 412:15, III and RSA 412:16 and that is identified by the insurer or any entity acting on behalf of the insurer as commercial or financial information or otherwise exempt from public disclosure under RSA 91-A:5 shall be afforded the same confidentiality protections provided to information obtained during an investigation as set forth in RSA 400-A:16.

History

#9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3309 Notice to Insured, Use of Information from Consumer Reports; Adverse Action

N.H. Code Admin. R. Ann. Ins 3309.01 Initial Notification {#sec-ins-3309.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3309.01}

(a) If an insurer uses an insurance score or information from a consumer report in the rating or underwriting of any private passenger automobile or homeowners insurance policy, the insurer shall:

(1) Disclose, either on the insurance application or at the time the insurance application is taken, that it may obtain an insurance score or information from a consumer report in connection with such application, where:

a. Such disclosure shall be either written or provided to the applicant in the same medium as the application for insurance;

b. The insurer need not provide the disclosure statement required under this section to any insured on a renewal policy if such insured has previously been provided a disclosure statement;

c. The disclosure statements shall be maintained by the insurer as part of the policy record file pursuant to RSA 400-B:4; and

d. Use of the following example disclosure statement constitutes compliance with this section:

"In connection with this application for information, we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your insurance score."

(2) Provide a statement notifying the consumer of the company's general timeframe in which credit is ordered in relationship to the date of application or renewal offer; and

(3) Provide notification to the consumer the insurance score or consumer report information is used in the rating or underwriting of the policy. Such disclosure may be provided at either the time of application in the same medium as the application, with the policy, or at the applicant's request. Use of the following example disclosure statement constitutes compliance with this section:

"We use information contained in a consumer report to develop a credit-based insurance score. That score is just one of many factors that are used to [underwrite and/or rate] your policy."; and

(4) If a policy is being offered to the consumer, provide an explanation of:

a. How the insurer will make adjustments in rating or underwriting if the consumer's insurance scores or consumer report information changes; and

b. The process by which the consumer can request the policy be re-rated or re-underwritten to reflect current insurance scoring or consumer report information.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

N.H. Code Admin. R. Ann. Ins 3309.02 Adverse Action Notification {#sec-ins-3309.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3309.02}

(a) Any notice required pursuant to this section shall include the following information:

(1) Notification to the consumer that an adverse action has been taken in accordance with the requirement of the federal Fair Credit Reporting Act, 15 U.S.C. 1681m(a);

(2) The name, address, and telephone number of the consumer reporting agency, including a toll-free number established by the agency if the agency compiles and maintains files on consumers on a nationwide basis, that furnished the report to the insurer;

(3) A statement that the insurer, and not the credit reporting agency, used an insurance score or information from a consumer report in the rating or underwriting of the private passenger automobile or homeowners insurance policy, and the credit reporting agency is unable to provide the consumer with any explanations or reasons as to the actions taken by the insurer;

(4) A telephone contact number the consumer may call to discuss aspects of the adverse action notice with a representative of the insurer who can:

a. Review the notice;

b. Be available to address questions related to:

The insurer's use of credit; and
The insurer's adverse action notice and factors reflected therein; and

(5) Provide a statement advising of the consumer's rights to obtain a free copy of their credit report from the consumer reporting agency and the right to file a dispute with the consumer reporting agency over the accuracy or completeness of any information in the credit report furnished by the agency.

(b) In addition to the information set forth in Ins 3309.02 (a) above, any notice required pursuant to this section shall also include the following information:

(1) A statement advising of the consumer's rights to obtain a free copy of their credit report from the consumer reporting agency and the right to file a dispute with the consumer reporting agency over the accuracy or completeness of any information in the credit report furnished by the agency; and

(2) An explanation of the reasons for the adverse action that shall include:

a. Up to 4 credit factors that were the primary factors influencing the adverse action; and

b. An explanation of each of the factors in (b)(2)a. above that meets the standards provided under paragraph (c).

(1) Be provided in clear and simple language so that a person can identify the basis for the insurer's decision to take an adverse action;

(2) Not use general terms or terminologies that do not provide specific information relevant to the consumer. Examples of such general terminology include, but are not limited to:

a. Poor credit history;

b. Poor credit rating;

c. Poor insurance score; and

d. Other descriptors such as "unfavorable" or "unsatisfactory" if they do not provide clear standards for the consumer to evaluate the actions of the insurer; and

(3) Rely, at the option of the insurer, upon standardized credit explanations provided by consumer reporting agencies or other third party vendors as long as such explanations comply with all provisions enumerated in this chapter.

History

#9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3310 Additional Consumer Protections

N.H. Code Admin. R. Ann. Ins 3310.01 Review of Action {#sec-ins-3310.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3310.01}

(a) If a consumer believes that any adverse action taken by an insurer violates this chapter or the provisions of RSA 417:4, VIII (g), RSA 417-A, or RSA 417-B, the consumer may request in writing, within 10 days of receipt of the insurer’s or producer’s notice, that the commissioner review the action of the insurer.

(b) If an insurer shall receive confirmation of an inaccuracy in a credit report from a consumer reporting agency, the insurer shall, within 30 days after receipt of the notice and retroactive to the effective date:

(1) Re-underwrite the consumer, if applicable;

(2) Re-rate the consumer's insurance policy; and

(3) Adjust the premium accordingly.

History

#7658, eff 9-1-02; ss by #8052, eff 7-1-04; ss by #9634, eff 7-1-10; ss by #12599, eff 8-3-18

Part Ins 3311 Penalty Provision

N.H. Code Admin. R. Ann. Ins 3311.01 Penalty Provision {#sec-ins-3311.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3311.01}

Any violations of these rules shall be subject to such suspension or revocation of certificate of authority or license, or administrative fine not to exceed $2,500 per violation, as may be applicable under Title XXXVII.

APPENDIX

Regulation

Statute

Ins 3301.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:43, I

Ins 3301.02

RSA 400-A:15, I; RSA 412:15, III; RSA 412:43, I

Ins 3301.03

RSA 400-A:15, I; RSA 402-J; RSA 412:15, III; RSA 412:43, I

Ins 3301.04

RSA 400-A:15, I; RSA 541-A:22, IV

Ins 3302.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:43, I; RSA 417:4 VIII(e)

Ins 3303.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:16; RSA 412:43, I;

RSA 417:4, VIII(e); RSA 417-A; RSA 417-B

Ins 3304.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:16; RSA 412:43, I;

RSA 417:4, VIII(g)

Ins 3305.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:16; RSA 412:43, I

Ins 3305.02

RSA 400-A:15, I; RSA 412:15, III; RSA 412:16; RSA 412:43, I

Ins 3306.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:16; RSA 412:43, I

Ins 3307.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:16; RSA 412:43, I

Ins 3308.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:16; RSA 412:43, I;

RSA 417:4, VIII(e) & (g); RSA 417:27; RSA 417-A; RSA 417-B

Ins 3308.02

RSA 91-A:5; RSA 400-A:15, I; RSA 400-A:16;RSA 412:15, III; RSA 412:16;

RSA 412:43, I

Ins 3309.01

RSA 400-A:15, I; RSA 400-B:4; RSA 412:15, III; RSA 412:16; RSA 412:43, I

Ins 3309.02

RSA 400-A;15, I; RSA 412:15, III; RSA 412:43, I

Ins 3310.01

RSA 400-A:15, I; RSA 412:15, III; RSA 412:43, I; RSA 417:4 VIII(g);

RSA 417-A; RSA 417-B

Ins 3311.01

RSA 400-A:15, I & III; RSA 412:15, III; RSA 412:43, I; RSA 412:40

History

#9634, eff 7-1-10; ss by #12599, eff 8-3-18

Chapter Ins 3400 Purchasing Alliances

Part Ins 3401 Purchasing Alliance Standards

N.H. Code Admin. R. Ann. Ins 3401.01 Purpose {#sec-ins-3401.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.01}

The purpose of this part is to:

(a) Increase the affordability, efficiency, and fairness of health insurance coverage for small employers by setting standards for the licensure and oversight of voluntary purchasing alliances through which small employers and their employees may purchase health coverage in the manner of large employer groups;

(b) Allow small employers and their employees to obtain better value in purchasing health insurance by consolidating purchasing responsibilities and resources, thereby increasing bargaining power and purchasing expertise and reducing the administrative cost of health plan contracting, enrollment, premium collection and payment for multiple employers;

(c) Provide small employers and their employees a choice of health carrier or carriers and health benefit plan or plans through an open and fair process in which qualified carriers compete to provide health coverage to alliance members; and

(d) Foster competition based on value.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.02 Definitions {#sec-ins-3401.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.02}

(a) "Commissioner" means the insurance commissioner.

(b) "Eligible dependent" means "eligible dependents" as defined in RSA 420-G:2, V.

(d) "Employee enrollee" means an eligible employee, self-employed individual or an eligible dependent of an eligible employee who is enrolled in a health benefit plan offered through an alliance by a participating carrier.

(e) "Health benefit plan" means "health coverage" as defined in RSA 420-G:2, IX.

(f) "Health carrier" means "health carrier" as defined in RSA 420-G:2, VIII.

(g) "Member small employer" means a small employer who enrolls in an alliance.

(h) "Participating carrier" means a carrier having a contractual relationship with an alliance.

(i) "Purchasing alliance" means a corporation or other entity licensed pursuant to RSA 420-G:10-a that provides, on a voluntary basis, health insurance coverage through a participating carrier or carriers to member small employers and their employees within a defined service area authorized by the commissioner.

(j) "Small employer" means "small employer" as defined in RSA 420-G:2, XVI.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.03 Jurisdiction of the Commissioner; Penalties {#sec-ins-3401.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.03}

(a) The commissioner shall regulate the establishment and conduct of purchasing alliances.

(b) No person or entity may market, sell, offer, or arrange for a package of one or more health benefit plans underwritten by a participating carrier or carriers to 2 or more small employers or their eligible employees without first being licensed by the commissioner pursuant to this part.

(c) A person or entity not licensed by the commissioner as a purchasing alliance and engaged in the purchase, sale, marketing or distribution of health insurance or heath care benefit plans shall not hold itself out as an alliance, health insurance purchasing alliance, purchasing alliance, health insurance purchasing cooperative or purchasing cooperative or otherwise use a confusingly similar name.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.04 Purchasing Alliance Application, Licensing and Continuing Review Process {#sec-ins-3401.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.04}

(a) An application shall be completed and filed with the commissioner by an authorized representative of the corporation or other entity established as a precursor to being granted a purchasing alliance license. An application shall not be deemed filed until all information necessary to properly process the application has been received by the commissioner. Upon filing, the commissioner shall make a determination concerning the application and shall provide notice of the determination to the applicant. If approved, a copy of a license shall be provided to the purchasing alliance. The license shall serve as authorization to operate pursuant to this part.

(b) Each applicant shall prepare a business plan as follows:

(1) The business plan shall include, but not be limited to, the following information:

a. A detailed, written plan of operations explaining how the applicant intends to fulfill the purposes and requirements of this part.

b. A written commitment by the alliance;

c. The specific steps planned to increase affordability, efficiency and fairness of health insurance coverage;

d. The specific steps planned to allow small employers and their employees to obtain health insurance that is a better value to them than what is otherwise available;

e. The specific steps planned to provide small employers and their employees meaningful choice of health carriers and health benefit plans, and foster competition based on value;

f. The scope of service to be offered in the proposed service area and the resources and expertise to be used to implement and administer those services;

g. A provision requiring that any coverage procured by the alliance shall include a provision requiring that the members of the alliance be notified directly by the insurer of cancellation due to nonpayment of premium;

h. The personal biographical information and descriptions of the officers of the alliance;

i. A written statement demonstrating that those involved in the operation of the alliance have the expertise and experience to effectively and professionally represent small employers and their eligible employees in a fiduciary capacity; and

j. A affirmative demonstration that financial controls are in place as a condition of licensure; and

(2) Proposed substantive changes in the policy or operations of the business plan shall not take effect without approval from the commissioner.

(1) A business plan;

(2) A plan that affirmatively demonstrates that the alliance has the technical expertise and capacity to serve a significant group of small employers and their eligible employees over the service area;

(3) A plan that demonstrates that the alliance has the technical capacity to provide service quality throughout the entire service area;

(4) The applicant’s articles of incorporation, bylaws or other formation and business operation documents;

(5) A list of officers and directors of the applicant and the contract administrator, if one is employed, and personal biographical information or firm descriptions for each;

(6) Evidence of security and prudence in the accounting, deposit, collection, handling, and transfer of moneys;

(7) A description of the service area in which the alliance will be marketing and offering services; and

(8) An annual report that shows:

a. The alliance is operating in a sound financial fashion;

b. The alliance is not a risk-bearing entity and obtains insurance to cover its member; and

c. The alliance is utilizing sound financial controls and money management.

(d) The commissioner shall approve all assessments made upon member small employers by the alliance for costs incurred or anticipated in connection with the operation of the alliance.

(e) The following acts shall constitute a basis for denial, non-renewal or suspension of an application or existing license, following notice and an opportunity for hearing: If the acts are intentional, they shall constitute a basis for revocation, after notice and hearing.

(1) Failure to comply with the provisions of RSA 420-G;

(2) Failure to comply with the business plan filed and approved by the commissioner;

(3) Failure to maintain adequate financial controls;

(4) Failure to extend alliance health benefit plan coverage to eligible employees;

(5) Failure to comply with a lawful order of the commissioner;

(6) Engaging in an unfair or deceptive act or practice;

(7) Filing any necessary form, including the application form, with the commissioner that contains false or materially incorrect information or omissions; or

(8) Misappropriation, conversion, illegal withholding, or refusal to pay over upon proper demand any moneys that belong to a person or participating carrier and that have been entrusted to the alliance in its fiduciary capacity.

(f) The commissioner shall require the removal and replacement of managerial or marketing staff or third party contractors if necessary to remedy compliance or performance problems.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.05 Powers and Duties of and Restrictions on Purchasing Alliances {#sec-ins-3401.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.05}

(a) A purchasing alliance shall:

(1) Offer health benefit plans that are available to all small employers in the alliance’s service area;

(2) Establish administrative and accounting procedures for operating the alliance, for providing services to member small employers and enrollees and for preparing an annual budget;

(3) Establish conditions of participation for small employers that conform to the requirements of this part and RSA 420-G and include, but are not limited to, the following:

a. Assurances that the member small employer is a valid small employer group and is not formed for the purpose of securing health benefits coverage; and

b. Prepayment of premiums or other mechanisms to assure that payment will be made for coverage;

(4) Provide that each eligible employee is permitted to enroll in any health benefit plan offered by the participating carrier or carriers so long as the health benefit plan provides coverage where he or she works or lives;

(5) Establish conditions of participation for the participating carrier or carriers;

(6) Establish conditions of participation for producers;

(7) Place into its contracts between the alliance and member small employers the following:

a. A provision stating that, for administrative purposes, the alliance shall be the policyholder or contract holder of the health benefit plan on behalf of member small employers, their eligible employees and eligible dependents; and

b. A provision stating that the participating carrier shall issue a certificate of coverage, or equivalent document, specifying the essential features of the health benefit plan's coverage to each enrolled eligible employee.

(8) Transmit enrollment and eligibility information to the participating carrier or carriers on a timely basis;

(9) Maintain a trust account or accounts for deposit of all moneys received and collected for the operation of the alliance;

(10) The alliance, its board members, employees and agents shall have a fiduciary duty with respect to all moneys received or owed to it to assure payments of its obligations and a full accounting to its members and the commissioner; and

(11) Assure the offering of the same premiums and prices on negotiated health care coverage to all member classes equally, and treat all members within a class equally with regard to membership and administrative fees and benefits of membership;

(b) A purchasing alliance may:

(1) Receive, review, and act on grievances against participating carriers by member small employers or enrollees;

(2) Undertake any activity necessary to administer the alliance, including marketing and publicizing the alliance, and assuring that the participating carrier or carriers, contractors, participating small employers, and enrollees are in compliance with alliance requirements;

(3) Establish contracts with the participating carrier or carriers to provide health coverage to alliance members;

(4) Establish contracts with small employer members;

(5) Contract with qualified, independent third parties for services necessary to carry out the powers and duties of the alliance;

(6) Enter into all other contracts as are necessary to carry out the powers and duties of the alliance;

(7) Appoint a beneficiary advisory council to evaluate alliance functions and the performance of the participating carrier or carriers in order to assess the efficacy of the operations for member small employers and enrollees;

(8) Appoint advisory committees, as necessary, to provide technical assistance in the operation of the program and in carrying out the purposes of this part;

(9) Assess member small employers a fee for costs incurred or anticipated in connection with the operation of the alliance;

(10) Require as a condition of membership that all employers include all their eligible employees or a minimum percentage of employees in coverage purchased through the alliance;

(11) Require an employer that makes a membership application to the purchasing alliance that would entail enrolling fewer than 100 percent of the employer’s eligible employees or dependents to demonstrate that the enrollment section is based on factors other than risk selection;

(12) Reject or allow a carrier to reject an employer from membership, or drop or allow a carrier to drop a member small employer, if the member fails to pay premiums or engages in fraud or material misrepresentation in connection with a health benefit plan purchased through the alliance;

(13) Contract with licensed insurance producers to market and service coverage made available through the alliance to its members. Compensation for producers shall not vary based on the actual or expected health status or medical utilization of the group to which coverage is sold;

(14) Define a set of standardized health benefit plans which the alliance shall contract to purchase from the participating carrier or carriers;

(15) Exclude a carrier or freeze enrollment in a carrier for failure to achieve established quality, access or information reporting standards of the alliance;

(16) Require that member employers and their eligible employees continue to pay administrative fees that are part of the contract with the alliance if a member employer or enrollee cancels prior to completion of a contract period;

(17) Negotiate with the participating carrier or carriers the premium rates charged for coverage offered through the alliance consistent with the rating restrictions contained in RSA 420-G;

(18) Request such information from the participating carrier or carriers as is necessary to carry out the powers and duties of this part;

(19) Sue or be sued, including taking action necessary for securing legal remedies on behalf of the alliance, member small employers, or enrollees;

(20) Apply for loans or loan guarantees from the New Hampshire business finance authority under RSA 162-A for the purpose of funding startup costs;

(21) Receive and accept loans, grants, funds, or anything of value from a public or private entity including:

a. Employer premiums;

b. Employer participation fees;

c. Employer late fees;

d. Employer reinstatement fees;

e. Producer fees paid by the employer;

f. Interest earned on accounts;

g. Funds paid by the participating carrier or carriers for a pooled marketing effort;

h. Public sector and private sector grants, gifts, loans or donations; or

i. Other lawful sources;

(22) The alliance may also receive and accept contributions of property, labor, or any other thing of value;

(23) Expend funds to pay:

a. The participating carrier or carriers under their contracts;

b. Third parties for services provided under contract;

c. Employer billing adjustments;

d. Producer fees;

e The alliance’s administrative expenses; and

f. All other expenditures duly authorized by the board;

(24) Develop standard enrollment procedures for enrolling small employers and their eligible employees and dependents;

(25) Establish procedures for annual or rolling open enrollment periods;

(26) Establish procedures and mechanisms for billing and collection of premiums from member small employers, including any share of the premium paid by employee enrollees;

(27) Develop model contracts which detail for potential contractors the requirements of the alliance and provide a copy of the contract to interested carriers;

(28) Develop and make available a list of objective criteria that shall be met by the participating carrier or carriers in order to be eligible to participate in the alliance;

(29) Provide to alliance members clear, standardized information on each participating carrier or carriers and the qualified health benefit plans offered by each participating carrier or carriers, including information on:

a. Price;

b. Benefits;

c. Enrollee costs;

d. Quality;

e. Patient satisfaction;

f. Enrollment; and

g. Grievance procedures and rights and responsibilities.

(30) Provide qualified health benefit plan comparison sheets to participating members and their employees with information regarding coverage that may be obtained through the participating carrier or carriers;

(31) Require the participating carrier or carriers to maintain health care data;

(32) Specify in contracts with the participating carrier or carriers how all premiums shall be transmitted and the frequency of that transmission and how penalties and grace periods on late payments of premiums shall be calculated;

(33) Review information and recommendations from consumers, employers, participating carriers or health care providers and other sources and, issue periodic reports or recommendations to the commissioner to improve the delivery of health services and the purchasing of health coverage; and

(34) Exercise all powers reasonably necessary to carry out the powers granted and duties imposed under this part.

(1) Purchase health care services, assume risk for the cost or provision of health care services, or otherwise contract with health care providers for the provision of health care services to enrollees;

(2) Exclude from membership in the alliance a small employer, eligible employee or eligible dependent of an eligible employee who is in the service area of the alliance and who agrees to pay fees for membership and the premium for health coverage through the alliance and who abides by the bylaws and rules of the alliance;

(3) Prohibit the participation of small employers, or differentiate classes of membership, based on industry type, experience, gender, family status, education, health status, income, or other means in conflict with the rating methodology specified in RSA 420-G:4;

(4) Charge a fee not directly related to the operation of the alliance or for non-health coverage related activities;

(5) As a condition of membership, require a small employer, eligible employee, or eligible dependent to subscribe to limited health coverage or non-health coverage related products or services;

(6) Engage in any competitive act or practice that results in the selection of member small employers and enrollees based on industry type, experience, gender, family status, education, health status, income, small employer size, or other factors in conflict with the rating methodology specified in RSA 420-G:4; or

(7) Require or take any action inconsistent or in conflict with state laws or rules.

(d) The contracts entered into by the alliance shall:

(1) Establish performance standards for specific contractual elements;

(2) Set liquidated damages for breach of the contract;

(3) Require the participating carrier or carriers to notify the member small employer of cancellation of the policy;

(4) Require the member small employer in the event of cancellation to arrange for continuation and conversion coverage for its employees to the extent provided under federal and state law; and

(5) Contain a provision stating that if after timely receipt of the premium payment from the employer, the alliance fails to make the premium payment to the insurer, with the result that coverage is terminated, that the alliance shall be liable for benefits to the same extent as the insurer or carrier would have been liable if coverage had not been terminated.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.06 Requirements for Participating Carriers {#sec-ins-3401.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.06}

(a) To qualify as a participating carrier, a carrier shall demonstrate all the following operating characteristics:

(1) That it is licensed and in good standing with the department of insurance;

(2) That it has the ability to administer health coverage, to provide adequate service, and to comply with all contractual requirements of the alliance;

(3) That it has the ability to provide enrollees with access to covered services;

(4) That it has the ability to provide coverage for enrollees in any service area in which the carrier plans to participate through the alliance;

(5) That it has the ability to arrange and pay for quality health care services;

(6) That it has the ability to provide standard data required by the alliance, in a manner prescribed by the alliance, including information on:

a. Plan performance;

b. Enrollee satisfaction;

c. Provider payment and incentive structures;

d. Such other standard surveys prescribed by the alliance; and

e. Meeting satisfaction measures established by the alliance;

(7) That it has the ability to meet quality of care standards established by government and industry authorities;

(8) That it is financially strong and has competent management;

(9) That it has a procedure in place to address enrollee grievances and appeals; and

(10) That it has the ability to achieve satisfactory enrollment levels within the service area in which the carrier is licensed.

(b) In evaluating the requirements for a participating carrier, the alliance shall consider:

(1) The minimum geographic service area and participation requirements, maximum thresholds for premium rates, and standards for determining whether a carrier operates efficiently;

(2) The ability of a carrier to provide high quality services within a service area;

(3) Pricing and the competitiveness of each bid from a carrier; and

(4) The effect of contracting with additional carriers on the administrative costs of the alliance and member small employers, the efficiency of the alliance, and the competitiveness of the premiums that will be paid to the participating carrier or carriers;

(c) A participating carrier or carriers that contract with or employ health care providers shall have mechanisms to accomplish all of the following, in a manner satisfactory to the alliance:

(1) Review the quality of care covered;

(2) Review the appropriateness of care covered; and

(3) Provide accessible health care services;

(d) Each participating carrier shall:

(1) Meet the standards established by the alliance pursuant to this part;

(2) Provide data and information as required by the alliance;

(3) Comply with all laws and rules regarding underwriting, rating, claims handling, sales, solicitation, licensing, fair marketing, unfair trade practices, the provisions of this part, and other applicable state statutes;

(4) Enroll and terminate individuals in the manner specified by the alliance; and

(5) Comply with other requirements established by the alliance pursuant to this part;

(e) Nothing in this part shall prohibit the participating carrier or carriers from contracting with particular health care providers or types, classes, or categories of health care providers, or setting reimbursement methodology.

(f) A participating carrier or carriers contracting to provide one or more such benefit plans through the alliance shall be deemed to be in compliance with the guaranteed issue and renewal requirements in RSA 420-G:6, III with respect to such benefit plan or plans so long as it actively markets, issues, and renews such plan or plans to all eligible employees of all member small employers of the alliance.

(g) In the event that the participating carrier or carriers elect to terminate its or their contracts with the alliance, the participating carrier or carriers shall:

(1) Provide advance notice of its or their decision to the alliance; and

(2) Provide notice of the decision at least 180 days prior to the non-renewal of health coverage to the member small employers and employee enrollees.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.07 Marketing Health Benefit Plans {#sec-ins-3401.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.07}

(a) The alliance shall establish marketing standards for use by the participating carrier or carriers.

(b) Any marketing, advertisement, or educational material for health coverage sold through the alliance shall be approved by the alliance prior to its use. The alliance shall review all materials submitted to it and the materials shall be deemed approved if not disapproved within 30 days. The alliance may, through its contracts with the participating carrier or carriers, deem certain classes of materials to be approved.

(c) The alliance shall make approved marketing materials available to member small employers in an efficient and standardized manner. These materials shall include, but not be limited to, an accurate summary of benefit plans, rates, cost, and accreditation information relating to the offerings of the participating carrier or carriers.

(d) This section shall not be construed to prohibit or to compel the alliance or a participating carrier from using the services of a producer.

(e) The participating carrier or carriers, contract administrator or producer of the participating carrier or carriers, or independent insurance producer shall not engage, directly or indirectly, in an activity or marketing practice that would encourage member small employers or eligible employees to:

(1) Refrain from enrolling in a health benefit plan offered through the alliance because of their health status or claims experience;

(2) Seek coverage from other participating carriers because of their health status or claims experience; or

(3) Enroll or fail to enroll in the alliance because of their health status or claims experience.

(f) Alliance members shall notify the commissioner of marketing practices or materials that are contrary to the provisions of this section. The commissioner shall monitor compliance with this section and investigate possible violations of the provisions of this section or other related unfair trade practices.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.08 Risk Adjustment Mechanism {#sec-ins-3401.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.08}

In order to reduce the incentive for risk selection and to improve fairness and efficiency, and in the absence of a risk adjustment mechanism established by rule or order for the entire small group market, an alliance may establish a payment mechanism to adjust payments to the participating carrier or carriers prospectively or retrospectively based on the amount of risk covered by each participating carrier. To establish such a mechanism, the alliance may appoint an advisory committee composed of individuals that have risk adjustment and actuarial expertise to help establish the risk adjusters.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.09 Conflict of Interest {#sec-ins-3401.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.09}

No officer or board member or director or contract administrator of a purchasing alliance or members of their households may be employed by, be a consultant for, be a member of the board of directors of, or be affiliated with, or otherwise be a representative of a carrier or other insurer. This provision shall not preclude an officer or board member or director or contract administrator of a purchasing alliance from purchasing health coverage through the alliance.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.10 Purchasing Alliance Distinguished From Multiple Employer Welfare Arrangement. {#sec-ins-3401.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.10}

Purchasing alliances shall not bear risk.

History

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

N.H. Code Admin. R. Ann. Ins 3401.11 Purchasing Alliance Evaluation {#sec-ins-3401.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 3401.11}

(a) Purchasing alliances shall submit an annual evaluation to the commissioner which includes the following:

(1) The progress achieved in making affordable health care coverage available to employees of member small employers;

(2) The progress achieved in assuring choice of health carriers and health care coverage to employees of member small employers;.

(3) The need, if any, for financial incentives or other mechanisms to increase participation in the alliance; and

(4) Other changes in the law or procedure needed to accomplish the purposes set out in Ins 3401.01.

APPENDIX

RULE

STATUTE

Ins 3401.01-Ins 3401.11

RSA 400-A:15, I.; 420-G:10-a, I-IV

History

#7434, INTERIM, eff 2-1-01, EXPIRES: 7-31-01
#7583, eff 11-1-01; ss by #9564, eff 10-19-09

Chapter Ins 3500 Valuation of Life Insurance Policies

Part Ins 3501 Purpose

N.H. Code Admin. R. Ann. Ins 3501.01 Purpose {#sec-ins-3501.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3501.01}

(a) The purpose of this rule is to provide:

(1) Tables of select mortality factors and rules for their use;

(2) Rules concerning a minimum standard for the valuation of plans with nonlevel premiums or benefits; and

(3) Rules concerning a minimum standard for the valuation of plans with secondary guarantees.

(b) The method for calculating basic reserves defined in this rule will constitute the commissioner’s reserve valuation method for policies to which this rule is applicable.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

Part Ins 3502 Applicability

N.H. Code Admin. R. Ann. Ins 3502.01 Applicability {#sec-ins-3502.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3502.01}

(a) This rule shall apply to all life insurance policies, with or without nonforfeiture values, issued on or after the 2017 effective date of this rule, subject to the following exceptions and conditions:

(1) Exceptions are:

a. This rule shall not apply to any individual life insurance policy issued on or after the 2017 effective date of this rule if the policy is issued in accordance with and as a result of the exercise of a reentry provision contained in the original life insurance policy of the same or greater face amount, issued before the 2017 effective date of this rule, that guarantees the premium rates of the new policy. This rule also shall not apply to subsequent policies issued as a result of the exercise of such a provision, or a deviation of the provision, in the new policy;

b. This rule shall not apply to any universal life policy that meets all the following requirements:

Secondary guarantee period, if any, is 5 years or less;
Specified premium for the secondary guarantee period is not less than the net level reserve premium for the secondary guarantee period based on the 1980 CSO valuation tables as defined in Part Ins 3503 and the applicable valuation interest rate; and
The initial surrender charge is not less than 100 percent of the first year annualized specified premium for the secondary guarantee period;

c. This rule shall not apply to any variable life insurance policy that provides for life insurance, the amount or duration of which varies according to the investment experience of any separate account or accounts;

d. This rule shall not apply to any variable universal life insurance policy that provides for life insurance, the amount or duration of which varies according to the investment experience of any separate account or accounts; and

e. This rule shall not apply to a group life insurance certificate unless the certificate provides for a stated or implied schedule of maximum gross premiums required in order to continue coverage in force for a period in excess of one year.

(2) Conditions are:

a. Calculation of the minimum valuation standard for policies with guaranteed nonlevel gross premiums or guaranteed nonlevel benefits, other than universal life policies, or both, shall be in accordance with the provisions of Ins 3506; and

b. Calculation of the minimum valuation standard for flexible premium and fixed premium universal life insurance policies, that contain provisions resulting in the ability of a policyholder to keep a policy in force over a secondary guarantee period shall be in accordance with provisions of Ins 3506.

(b) In addition to the exceptions and conditions set out in (a) above, the commissioner, upon the commissioner’s own initiative or upon request by an insurer, shall waive any requirement of this chapter if such waiver does not contradict the objective or intent of the rule and:

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the specific circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision; and

(5) No requirement prescribed by statute shall be waived unless expressly authorized by law; and

(7) Any request for a waiver shall be in writing and shall specify the basis for the waiver and proposed alternative, if any.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

Part Ins 3503 Definitions

N.H. Code Admin. R. Ann. Ins 3503.01 Definitions {#sec-ins-3503.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3503.01}

(a) “Basic reserves” means reserves calculated in accordance with RSA 410:4, Standard Valuation Law.

(b) “Contract segmentation method” means the method of dividing the period from issue to mandatory expiration of a policy into successive segments, with the length of each segment being defined as the period from the end of the prior segment (from policy inception, for the first segment) to the end of the latest policy year as determined below. All calculations are made using the 1980 CSO valuation tables as defined in Ins 3503.01(f), (or any other valuation mortality table adopted by the National Association of Insurance Commissioner (NAIC) after the 2017 effective date of this rule and promulgated by rule by the commissioner for this purpose), and, if elected, the optional minimum mortality standard for deficiency reserves stipulated in Ins 3505.02 of this rule.

(1) The length of a particular contract segment shall be set equal to the minimum of the value t for which Gt is greater than Rt (if Gt never exceeds Rt the segment length is deemed to be the number of years from the beginning of the segment to the mandatory expiration date of the policy), where Gt and Rt are defined as follows:

Gt = GPx+k+t

GPx+k+t-1

where:

x = original issue age;

k = the number of years from the date of issue to the beginning of the segment;

t = 1,2,....; t is reset to 1 at the beginning of each segment;

GPx+k+t-1 = Guaranteed gross premium per thousand of face amount for year t of the segment,

ignoring policy fees only if level for the premium paying period of the policy.

Rt = qx+k+t

qx+k+t-1 , However, Rt may be increased or decreased by one percent

in any policy year, at the company’s option, but Rt , shall not be

less than one;

where:

x, k and t are as defined above, and

qx+k+t-1 = valuation mortality rate for deficiency reserves in policy year k+t

but using the mortality of Ins 3504.02(a)(2) if Ins 3504.02(a)(3) is elected for deficiency reserves.

However, if GPx+k+t is greater than 0 and GPx+k+t-1 is equal to 0, Gt shall be deemed to be 1000. If GPx+k+t and GPx+k+t-1 are both equal to 0, Gt shall be deemed to be 0.

(1) Minimum reserves calculated in accordance with RSA 410:7, Standard Valuation Law, over

(2) Basic reserves.

(d) “Guaranteed gross premiums” means the premiums under a policy of life insurance that are guaranteed and determined at issue.

(e) “Maximum valuation interest rates” means the interest rates in RSA 410:3-b, Standard Valuation Law, (Interest Rates), that are to be used in determining the minimum standard for the valuation of life insurance policies.

(f) “1980 CSO valuation tables” means the Commissioners’ 1980 Standard Ordinary Mortality Table (1980 CSO Table) without ten-year selection factors, incorporated into the 1980 amendments to the NAIC Standard Valuation Law, and variations of the 1980 CSO Table approved by the NAIC, such as the smoker and nonsmoker versions approved in December 1983. These tables are available as referenced in Appendix B.

(g) “Scheduled gross premium” means the smallest illustrated gross premium at issue for other than universal life insurance policies. For universal life insurance policies, scheduled gross premium means the smallest specified premium described in Ins 3506.01(c), if any, or else the minimum premium described in Ins 3506.01(d).

(h) “Segmented reserves” means reserves, calculated using segments produced by the contract segmentation method, equal to the present value of all future guaranteed benefits less the present value of all future net premiums to the mandatory expiration of a policy, where the net premiums within each segment are a uniform percentage of the respective guaranteed gross premiums within the segment and:

(1) The uniform percentage for each segment is such that, at the beginning of the segment, the present value of the net premiums within the segment equals:

a. The present value of the death benefits within the segment, plus;

b. The present value of any unusual guaranteed cash value (see Ins 3505.04) occurring at the end of the segment, less;

c. Any unusual guaranteed cash value occurring at the start of the segment, plus;

d. For the first segment only, the excess of Item a. over Item b. as follows:

A net level annual premium equal to the present value, at the date of issue, of the benefits provided for in the first segment after the first policy year, divided by the present value, at the date of issue, of an annuity of one per year payable on the first and each subsequent anniversary within the first segment on which a premium falls due. However, the net level annual premium shall not exceed the net level annual premium on the nineteen-year premium whole life plan of insurance of the same renewal year equivalent level amount at an age one year higher than the age at issue of the policy; and
A net one year term premium for the benefits provided for in the first policy year;

(2) The length of each segment is determined by the “contract segmentation method”, as defined in this section;

(3) The interest rates used in the present value calculations for any policy may not exceed the maximum valuation interest rate, determined with a guarantee duration equal to the sum of the lengths of all segments of the policy; and

(4) For both basic reserves and deficiency reserves computed by the segmented method, present values shall include future benefits and net premiums in the current segment and in all subsequent segments.

(i) “Tabular cost of insurance” means the next single premium at the beginning of a policy year for one-year term insurance in the amount of the guaranteed death benefit in that policy year.

(j) “Ten-year select factors” means the select factors adopted with the 1980 amendments to the NAIC Standard Valuation Law.

(k) “Unitary reserves” means the present value of all future guaranteed benefits less the present value of all future modified net premiums, where:

(1) Guaranteed benefits and modified net premiums are considered to the mandatory expiration of the policy;

(2) Modified net premiums are a uniform percentage of the respective guaranteed gross premiums, where the uniform percentage is such that, at issue, the present value of the net premiums equals the present value of all death benefits and pure endowments, plus the excess of Item a. over Item b., as follows:

a. A net level annual premium equal to the present value, at the date of issue, of the benefits provided for after the first policy year, divided by the present value, at the date of issue, of an annuity of one per year payable on the first and each subsequent anniversary of the policy on which a premium falls due. However, the net level annual premium shall not exceed the net level annual premium on the nineteen-year premium whole life plan of insurance of the same renewal year equivalent level amount at an age one year higher than the age at issue of the policy; and

b. A net one year term premium for the benefits provided for in the first policy year; and

(3) The interest rates used in the present value calculations for any policy may not exceed the maximum valuation interest rate, determined with a guarantee duration equal to the length from issue to the mandatory expiration of the policy.

(l) “Universal life insurance policy” means any individual life insurance policy under the provisions of which separately identified interest credits (other than in connection with dividend accumulations, premium deposit funds, or other supplementary accounts) and mortality or expense charges are made to the policy.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

Part Ins 3504 General Calculation Requirements for Basic Reserves and Premium Deficiency Reserves

N.H. Code Admin. R. Ann. Ins 3504.01 Basic Reserves Calculation Requirements {#sec-ins-3504.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3504.01}

(a) At the election of the company for any one or more specified plans of life insurance, the minimum mortality standard for basic reserves may be calculated using the 1980 CSO valuation tables with select mortality factors (or any other valuation mortality table adopted by the NAIC after the 2017 effective date of this rule and promulgated by rule by the commissioner for this purpose). If select mortality factors are elected, they may be:

(1) The ten-year select mortality factors incorporated into the 1980 amendments to the NAIC Standard Valuation Law, available as referenced in Appendix B;

(2) The select mortality factors in Appendix 1; or

(3) Any other table of select mortality factors adopted by the NAIC after the 2017 effective date of this rule and promulgated by rule by the commissioner for the purpose of calculating basic reserves.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3504.02 Deficiency Reserves Calculation Requirements {#sec-ins-3504.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3504.02}

(a) Deficiency reserves, if any, are calculated for each policy as the excess, if greater than zero, of the quantity A over the basic reserve. The quantity A is obtained by recalculating the basic reserve for the policy using guaranteed gross premiums instead of net premiums when the guaranteed gross premiums are less than the corresponding net premiums. At the election of the company for any one or more specified plans of insurance, the quantity A and the corresponding net premiums used in the determination of quantity A may be based upon the 1980 CSO valuation tables with select mortality factors (or any other valuation mortality table adopted by the NAIC after the 2017 effective date of this rule and promulgated by rule by the commissioner). If selected mortality factors are elected, they may be:

(1) The ten-year select mortality factors incorporated into the 1980 amendments to the NAIC Standard Valuation Law;

(2) The select mortality factors in Appendix 1 of this rule;

(3) For durations in the first segment, X percent of the select mortality factors in Appendix 1, subject to the following:

a. X may vary by policy year, policy form, underwriting classification, issue age, or any other policy factor expected to affect mortality experience;

b. X shall not be less than twenty percent (20%);

c. X shall not decrease in any successive policy years;

d. X is such that, when using the valuation interest rate used for basic reserves, Item 1. is greater than or equal to Item 2.:

The actuarial present value of future death benefits, calculated using the mortality rates resulting from the application of X; and
The actuarial present value of future death benefits calculated using anticipated mortality experience without recognition of mortality improvement beyond the valuation date;

e. X is such that the mortality rates resulting from the application of X are at least as great as the anticipated mortality experience, without recognition of mortality improvement beyond the valuation date, in each of the first five (5) years after the valuation date;

f. The appointed actuary shall increase X at any valuation date where it is necessary to continue to meet all the requirements of Ins 3504.02(a)(3);

g. The appointed actuary may decrease X at any valuation date as long as X does not decrease in any successive policy years and as long as it continues to meet all the requirements of Ins 3504.02(a)(3);

h. The appointed actuary shall specifically take into account the adverse effect on expected mortality and lapsation of any anticipated or actual increase in gross premiums; and

i. If X is less than 100 percent at any duration for any policy, the following requirements shall be met:

The appointed actuary shall annually prepare an actuarial opinion and memorandum for the company in conformance with the requirements of Ins 2400, Actuarial Opinion and Memorandum;
The appointed actuary shall disclose, in the Regulatory Asset-Adequacy Issues Summary, the impact of the insufficiency of assets to support the payment of benefits and expenses and the establishment of statutory reserves during one or more interim periods; and
The appointed actuary shall annually opine for all policies subject to this rule as to whether the mortality rates resulting from the application of X meet the requirements of Ins 3504.02(a)(3). This opinion shall be supported by an actuarial report, subject to appropriate Actuarial Standards of Practice promulgated by the Actuarial Standards Board of American Academy of Actuaries and available as referenced in Appendix B. The X factors shall reflect anticipated future mortality, without recognition of mortality improvement beyond the valuation date, taking into account relevant emerging experience; and

(4) Any other table of select mortality factors adopted by the NAIC after the 2017 effective date of this rule and promulgated by rule by the commissioner for the purpose of calculating deficiency reserves.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3504.03 Other Calculation Requirements {#sec-ins-3504.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3504.03}

(a) This subsection applies to both basic reserves and deficiency reserves. Any set of select mortality factors may be used only for the first segment. However, if the first segment is less than ten (10) years, the appropriate ten-year select mortality factors incorporated into the 1980 amendments to the NAIC Standard Valuation Law may be used thereafter through the tenth policy year from the date of issue.

(b) In determining basic reserves or deficiency reserves, guaranteed gross premiums without policy fees may be used where the calculation involves the guaranteed gross premium but only if the policy fee is a level dollar amount after the first policy year. In determining deficiency reserves, policy fees may be included in guaranteed gross premiums, even if not included in the actual calculation of basic reserves.

(c) Reserves for policies that have changes to guaranteed gross premiums, guaranteed benefits, guaranteed charges, or guaranteed credits that are unilaterally made by the insurer after issue and that are effective for more than one year after the date of the change shall be the greatest of the following:

(1) Reserves calculated ignoring the guarantee;

(2) Reserves assuming the guarantee was made at issue; and

(3) Reserves assuming that the policy was issued on the date of the guarantee.

(d) The commissioner may require that the company document the extent of the adequacy of reserves for specified blocks, including but not limited to policies issued prior to the 2017 effective date of this rule. This documentation may include a demonstration of the extent to which aggregation with other non-specified blocks of business is relied upon in the formation of the appointed actuary opinion pursuant to and consistent with the requirements of Ins 2400, Actuarial Opinion and Memorandum.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

Part Ins 3505 Calculation of Minimum Valuation Standard for Policies with Guaranteed Nonlevel Gross Premiums or Guaranteed Nonlevel Benefits (other Than Universal Life Policies)

N.H. Code Admin. R. Ann. Ins 3505.01 Calculation of Basic Reserves {#sec-ins-3505.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3505.01}

(a) Basic reserves shall be calculated as the greater of the segmented reserves and the unitary reserves. Both the segmented reserves and the unitary reserves for any policy shall use the same valuation mortality table and selection factors. At the option of the insurer, in calculating segmented reserves and net premiums, either of the adjustments described in paragraph (1) or (2) below may be made:

(1) Treat the unitary reserve, if greater than zero, applicable at the end of each segment as a pure endowment and subtract the unitary reserve, if greater than zero, applicable at the beginning of each segment from the present value of guaranteed life insurance and endowment benefits for each segment; or

(2) Treat the guaranteed cash surrender value, if greater than zero, applicable at the end of each segment as a pure endowment and subtract the guaranteed cash surrender value, if greater than zero, applicable at the beginning of each segment from the present value of guaranteed life insurance and endowment benefits for each segment.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3505.02 Calculation of Deficiency Reserves {#sec-ins-3505.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3505.02}

(a) The deficiency reserve at any duration shall be calculated:

(1) On a unitary basis if the corresponding basic reserve determined by Ins 3505.01 is unitary;

(2) On a segmented basis if the corresponding basic reserve determined by Ins 3505.01 is segmented; or

(3) On the segmented basis if the corresponding basic reserve determined by Ins 3506.01 is equal to both the segmented reserve and the unitary reserve.

(b) This subsection shall apply to any policy for which the guaranteed gross premium at any duration is less than the corresponding net premium calculated by the method used in determining the basic reserves, but using the minimum valuation standards of mortality (specified in Ins 3504.01) and rate of interest.

(c) Deficiency reserves, if any, shall be calculated for each policy as the excess, if greater than zero, for the current and all remaining periods, of the quantity A over the basic reserve, where A is obtained as indicated in Ins 3504.01.

(d) For deficiency reserves determined on a segmented basis, the quantity A is determined using segment lengths equal to those determined for segmented basic reserves.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3505.03 Minimum Value {#sec-ins-3505.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3505.03}

Basic reserves may not be less than the tabular cost of insurance for the balance of the policy year, if mean reserves are used. Basic reserves may not be less than the tabular cost of insurance for the balance of the current modal period or to the paid-to-date, if later, but not beyond the next policy anniversary, if mid-terminal reserves are used. The tabular cost of insurance shall use the same valuation mortality table and interest rates as that used for the calculation of the segmented reserves. However, if select mortality factors are used, they shall be the ten-year select factors incorporated into the 1980 amendments of the NAIC Standard Valuation Law. In no case may total reserves (including basic reserves, deficiency reserves and any reserves held for supplemental benefits that would expire upon contract termination) be less than the amount that the policyowner would receive (including the cash surrender value of the supplemental benefits, if any, referred to above), exclusive of any deduction for policy loans, upon termination of the policy.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3505.04 Unusual Pattern of Guaranteed Cash Surrender Values {#sec-ins-3505.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3505.04}

(a) For any policy with an unusual pattern of guaranteed cash surrender values, the reserves actually held prior to the first unusual guaranteed cash surrender value shall not be less than the reserves calculated by treating the first unusual guaranteed cash surrender value as a pure endowment and treating the policy as an n year policy providing term insurance plus a pure endowment equal to the unusual cash surrender value, where n is the number of years from the date of issue to the date the unusual cash surrender value is scheduled.

(b) The reserves actually held subsequent to any unusual guaranteed cash surrender value shall not be less than the reserves calculated by treating the policy as an n year policy providing term insurance plus a pure endowment equal to the next unusual guaranteed cash surrender value, and treating any unusual guaranteed cash surrender value at the end of the prior segment as a net single premium, where

(1) n is the number of years from the date of the last unusual guaranteed cash surrender value prior to the valuation date to the earlier of:

a. The date of the next unusual guaranteed cash surrender value, if any, that is scheduled after the valuation date; or

b. The mandatory expiration date of the policy; and

(2) The net premium for a given year during the n year period is equal to the product of the net to gross ratio and the respective gross premium; and

(3) The net to gross ratio is equal to Item a. divided by Item b. as follows:

a. The present value, at the beginning of the n year period, of death benefits payable during the n year period plus the present value, at the beginning of the n year period, of the next unusual guaranteed cash surrender value, if any, minus the amount of the least unusual guaranteed cash surrender value, if any, scheduled at the beginning of the n year period; and

b. The present value, at the beginning of the n year period, of the scheduled gross premiums payable during the n year period.

(c) For purposes of this subsection, a policy is considered to have an unusual pattern of guaranteed cash surrender values if any future guaranteed cash surrender value exceeds the prior year’s guaranteed cash surrender value by more than the sum of:

(1) One hundred ten percent (110%) of the scheduled gross premium for that year;

(2) One hundred ten percent (110%) of one year’s accrued interest on the sum of the prior year’s guaranteed cash surrender value and the scheduled gross premium using the nonforfeiture interest rate used for calculating policy guaranteed cash surrender values; and

(3) Five percent (5%) of the first policy year surrender charge, if any.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3505.05 Optional Exemption for Yearly Renewable Term Reinsurance {#sec-ins-3505.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3505.05}

(a) At the option of the company, the following approach for reserves on YRT reinsurance may be used:

(1) Calculate the valuation net premium for each future policy year as the tabular cost of insurance for that future year;

(2) Basic reserves shall never be less than the tabular cost of insurance for the appropriate period, as defined in Ins 3505.03;

(3) Deficiency reserves:

a. For each policy year, calculate the excess, if greater than zero, of the valuation net premium over the respective maximum guaranteed gross premium; and

b. Deficiency reserves shall never be less than the sum of the present values, at the date of valuation, of the excesses determined in accordance with subparagraph a. above;

(4) For purposes of this subsection, the calculations use the maximum valuation interest rate and the 1980 CSO mortality tables with or without ten-year select mortality factors, or any other table adopted after the 2017 effective date of this rule by the NAIC and promulgated by rule by the commissioner for this purpose;

(5) A reinsurance agreement shall be considered YRT reinsurance for purposes of this subsection if only the mortality risk is reinsured; and

(6) If the assuming company chooses this optional exemption, the ceding company’s reinsurance reserve credit shall be limited to the amount of reserve held by the assuming company for the affected policies.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3505.06 Optional Exemption for Attained-Age-Based Yearly Renewable Term Life Insurance Policies {#sec-ins-3505.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3505.06}

(a) At the option of the company, the following approach for reserves for attained-age-based YRT life insurance policies may be used:

(1) Calculate the valuation net premium for each future policy year as the tabular cost of insurance for that future year;

(2) Basic reserves shall never be less than the tabular cost of insurance for the appropriate period, as defined in Ins 3505.03;

(3) Deficiency reserves:

a. For each policy year, calculate the excess, if greater than zero, of the valuation net premium over the respective maximum guaranteed gross premium; and

b. Deficiency reserves shall never be less than the sum of the present values, at the date of valuation, of the excesses determined in accordance with subparagraph a. above;

(4) For purposes of this subsection, the calculations use the maximum valuation interest rate and the 1980 CSO valuation tables with or without ten-year select mortality factors, or any other table adopted after the 2017 effective date of this rule by the NAIC and promulgated by rule by the commissioner for this purpose;

(5) A policy shall be considered an attained-age-based YRT life insurance policy for purposes of this subsection if:

a. The premium rates (on both the initial current premium scale and the guaranteed maximum premium scale) are based upon the attained age of the insured such that the rate for any given policy at a given attained age of the insured is independent of the year the policy was issued; and

b. The premium rates (on both the initial current premium scale and the guaranteed maximum premium scale) are the same as the premium rates for policies covering all insureds of the same sex, risk class, plan of insurance and attained age;

(6) For policies that become attained-age-based YRT policies after an initial period of coverage, the approach of this subsection may be used after the initial period if:

a. The initial period is constant for all insureds of the same sex, risk class and plan of insurance; or

b. The initial period runs to a common attained age for all insureds of the same sex, risk class and plan of insurance; and

c. After the initial period of coverage, the policy meets the conditions of subparagraph (5) above; and

(7) If this election is made, this approach shall be applied in determining reserves for all attained-age-based YRT life insurance policies issued on or after the 2017 effective date of this rule.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3505.07 Exemption from Unitary Reserves for Certain n-Year Renewable Term Life Insurance Policies {#sec-ins-3505.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3505.07}

(a) Unitary basic reserves and unitary deficiency reserves need not be calculated for a policy if the following conditions are met:

(1) The policy consists of a series of n-year periods, including the first period and all renewal periods, where n is the same for each period, except that for the final renewal period, n may be truncated or extended to reach the expiry age, provided that this final renewal period is less than 10 years and less than twice the size of the earlier n-year periods, and for each period, the premium rates on both the initial current premium scale and the guaranteed maximum premium scale are level;

(2) The guaranteed gross premiums in all n-year periods are not less than the corresponding net premiums based upon the 1980 CSO Table with or without the ten-year select mortality factors; and

(3) There are no cash surrender values in any policy year.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3505.08 Exemption from Unitary Reserves for Certain Juvenile Policies {#sec-ins-3505.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 3505.08}

(a) Unitary basic reserves and unitary deficiency reserves need not be calculated for a policy if the following conditions are met, based upon the initial current premium scale at issue:

(1) At issue, the insured is age twenty-four (24) or younger;

(2) Until the insured reaches the end of the juvenile period, which shall occur at or before age twenty-five (25), the gross premiums and death benefits are level, and there are no cash surrender values; and

(3) After the end of the juvenile period, gross premiums are level for the remainder of the premium paying period, and death benefits are level for the remainder of the life of the policy.

History

#7419, eff 7-1-01; ss by #9516, eff 7-25-09; ss by #12219, eff 7-25-17

Part Ins 3506 Calculation of Minimum Valuation Standard for Flexible Premium and Fixed Premium Universal Life Insurance Policies That Contain Provisions Resulting in the Ability of a Policyowner to Keep a Policy in Force Over a Secondary Guarantee Period

N.H. Code Admin. R. Ann. Ins 3506.01 General Provisions {#sec-ins-3506.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3506.01}

(a) Policies with a secondary guarantee include:

(1) A policy with a guarantee that the policy will remain in force at the original schedule of benefits, subject only to the payment of specified premiums;

(2) A policy in which the minimum premium at any duration is less than the corresponding one year valuation premium, calculated using the maximum valuation interest rate and the 1980 CSO valuation tables with or without ten-year select mortality factors, or any other table adopted after the 2017 effective date of this rule by the NAIC and promulgated by rule by the commissioner for this purpose; or

(3) A policy with any combination of subparagraphs (1) and (2) above.

(b) A secondary guarantee period is the period for which the policy is guaranteed to remain in force subject only to a secondary guarantee. When a policy contains more than one secondary guarantee, the minimum reserve shall be the greatest of the respective minimum reserves at that valuation date of each unexpired secondary guarantee, ignoring all other secondary guarantees. Secondary guarantees that are unilaterally changed by the insurer after issue shall be considered to have been made at issue. Reserves described in Ins 3506.02 and Ins 3506.03 below shall be recalculated from issue to reflect these changes.

(c) Specified premiums mean the premiums specified in the policy, the payment of which guarantees that the policy will remain in force at the original schedule of benefits, but which otherwise would be insufficient to keep the policy in force in the absence of the guarantee if maximum mortality and expense charges and minimum interest credits were made and any applicable surrender charges were assessed.

(d) For purposes of this section, the minimum premium for any policy year is the premium that, when paid into a policy with a zero account value at the beginning of the policy year, produces a zero account value at the end of the policy year. The minimum premium calculation shall use the policy cost factors (including mortality charges, loads and expense charges) and the interest crediting rate, which are all guaranteed at issue.

(e) The one-year valuation premium means the net one-year premium based upon the original schedule of benefits for a given policy year. The one-year valuation premiums for all policy years are calculated at issue. The select mortality factors defined in Ins 3504.02(a)(2), Ins 3504.02(a)(3), and Ins 3504.02(a)(4) may not be used to calculate the one-year valuation premiums.

(f) The one-year valuation premium should reflect the frequency of fund processing, as well as the distribution of deaths assumption employed in the calculation of the monthly mortality charges to the fund.

History

#7419, eff 7-1-01; ss by # 9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3506.02 Basic Reserves for the Secondary Guarantees {#sec-ins-3506.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3506.02}

Basic reserves for the secondary guarantees shall be the segmented reserves for the secondary guarantee period. In calculating the segments and the segmented reserves, the gross premiums shall be set equal to the specified premiums, if any, or otherwise to be minimum premiums, that keep the policy in force and the segments will be determined according to the contract segmentation method as defined in Ins 3503.01(b).

History

#7419, eff 7-1-01; ss by # 9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3506.03 Deficiency Reserves for the Secondary Guarantees {#sec-ins-3506.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3506.03}

Deficiency reserves, if any, for the secondary guarantees shall be calculated for the secondary guarantee period in the same manner as described in Ins 3505.02 with gross premiums set equal to the specified premiums, if any, or otherwise to the minimum premiums that keep the policy in force.

History

#7419, eff 7-1-01; ss by # 9516, eff 7-25-09; ss by #12219, eff 7-25-17

N.H. Code Admin. R. Ann. Ins 3506.04 Minimum Reserves {#sec-ins-3506.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3506.04}

(a) The minimum reserves during the secondary guarantee period are the greater of:

(1) The basic reserves for the secondary guarantee plus the deficiency reserve, if any, for the secondary guarantees; or

(2) The minimum reserves required by other rules or rules governing universal life plans.

APPENDIX 1

SELECT MORTALITY FACTORS

This appendix contains tables of select mortality factors that are the bases to which the respective percentage of Ins 3504.01 (a) (2), Ins 3504.02 (a) (2), and Ins 3504.02 (a) (3) are applied.

The six tables of select mortality factors contained herein include:

(1) male aggregate,

(2) male nonsmoker,

(3) male smoker,

(4) female aggregate,

(5) female nonsmoker, and

(6) female smoker.

These tables apply to both age last birthday and age nearest birthday mortality tables.

For sex-blended mortality tables, compute select mortality factors in the same proportion as the underlying mortality. For example, for the 1980 CSO-B Table, the calculated select mortality factors are eighty percent (80%) of the appropriate male table in this Appendix, plus twenty percent (20%) of the appropriate female table in this Appendix.

Appendix

SELECT MORTALITY FACTORS

Male, Aggregate

Issue Duration

Age

20+

0-15

100

Male, Aggregate

Issue Duration

Age

20+

100

Male, Aggregate

Issue Duration

Age

20+

100

85+

100

Male, Non-Smoker

Issue Duration

Age

20+

0-15

100

Male, Non-Smoker

Issue Duration

Age

20+

100

Male, Non-Smoker

Issue Duration

Age

20+

100

85+

100

Male, Smoker

Issue Duration

Age

20+

0-15

100

Male, Smoker

Issue Duration

Age

20+

100

Male, Smoker

Issue Duration

Age

20+

100

85+

100

Female, Aggregate

Issue Duration

Age

20+

0-15

100

Female, Aggregate

Issue Duration

Age

20+

100

Female, Aggregate

Issue Duration

Age

20+

100

85+

100

Female, Non-Smoker

Issue Duration

Age

20+

0-15

100

Female, Non-Smoker

Issue Duration

Age

20+

100

37`

100

344

100

Female, Non-Smoker

Issue Duration

Age

20+

100

85+

100

Female, Smoker

Issue Duration

Age

20+

0-15

100

Female, Smoker

Issue Duration

Age

20+

100

Female, Smoker

Issue Duration

Age

20+

100

85+

100

History

#7419, eff 7-1-01; ss by # 9516, eff 7-25-09; ss by #12219, eff 7-25-17

Part Ins 3507 Recognition of the 2001 Cso Mortality Table for Use in Determining Minimum Reserve Liabilities and Nonforfeiture Benefits

N.H. Code Admin. R. Ann. Ins 3507.01 Purpose {#sec-ins-3507.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3507.01}

The purpose of this part is to recognize, permit, and prescribe the use of the 2001 Commissioners' Standard Ordinary (CSO) Mortality Table in accordance with RSA 410:3, I, RSA 409:5-b, VIII(f), Ins 3504.01, and Ins 3504.02.

History

#8144, eff 9-1-04; ss by #10194, eff 10-1-12; ss by #13471, eff 10-24-22

N.H. Code Admin. R. Ann. Ins 3507.02 Definitions Used in This Part {#sec-ins-3507.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3507.02}

(a) "2001 CSO Mortality Table" means that mortality table, consisting of separate rates of mortality for male and female lives, developed by the American Academy of Actuaries CSO Task Force from the Valuation Basic Mortality Table developed by the Society of Actuaries Individual Life Insurance Valuation Mortality Task Force, and adopted by the National Association of Insurance Commissioners (NAIC) in December 2002. The 2001 CSO Mortality Table is included in the proceedings of the NAIC (2nd Quarter 2002). Unless the context indicates otherwise, the "2001 CSO Mortality Table" includes both the ultimate form of that table and the select and ultimate form of that table and includes both the smoker and nonsmoker mortality tables and the composite mortality tables. It also includes both the age-nearest-birthday and age-last-birthday bases of the mortality tables.

(b) "2001 CSO Mortality Table (F)" means that mortality table consisting of the rates of mortality for female lives from the 2001 CSO Mortality Table.

(c) "2001 CSO Mortality Table (M)" means that mortality table consisting of the rates of mortality for male lives from the 2001 CSO Mortality Table.

(d) "Composite mortality tables" means mortality tables with rates of mortality that do not distinguish between smokers and nonsmokers.

(e) "Smoker and nonsmoker mortality tables" means mortality tables with separate rates of mortality for smokers and nonsmokers.

History

#8144, eff 9-1-04; ss by #10194, eff 10-1-12; ss by #13471, eff 10-24-22

N.H. Code Admin. R. Ann. Ins 3507.03 2001 CSO Mortality Table {#sec-ins-3507.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3507.03}

(a) At the election of the company for any one or more specified plans of insurance and subject to the conditions stated in this rule, the 2001 CSO Mortality Table may be used as the minimum standard for policies issued on or after January 1, 2005 and before the date specified in (b) to which RSA 410:3, I, RSA 409:5-b, VIII(f), Ins 3504.01, and Ins 3504.02 are applicable. If the company elects to use the 2001 CSO Mortality Table, it shall do so for both valuation and nonforfeiture purposes.

(b) Subject to the conditions stated in this rule, the 2001 CSO Mortality Table shall be used in determining minimum standards for policies issued on and after January 1, 2009, to which RSA 410:3, I, RSA 409:5-b, VIII(f), Ins 3504.01, and Ins 3504.02 are applicable.

History

#8144, eff 9-1-04; ss by #10194, eff 10-1-12; ss by #13471, eff 10-24-22

N.H. Code Admin. R. Ann. Ins 3507.04 Conditions {#sec-ins-3507.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3507.04}

(a) For each plan of insurance with separate rates for smokers and nonsmokers an insurer may use:

(1) Composite mortality tables to determine minimum reserve liabilities and minimum cash surrender values and amounts of paid-up nonforfeiture benefits;

(2) Smoker and nonsmoker mortality tables to determine the valuation net premiums and additional minimum reserves, if any, required by RSA 410:7 and use composite mortality tables to determine the basic minimum reserves, minimum cash surrender values and amounts of paid-up nonforfeiture benefits; or

(3) Smoker and nonsmoker mortality to determine minimum reserve liabilities and minimum cash surrender values and amounts of paid-up nonforfeiture benefits.

(b) For plans of insurance without separate rates for smokers and nonsmokers the composite mortality tables shall be used.

(c) For the purpose of determining minimum reserve liabilities and minimum cash surrender values and amounts of paid-up nonforfeiture benefits, the 2001 CSO Mortality Table may, at the option of the company for each plan of insurance, be used in its ultimate or select and ultimate form, subject to the restrictions of Ins 3505.01 through Ins 3505.08 relative to use of the select and ultimate form.

(d) When the 2001 CSO Mortality Table is the minimum reserve standard for any plan for a company, the actuarial opinion in the annual statement filed with the commissioner shall be based on an asset adequacy analysis as specified in Ins 2401.05. The commissioner may exempt a company from this requirement if it only does business in this state and in no other state.

History

#8144, eff 9-1-04; ss by #10194, eff 10-1-12; ss by #13471, eff 10-24-22

N.H. Code Admin. R. Ann. Ins 3507.05 Applicability of the 2001 CSO Mortality Table {#sec-ins-3507.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3507.05}

(a) The 2001 CSO Mortality Table may be used in the following manner, subject to the transition dates for use of the 2001 CSO Mortality Table in Ins 3507.03:

(1) Ins 3502.01 (a)(1)b.2.: The net level reserve premium is based on the ultimate mortality rates in the 2001 CSO Mortality Table.

(2) Ins 3503.01 (b): All calculations are made using the 2001 CSO Mortality Rate, and, if elected, the optional minimum mortality standard for deficiency reserves stipulated in Ins 3507.05 (a)(4). The value of "qx+k+t-1" is the valuation mortality rate for deficiency reserves in policy year k+t, but using the unmodified select mortality rates if modified select mortality rates are used in the computation of deficiency reserves.

(3) Ins 3504.01: The 2001 CSO Mortality Table is the minimum standard for basic reserves.

(4) Ins 3504.02: The 2001 CSO Mortality Table is the minimum standard for deficiency reserves. If select mortality rates are used, they may be multiplied by X percent for durations in the first segment, subject to the conditions specified in Ins 3504.02 (a)(3). In demonstrating compliance with those conditions, the demonstrations may not combine the results of tests that utilize the 1980 CSO Mortality Table with those tests that utilize the 2001 CSO Mortality Table, unless the combination is explicitly required by rule or necessary to be in compliance with relevant Actuarial Standards of Practice.

(5) Ins 3505.03: The valuation mortality table used in determining the tabular cost of insurance shall be the ultimate mortality rates in the 2001 CSO Mortality Table.

(6) Ins 3505.05 (a)(4): The calculations specified in Ins 3505.05 shall use the ultimate mortality rates in the 2001 CSO Mortality Table.

(7) Ins 3505.06 (a)(4): The calculations specified in Ins 3505.06 shall use the ultimate mortality rates in the 2001 CSO Mortality Table.

(8) Ins 3505.07 (a)(2): The calculations specified in Ins 3505.07 shall use the ultimate mortality rates in the 2001 CSO Mortality Table.

(9) Ins 3506.01 (a)(2): The one-year valuation premium shall be calculated using the ultimate mortality rates in the 2001 CSO Mortality Table.

(b) Nothing in this section shall be construed to expand the applicability of Ins 3500 to include life insurance policies exempted under Ins 3502.01.

History

#8144, eff 9-1-04; ss by #10194, eff 10-1-12; ss by #13471, eff 10-24-22

N.H. Code Admin. R. Ann. Ins 3507.06 Gender-Blended Tables {#sec-ins-3507.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3507.06}

(a) For any ordinary life insurance policy delivered or issued for delivery in this state on and after January 1, 2005, that utilizes the same premium rates and charges for male and female lives or is issued in circumstances where applicable law does not permit distinctions on the basis of gender, a mortality table that is a blend of the 2001 CSO Mortality Table (M) and the 2001 CSO Mortality Table (F) may, at the option of the company for each plan of insurance, be substituted for the 2001 CSO Mortality Table for use in determining minimum cash surrender values and amounts of paid-up nonforfeiture benefits. No change in minimum valuation standards is implied by this subsection of the rule.

(b) The company may choose from among the blended tables developed by the American Academy of Actuaries CSO Task Force and adopted by the NAIC in December 2002.

(c) It shall not, in and of itself, be a violation of RSA 417 for an insurer to issue the same kind of policy of life insurance on both a sex-distinct and sex-neutral basis.

History

#8144, eff 9-1-04; ss by #10194, eff 10-1-12; ss by #13471, eff 10-24-22

N.H. Code Admin. R. Ann. Ins 3507.07 Waiver or Suspension of Rules {#sec-ins-3507.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3507.07}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

(e) Waivers that are granted shall be in effect for the period of time requested and approved by the commissioner.

History

#13471, eff 10-24-22

Part Ins 3508 Permitting the Recognition of Preferred Mortality Tables for Use in Determining Minimum Reserve Liabilities

N.H. Code Admin. R. Ann. Ins 3508.01 Purpose {#sec-ins-3508.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3508.01}

The purpose of this part is to recognize, permit, and prescribe the use of mortality tables that reflect differences in mortality between preferred and standard lives in determining minimum reserve liabilities in accordance with RSA 410:3, I, RSA 409:5-b, VIII(f), Ins 3504.01,and Ins 3504.02.

History

#8886, eff 6-1-07; ss by #10879, eff 7-10-15; ss by #14509, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3508.02 Definitions {#sec-ins-3508.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3508.02}

(a) "2001 CSO Mortality Table" means that mortality table, consisting of separate rates of mortality for male and female lives, developed by the American Academy of Actuaries CSO Task Force from the Valuation Basic Mortality Table developed by the Society of Actuaries Individual Life Insurance Valuation Mortality Tax Force, and adopted by the National Association of Insurance Commissioners (NAIC) in December 2002. The 2001 CSO Mortality Table is included in the proceedings of the NAIC (2nd Quarter 2002) and supplemented by the 2001 CSO Preferred Class Structure Mortality Table defined in (b) below. Unless the context indicates otherwise, the "2001 CSO Mortality Table" includes both the ultimate form of that table and the select and ultimate form of that table and includes both the smoker and nonsmoker mortality tables and the composite mortality tables. It also includes both the age-nearest-birthday and age-last-birthday bases of the mortality tables. Mortality tables in the 2001 CSO Mortality Table include the following:

(1) "2001 CSO Mortality Table (F)" means that mortality table consisting of the rates of mortality for female lives from the 2001 CSO Mortality Table.

(2) "2001 CSO Mortality Table (M)" means that mortality table consisting of the rates of mortality for male lives from the 2001 CSO Mortality Table.

(3) "Composite mortality tables" means mortality tables with rates of mortality that do not distinguish between smokers and nonsmokers.

(4) "Smoker and nonsmoker mortality tables" means mortality tables with separate rates of mortality for smokers and nonsmokers.

(b) "2001 CSO Preferred Class Structure Mortality Table" means mortality tables with separate rates of mortality for super preferred nonsmokers, preferred nonsmokers, residual standard nonsmokers, preferred smokers, and residual standard smoker splits of the 2001 CSO Nonsmoker and Smoker tables, as adopted by the NAIC at the September, 2006 national meeting and published in the NAIC Proceedings [3rd Quarter 2006]. Unless the context indicates otherwise, the "2001 CSO Preferred Class Structure Mortality Table" includes both the ultimate form of that table and the select and ultimate form of that table. It includes both the smoker and nonsmoker mortality tables. It includes both the male and female mortality tables and the gender composite mortality tables. It also includes both the age-nearest-birthday and age-last-birthday bases of the mortality table.

(c) "Statistical agent" means an entity with proven systems for protecting the confidentiality of individual insured and insurer information; demonstrated resources for and history of ongoing electronic communications and data transfer ensuring data integrity with insurers, which are its members or subscribers; and a history of and means for aggregation of data and accurate promulgation of the experience modifications in a timely manner.

History

#8886, eff 6-1-07; ss by #10879, eff 7-10-15; ss by #14509, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3508.03 2001 CSO Preferred Class Structure Table {#sec-ins-3508.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3508.03}

At the election of the company, for each calendar year of issue, for any one or more specified plans of insurance and subject to satisfying the conditions stated in this part, the 2001 CSO Preferred Class Structure Mortality Table may be substituted in place of the 2001 CSO Smoker or Nonsmoker Mortality Table as the minimum valuation standard for policies issued on or after January 1, 2007. For policies issued on or after September 1, 2004, and prior to January 1, 2007, these tables may be substituted with the consent of the commissioner and subject to the conditions of Ins 3508.04. In determining such consent, the commissioner may rely on the consent of the commissioner of the company’s state of domicile. No such election shall be made until the company demonstrates at least 20% of the business to be valued on this table is in one or more of the preferred classes. A table from the 2001 CSO Preferred Class Structure Mortality Table used in place of a 2001 CSO Mortality Table, pursuant to the requirements of this part, will be treated as part of the 2001 CSO Mortality Table only for purposes of reserve valuation pursuant to the requirements of Ins 3507 “Recognition of the 2001 CSO Mortality Table for Use in Determining Minimum Reserve Liabilities and Nonforfeiture Benefits”.

History

#8886, eff 6-1-07; ss by #10879, eff 7-10-15; ss by #14509, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3508.04 Conditions {#sec-ins-3508.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3508.04}

(a) For each plan of insurance with separate rates for preferred and standard nonsmoker lives, an insurer may use the super preferred nonsmoker, preferred nonsmoker, and residual standard nonsmoker tables to substitute for the nonsmoker mortality table found in the 2001 CSO Mortality Table to determine minimum reserves. At the time of election and annually thereafter, except for business valued under the residual standard nonsmoker table, the appointed actuary shall certify that:

(1) The present value of death benefits over the next 10 years after the valuation date, using the anticipated mortality experience without recognition of mortality improvement beyond the valuation date for each class, is less than the present value of death benefits using the valuation basic table corresponding to the valuation table being used for that class.

(2) The present value of death benefits over the future life of the contracts, using anticipated mortality experience without recognition of mortality improvement beyond the valuation date for each class, is less than the present value of death benefits using the valuation basic table corresponding to the valuation table being used for that class.

(b) For each plan of insurance with separate rates for preferred and standard smoker lives, an insurer may use the preferred smoker and residual standard smoker tables to substitute for the smoker mortality table found in the 2001 CSO Mortality Table to determine minimum reserves. At the time of election and annually thereafter, for business valued under the preferred smoker table, the appointed actuary shall certify that:

(1) The present value of death benefits over the next 10 years after the valuation date, using the anticipated mortality experience without recognition of mortality improvement beyond the valuation date for each class, is less than the present value of death benefits using the preferred smoker valuation basic table corresponding to the valuation table being used for that class.

(c) Unless exempted by the commissioner, every authorized insurer using the 2001 CSO Preferred Class Structure Table shall annually file with the commissioner, with the NAIC, or with a statistical agent designated by the NAIC and acceptable to the commissioner, statistical reports showing mortality and such other information as the commissioner may deem necessary or expedient for the administration of the provisions of this part. The form of the reports shall be established by the commissioner or the commissioner may require the use of a form established by the NAIC or by a statistical agent designated by the NAIC and acceptable to the commissioner.

(d) The use of the 2001 Preferred Class Structure Table for the valuation of policies issued prior to January 1, 2007 shall not be permitted in any statutory financial statement in which a company reports, with respect to any policy or portion of a policy coinsured, either of the following:

(1) In cases where the mode of payment of the reinsurance premium is less frequent than the mode of payment of the policy premium, a reserve credit that exceeds, by more than the amount specified in this paragraph as Y, the gross reserve calculated before reinsurance. Y is the amount of the gross reinsurance premium that:

a. Provides coverage for the period from the next policy premium due date to the earlier of the end of the policy year and the next reinsurance premium due date; and

b. Would be refunded to the ceding entity upon the termination of the policy.

(2) In cases where the mode of payment of the reinsurance premium is more frequent than the mode of payment of the policy premium, a reserve credit that is less than the gross reserve, calculated before reinsurance, by an amount that is less than the amount specified in this paragraph as Z. Z is the amount of the gross reinsurance premium that the ceding entity would need to pay the assuming company to provide reinsurance coverage from the period of the next reinsurance premium due date to the next policy premium due date minus any liability established for the proportionate amount not remitted to the reinsurer.

(e) For purposes of the condition in (d), the reserve for the:

(1) Mean reserve method shall be defined as the mean reserve minus the deferred premium asset, and

(2) Mid-terminal reserve methods shall include the unearned premium reserve.

(f) A company may estimate and adjust its accounting on an aggregate basis in order to meet the conditions to use the 2001 CSO Preferred Class Structure Table.

History

#8886, eff 6-1-07; ss by #10879, eff 7-10-15; ss by #14509, eff 2-7-26, EXPIRES: 2-7-36

Part Ins 3509 Preneed Life Insurance Minimum Standards for Determining Reserve Liabilities and Nonforfeiture Values

N.H. Code Admin. R. Ann. Ins 3509.01 Purpose {#sec-ins-3509.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3509.01}

The purpose of this part is to establish for preneed insurance products minimum mortality standards for reserves and nonforfeiture values, and to require the use of the 1980 Commissioners Standard Ordinary (CSO) Life Valuation Mortality Table for use in determining the minimum standard of valuation of reserves and the minimum standard nonforfeiture values for preneed insurance products.

History

#9245, eff 9-2-08; ss by #11148, eff 9-2-16

N.H. Code Admin. R. Ann. Ins 3509.02 Applicability and Scope {#sec-ins-3509.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3509.02}

This section applies to preneed insurance contracts, as defined in Ins 3509.03, and to similar policies and certificates.

History

#9245, eff 9-2-08; ss by #11148, eff 9-2-16

N.H. Code Admin. R. Ann. Ins 3509.03 Definitions {#sec-ins-3509.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3509.03}

For the purposes of this section:

(a) "2001 CSO Mortality Table" means that mortality table, consisting of separate rates of mortality for male and female lives, developed by the American Academy of Actuaries CSO Task Force from the Valuation Basic Mortality Table developed by the Society of Actuaries Individual Life Insurance Valuation Mortality Task Force, and adopted by the NAIC in December 2002. The 2001 CSO Mortality Table is included in the Proceedings of the NAIC (2nd Quarter 2002) and as referenced in Appendix B. Unless the context indicates otherwise, the "2001 CSO Mortality Table" includes both the ultimate form of that table and the select and ultimate form of that table and includes both the smoker and nonsmoker mortality tables and the composite mortality tables. It also includes both the age-nearest-birthday and the age-last-birthday bases of the mortality tables.

(b) "Ultimate 1980 CSO" means the Commissioners' 1980 Standard Ordinary life Valuation Mortality Tables (1980 CSO) without 10-year selection factors, incorporated into the 1980 amendments to the NAIC Standard Valuation Law approved in December 1983 and as referenced in Appendix B.

(c) "Preneed insurance" means any life insurance policy or certificate that is issued in combination with, in support of, with an assignment to, or as a guarantee for a prearrangement agreement for goods and services to be provided at the time of and immediately following the death of the insured. Goods and services may include, but are not limited to embalming, cremation, body preparation, viewing or visitation, coffin or urn, memorial stone, and transportation of the deceased. The status of the policy or contract as preneed insurance is determined at the time of issue in accordance with the policy form filing.

History

#9245, eff 9-2-08; ss by #11148, eff 9-2-16

N.H. Code Admin. R. Ann. Ins 3509.04 Minimum Valuation Mortality Standards {#sec-ins-3509.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3509.04}

For preneed insurance contracts as defined in Ins 3905.03 (c), and similar policies and contracts, the minimum mortality standard for determining reserve liabilities and non-forfeiture values for both male and female insureds shall be the Ultimate 1980 CSO.

History

#9245, eff 9-2-08; ss by #11148, eff 9-2-16

N.H. Code Admin. R. Ann. Ins 3509.05 Minimum Valuation Interest Rate Standards {#sec-ins-3509.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3509.05}

(a) The interest rates used in determining the minimum standard for valuation of preneed insurance shall be the calendar year statutory valuation interest rates as defined in RSA 410.

(b) The interest rates used in determining the minimum standard for nonforfeiture values for preneed insurance shall be the calendar year statutory nonforfeiture interest rates as defined in RSA 409.

History

#9245, eff 9-2-08; ss by #11148, eff 9-2-16

N.H. Code Admin. R. Ann. Ins 3509.06 Minimum Valuation Method Standards {#sec-ins-3509.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3509.06}

(a) The method used in determining the standard for the minimum valuation of reserves of preneed insurance shall be the method defined in RSA 410.

(b) The method used in determining the standard for the minimum nonforfeiture values for preneed insurance shall be the method defined in RSA 409.

History

#9245, eff 9-2-08; ss by #11148, eff 9-2-16

N.H. Code Admin. R. Ann. Ins 3509.07 Transition Rules {#sec-ins-3509.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3509.07}

(a) For preneed insurance policies issued on or after September 2, 2008 and before January 1, 2012, the 2001 CSO may be used as the minimum standard for reserves and minimum standard for non-forfeiture benefits for both male and female insureds.

(b) If an insurer elects to use the 2001 CSO as a minimum standard for any policy issued on or after September 2, 2008 and before January 1, 2012, the insurer shall provide, as a part of the actuarial opinion memorandum submitted in support of the company's asset adequacy testing, an annual written notification to the domiciliary commissioner. The notification shall include:

(1) A complete list of all preneed forms that use the 2001 CSO as a minimum standard;

(2) A certification signed by the appointed actuary stating that the reserve methodology employed by the company in determining reserves for the preneed policies issued after the effective date and using the 2001 CSO as a minimum standard, develops adequate reserves. For the purposes of this certification, the preneed insurance policies using the 2001 CSO as a minimum standard shall not be aggregated with any other policies; and

(3) Supporting information regarding the adequacy of reserves for preneed insurance policies issued after September 2, 2008 and using the 2001 CSO as a minimum standard for reserves.

(c) Preneed insurance policies issued on or after January 1, 2012, shall use the Ultimate 1980 CSO in the calculation of minimum nonforfeiture values and minimum reserves.

Appendix A- Statutes Implemented

Rule

Specific State or Federal Statutes or Regulations the Rule Implements

Ins 3501.01

RSA 400-A:15, I; 410:3; 408:33

Ins 3502.01

RSA 400-A:15, I; 410:2; 408:33

Ins 3503.01

RSA 400-A:15, I; 410:2, 408:33

Ins 3504.01

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3504.02

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3504.03

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3505.01

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3505.02

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3505.03

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3505.04

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3505.05

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3505.06

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3505.07

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3505.08

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3506.01

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3506.02

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3506.03

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3506.04

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 408:33

Ins 3507.01

RSA 400-A:15; 410:3; RSA 408:33; RSA 409:5-b, VIII(f)(1)-(2)

Ins 3507.02

RSA 410:2; RSA 408:33; RSA 409:5-b; RSA 409:5-c; RSA 409:6-a

Ins 3507.03

RSA 410:4; RSA 410:5; RSA 410:7; RSA 408:33; 409:5-b; 409:5-c; RSA 409:6-a

Ins 3507.04

RSA 410:4; RSA 410:5; RSA 410:7; RSA 408:33; RSA 409:5-b; RSA 409:5-c;

RSA 409:6-a

Ins 3507.05

RSA 410:4; RSA 410:5; RSA 410:7; RSA 408:33; RSA 409:5-b; RSA 409:5-c;

RSA 409:6-a

Ins 3507.06

RSA 410:4; RSA 410:5; RSA 410:7; RSA 408:33; RSA 409:5-b; RSA 409:5-c;

RSA 409:6-a

Ins 3507.07

RSA 400-A:15

Ins 3508.01

RSA 400-A:15, I; RSA 410:3; RSA 408:33; RSA 409:5-b, VIII(f)

Ins 3508.02

RSA 410:2; RSA 408:33; RSA 409:5-b; RSA 409:5-c; RSA 409:6-a

Ins 3508.03

RSA 410:4; RSA 410:5; RSA 410:6; RSA 410:7; RSA 408:33; RSA 409:5-b; RSA 409:5-c; RSA 409:6-a

Ins 3508.04

RSA 410:4; RSA 410:5; RSA 410:6; RSA 410:7; RSA 408:33; RSA 409:5-b; RSA 409:5-c; RSA 409:6-a

Ins 3509.01

RSA 400-A:15, I; 409; 410

Ins 3509.02

RSA 400-A:15, I; 410:2; 409:2; 409:5-b; 409:5-c; 409:6-a

Ins 3509.03

RSA 400-A:15, I; 410:4; 410:5; 410:6; 410:7; 409:2; 409:5-b; 409:5-c; 409:6-a

Ins 3509.04

RSA 400-A:15, I; 410:2; 410:4; 410:5; 410:6; 410:7; 409:5-b; 409:5-c; 409:6-a

Ins 3509.05

RSA 400-A:15, I; 410:2; 410:3-b; 410:4; 410:5; 410:6; 410:7; 409:5-b; 409:5-c; 409:6-a

Ins 3509.06

RSA 400-A:15, I; 410:2; 410:4; 410:5; 410:6; 410:7; 409:5-b; 409:5-c; 409:6-a

Ins 3509.07

RSA 400-A:15, I; 409:5-a; 409:5-b; 409:5-c; 409:6; 409:6-a; 409:8; 410:3-a; 410:3-b

APPENDIX B

Incorporation by Reference Information

Rule

Title

Obtain at:

Ins 3502.01(a)(1)b.2; 3503.01(b); 3503.01(f); 3504.01(a); 3504.02(a); 3505.05(a)(4); 3505.06(a)(4); 3505.07(a)(2); 3506.01(a)(2)

1980 Commissioners’ Standard Ordinary Mortality Table (1980 CSO Table) developed by the Society of Actuaries

Published by Society of Actuaries

Available for no cost at: http://mort.soa.org/

Ins 3504.02(a)(3)i.2

Actuarial Standards of Practice Developed by the Actuarial Standards Board

Published by the Actuarial Standards Board

Available for no cost at:

http://www.actuarialstandardsboard.org/

standards-of-practice/

Ins 3504.01(a)(1); 3504.02(a)(1); 3505.03

Standard Valuation Law adopted by the National Association of Insurance Commissioners (NAIC) in 1980

Published by the NAIC

Available for no cost at:

http://www.naic.org/store/free/MDL-820.pdf

Ins 3509.01;

Ins 509.03(b);

Ins 3509.04;

Ins 3509.07(c)

Ultimate 1980 CSO

On-line, for no cost:

http://www.nh.gov/insurance/legal/documents/1980_cso_table_1980_cet_tbl.pdf

Ins 3509.03(a); Ins 3509.07

2001 CSO Mortality Table

On-line, for no cost: http://www.nh.gov/insurance/legal/documents/2001_cso_2002_naic_proc1153.pdf

History

#9245, eff 9-2-08; ss by #11148, eff 9-2-16

Chapter Ins 3600 Long-Term Care Insurance

Part Ins 3601 Long-Term Care Insurance

N.H. Code Admin. R. Ann. Ins 3601.01 Purpose {#sec-ins-3601.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.01}

The purpose of this rule is to implement RSA 415-D, to promote the public interest, to promote the availability of long-term care insurance coverage, to protect applicants for long-term care insurance, as defined, from unfair or deceptive sales or enrollment practices, to facilitate public understanding and comparison of long-term care insurance coverages, and to facilitate flexibility and innovation in the development of long-term care insurance.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.02 Applicability and Scope {#sec-ins-3601.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.02}

Except as otherwise specifically provided, this rule applies to all long-term care insurance policies, including qualified long-term care contracts and life insurance policies that accelerate benefits for long-term care delivered or issued for delivery in this state on or after the effective date by insurers; fraternal benefit societies; nonprofit health, hospital and medical service corporations; prepaid health plans; health maintenance organizations and all similar organizations. Certain provisions of this rule apply only to qualified long-term care insurance contracts as noted.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.03 Definitions {#sec-ins-3601.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.03}

For the purpose of this rule, the terms “long-term care insurance”, “qualified long-term care insurance”, “group long-term care insurance”, “commissioner”, “applicant”, “policy”, and “certificate” shall have the meanings set forth in RSA 415-D:3. In addition, the following definitions apply:

(a) “Benefit trigger”, for the purposes of independent review, means a contractual provision in the insured’s policy of long-term care insurance, conditioning the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. For purposes of a tax-qualified long-term care insurance contract, as defined in section 7702B of the Internal Revenue Code of 1986, as amended, “benefit trigger” shall include a determination by a licensed health care practitioner that an insured is a chronically ill individual;

(b) (1) “Exceptional increase” means only those increases filed by an insurer as exceptional for which the commissioner determines the need for the premium rate increase is justified due to changes in laws or rules applicable to long-term care coverage in this state;

(2) Except as provided in Ins 3601.19, exceptional increases are subject to the same requirements as other premium rate schedule increases;

(3) The commissioner may request a review by an independent actuary or a professional actuarial body of the basis for a request that an increase be considered an exceptional increase; and

(4) The commissioner, in determining that the necessary basis for an exceptional increase exists, shall also determine any potential offsets to higher claims costs;

(c) “Incidental”, as used in Ins 3601.19(k), means that the value of the long-term care benefits provided is less than 10 percent of the total value of the benefits provided over the life of the policy. These values shall be measured as of the date of issue;

(d) “Independent review organization” means an organization that conducts independent review of long-term care benefit trigger decisions;

(e) “Licensed health care professional” means an individual qualified by education and experience in an appropriate field to determine, by record review, an insured’s actual functional or cognitive impairment;

(f) “Qualified actuary” means a member in good standing of the American Academy of Actuaries; and

(g) “Similar policy forms” means all of the long-term care insurance policies and certificates issued by an insurer in the same long-term care benefit classification as the policy form being considered. Certificates of groups that meet the definition in RSA 415-D:3, IV(a) are not considered similar to certificates or policies otherwise issued as long-term care insurance but are similar to other comparable certificates with the same long-term care benefit classifications. For purposes of determining similar policy forms, long-term care benefit classifications are defined as follows: institutional long-term care benefits only, non-institutional long-term care benefits only, or comprehensive long-term care benefits.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; amd by #10782, eff 2-13-15; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.04 Policy Definitions {#sec-ins-3601.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.04}

No long-term care insurance policy delivered or issued for delivery in this state shall use the terms set forth below, unless the terms are defined in the policy and the definitions satisfy the following requirements:

(a) “Activities of daily living” means at least bathing, continence, dressing, eating, toileting, and transferring;

(b) “Acute condition” means that the individual is medically unstable. Such an individual requires frequent monitoring by medical professionals, such as physicians and registered nurses, in order to maintain his or her health status;

(c) “Adult day care” means a program for 6 or more individuals of social and health-related services provided during the day in a community group setting for the purpose of supporting frail, impaired elderly, or other disabled adults who can benefit from care in a group setting outside the home;

(d) “Bathing” means washing oneself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower;

(e) “Cognitive impairment” means a deficiency in a person's short or long-term memory, orientation as to person, place, and time, deductive or abstract reasoning, or judgment as it relates to safety awareness;

(f) “Continence” means the ability to maintain control of bowel or bladder function or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag);

(g) “Dressing” means putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs;

(h) “Eating” means feeding oneself by getting food into the body from a receptacle (such as a plate, cup, or table) or by a feeding tube or intravenously;

(i) “Hands-on assistance” means physical assistance (minimal, moderate, or maximal) without which the individual would not be able to perform the activity of daily living;

(j) “Home health care services” means medical and nonmedical services provided to ill, disabled, or infirm persons in their residences. Such services may include homemaker services, assistance with activities of daily living, and respite care services;

(k) “Medicare” means “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended” or “Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof”, or words of similar import;

(l) “Mental or nervous disorder” shall not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder;

(m) “Personal care” means the provision of hands-on services to assist an individual with activities of daily living;

(n) “Skilled nursing care”, “personal care”, “home care”, “specialized care”, “assisted living care”, and other services shall be defined in relation to the level of skill required, the nature of the care, and the setting in which care must be delivered;

(o) “Toileting” means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene;

(p) “Transferring” means moving into or out of bed, chair, or wheelchair; and

(q) All providers of services, including but not limited to “skilled nursing facility”, “extended care facility”, “convalescent nursing home”, “personal care facility”, “specialized care providers”, “assisted living facility”, and “home care agency” shall be defined in relation to the services and facilities required to be available and the licensure, certification, registration, or degree status of those providing or supervising the services. When the definition requires that the provider be appropriately licensed, certified, or registered, it shall also state what requirements a provider must meet in lieu of licensure, certification, or registration when the state in which the service is to be furnished does not require a provider of these services to be licensed, certified or registered, or when the state licenses, certifies, or registers the provider of services under another name.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.05 Policy Practices and Provisions {#sec-ins-3601.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.05}

(a) Renewability. The terms “guaranteed renewable” and “noncancellable” shall not be used in any individual long-term care insurance policy without further explanatory language in accordance with the disclosure requirements of Ins 3601.08.

(1) A policy issued to an individual shall not contain renewal provisions other than “guaranteed renewable” or “noncancellable”;

(2) The term “guaranteed renewable” may be used only when the insured has the right to continue the long-term care insurance in force by the timely payment of premiums and when the insurer has no unilateral right to make any change in any provision of the policy or rider while the insurance is in force, and cannot decline to renew, except that rates may be revised by the insurer on a class basis;

(3) The term “noncancellable” may be used only when the insured has the right to continue the long-term care insurance in force by the timely payment of premiums during which period the insurer has no right to unilaterally make any change in any provision of the insurance or in the premium rate;

(4) The term “level premium” may only be used when the insurer does not have the right to change the premium; and

(5) In addition to the other requirements of this paragraph, a qualified long-term care insurance contract shall be guaranteed renewable, within the meaning of Section 7702B(b)(1)(C) of the Internal Revenue Code of 1986, as amended.

(b) Limitations and Exclusions. A policy may not be delivered or issued for delivery in this state as long-term care insurance if the policy limits or excludes coverage by type of illness, treatment, medical condition, or accident, except as follows:

(1) Preexisting conditions or diseases;

(2) Mental or nervous disorders; however, this shall not permit exclusion or limitation of benefits on the basis of Alzheimer's Disease;

(3) Alcoholism and drug addiction;

(4) Illness, treatment, or medical condition arising out of:

a. War or act of war (whether declared or undeclared);

b. Participation in a felony, riot, or insurrection;

c. Service in the armed forces or units auxiliary thereto;

d. Suicide (sane or insane), attempted suicide, or intentionally self-inflicted injury; or

e. Aviation (this exclusion applies only to non-fare-paying passengers);

(5) Treatment provided in a government facility (unless otherwise required by law), services for which benefits are available under Medicare or other governmental program (except Medicaid), any state or federal workers’ compensation, employer’s liability, or occupational disease law, or any motor vehicle no-fault law, services provided by a member of the covered person’s immediate family, and services for which no charge is normally made in the absence of insurance;

(6) Expenses for services or items available or paid under another long-term care insurance or health insurance policy;

(7) In the case of a qualified long-term care insurance contract, expenses for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act or would be so reimbursable but for the application of a deductible or coinsurance amount;

(8) a. This paragraph is not intended to prohibit exclusions and limitations by type of provider. However, no long-term care issuer may deny a claim because services are provided in a state other than the state of policy issued under the following conditions:

When the state other than the state of policy issue does not have the provider licensing, certification, or registration required in the policy, but where the provider satisfies the policy requirements outlined for providers in lieu of licensure, certification, or registration; or
When the state other than the state of policy issue licenses, certifies, or registers the provider under another name; and

b. For purposes of this paragraph, “state of policy issue” means the state in which the individual policy or certificate was originally issued; and

(9) This paragraph is not intended to prohibit territorial limitations.

(c) Extension of Benefits. Termination of long-term care insurance shall be without prejudice to any benefits payable for institutionalization if the institutionalization began while the long-term care insurance was in force and continues without interruption after termination. The extension of benefits beyond the period the long-term care insurance was in force may be limited to the duration of the benefit period, if any, or to payment of the maximum benefits and may be subject to any policy waiting period and all other applicable provisions of the policy.

(d) Continuation or Conversion.

(1) Group long-term care insurance issued in this state on or after the effective date of this section shall provide covered individuals with a basis for continuation or conversion of coverage;

(2) For the purposes of this section, “a basis for continuation of coverage” means a policy provision that maintains coverage under the existing group policy when the coverage would otherwise terminate and which is subject only to the continued timely payment of premium when due. Group policies that restrict provision of benefits and services to, or contain incentives to use certain providers or facilities may provide continuation benefits that are substantially equivalent to the benefits of the existing group policy. The commissioner shall make a determination as to the substantial equivalency of benefits and, in doing so, shall take into consideration the differences between managed care and non-managed care plans, including, but not limited to, provider system arrangements, service availability, benefit levels, and administrative complexity;

(3) For the purposes of this section, “a basis for conversion of coverage” means a policy provision that an individual whose coverage under the group policy would otherwise terminate or has been terminated for any reasons, including discontinuance of the group policy in its entirety or with respect to an insured class, and who has been continuously insured under the group policy (and any group policy which it replaced) for at least six months immediately prior to termination, shall be entitled to the issuance of a converted policy by the insurer under whose group policy he or she is covered, without evidence of insurability;

(4) For the purpose of this section, “converted policy” means an individual policy of long-term care insurance providing benefits identical to, or benefits determined by the commissioner to be substantially equivalent to, or in excess of those provided under the group policy from which conversion is made. Where the group policy from which conversion is made restricts provision of benefits and services to, or contains incentives to use certain providers or facilities, the commissioner, in making a determination as to the substantial equivalency of benefits, shall take into consideration the differences between managed care and non-managed care plans, including, but not limited to, provider system arrangements, service availability, benefits levels, and administrative complexity;

(5) Written application for the converted policy shall be made and the first premium due, if any, shall be paid as directed by the insurer not later than 31 days after termination of coverage under the group policy. The converted policy shall be issued effective on the day following the termination of coverage under the group policy and shall be renewable annually;

(6) Unless the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated on the basis of the insured’s age at inception of coverage under the group policy from which conversion is made. Where the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated on the basis of the insured’s age at inception of coverage under the group policy replaced;

(7) Continuation of coverage or issuance of a converted policy shall be mandatory, except where:

a. Termination of group coverage resulted from an individual’s failure to make any required payment of premium or contribution when due; or

b. The terminating coverage is replaced, not later than 31 days after termination, by group coverage effective on the day following the termination of coverage:

Providing benefits identical to or benefits determined by the commissioner to be substantially equivalent to or in excess of those provided by the terminating coverage; and
The premium for which is calculated in a manner consistent with the requirements of subparagraph (6) of this paragraph;

(8) Notwithstanding any other provision of this section, a converted policy issued to an individual who, at the time of conversion is covered by another long-term care insurance policy that provides benefits on the basis of incurred expenses, may contain a provision that results in a reduction of benefits payable if the benefits provided under the additional coverage, together with the full benefits provided by the converted policy, would result in payment of more than 100 percent of incurred expenses. The provision shall only be included in the converted policy if the converted policy also provides for a premium decrease or refund which reflects the reduction in benefits payable;

(9) The converted policy may provide that benefits payable under the converted policy, together with the benefits payable under the group policy from which conversion is made, shall not exceed those that would have been payable had the individual's coverage under the group policy remained in force and effect;

(10) Notwithstanding any other provision of this section, an insured individual whose eligibility for group long-term care coverage is based upon his or her relationship to another person shall be entitled to continuation of coverage under the group policy upon termination of the qualifying relationship by death or dissolution of marriage; and

(11) For the purposes of this section, a “managed-care plan” is a health care or assisted living arrangement designed to coordinate patient care or control costs through utilization review, case management, or use of specific provider networks.

(e) Discontinuance and Replacement. If a group long-term care policy is replaced by another group long-term care policy issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group policy on its date of termination. Coverage provided or offered to individuals by the insurer and premiums charged to persons under the new group policy:

(1) Shall not result in an exclusion for preexisting conditions that would have been covered under the group policy being replaced; and

(2) Shall not vary or otherwise depend on the individual's health or disability status, claim experience, or use of long-term care services.

(f) (1) The premium charged to an insured shall not increase due to either:

a. The increasing age of the insured at ages beyond 65; or

b. The duration the insured has been covered under the policy;

(2) The purchase of additional coverage shall not be considered a premium rate increase, but for purposes of the calculation required under Ins 3601.25, the portion of the premium attributable to the additional coverage shall be added to and considered part of the initial annual premium; and

(3) A reduction in benefits shall not be considered a premium change, but for purpose of the calculation required under Ins 3601.25, the initial annual premium shall be based on the reduced benefits.

(g) Electronic Enrollment for Group Policies.

(1) In the case of a group defined in RSA 415-D:3 IV(a), any requirement that a signature of an insured be obtained by an agent or insurer shall be deemed satisfied if:

a. The consent is obtained by telephonic or electronic enrollment by the group policyholder or insurer. A verification of enrollment information shall be provided to the enrollee;

b. The telephonic or electronic enrollment provides necessary and reasonable safeguards to assure the accuracy, retention and prompt retrieval of records; and

c. The telephonic or electronic enrollment provides necessary and reasonable safeguards to assure that the confidentiality of individually identifiable information as defined by Ins 3001.04(v) is maintained; and

(2) The insurer shall make available, upon request of the commissioner, records that will demonstrate the insurer's ability to confirm enrollment and coverage amounts.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.06 Unintentional Lapse {#sec-ins-3601.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.06}

Each insurer offering long-term care insurance shall, as a protection against unintentional lapse, comply with the following:

(a) (1) Notice before lapse or termination. No individual long-term care policy or certificate shall be issued until the insurer has received from the applicant either a written designation of at least one person, in addition to the applicant, who is to receive notice of lapse or termination of the policy or certificate for nonpayment of premium, or a written waiver dated and signed by the applicant electing not to designate additional persons to receive notice. The applicant has the right to designate at least one person who is to receive the notice of termination, in addition to the insured. Designation shall not constitute acceptance of any liability on the third party for services provided to the insured. The form used for the written designation shall provide space clearly designated for listing at least one person. The designation shall include each person's full name and home address. In the case of an applicant who elects not to designate an additional person, the waiver shall state: “Protection against unintended lapse. I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long-term care insurance policy for nonpayment of premium. I understand that notice will not be given until 30 days after a premium is due and unpaid. I elect NOT to designate a person to receive this notice." The insurer shall notify the insured of the right to change this written designation, no less often than once every 2 years;

(2) When the policyholder or certificateholder pays premium for a long-term care insurance policy or certificate through a payroll or pension deduction plan, the requirements contained in subparagraph (a)(1) need not be met until 60 days after the policyholder or certificateholder is no longer on such a payment plan. The application or enrollment form for such policies or certificates shall clearly indicate the payment plan selected by the applicant; and

(3) Lapse or termination for nonpayment of premium. No individual long-term care policy or certificate shall lapse or be terminated for nonpayment of premium unless the insurer, at least 30 days before the effective date of the lapse or termination, has given notice to the insured and to those persons designated pursuant to subparagrpah (a)(1), at the address provided by the insured for purposes of receiving notice of lapse or termination. Notice shall be given by first class United States mail, postage prepaid; and notice may not be given until 30 days after a premium is due and unpaid. Notice shall be deemed to have been given as of 5 days after the date of mailing.

(b) Reinstatement. In addition to the requirement in paragraph (a), a long-term care insurance policy or certificate shall include a provision that provides for reinstatement of coverage, in the event of lapse, if the insurer is provided proof that the policyholder or certificateholder was cognitively impaired or had a loss of functional capacity before the grace period contained in the policy expired. This option shall be available to the insured if requested within 5 months after termination and shall allow for the collection of past due premium, where appropriate. The standard of proof of cognitive impairment or loss of functional capacity shall not be more stringent than the benefit eligibility criteria on cognitive impairment or the loss of functional capacity contained in the policy and certificate.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.07 Required Disclosure Provisions {#sec-ins-3601.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.07}

(a) Renewability. Individual long-term care insurance policies shall contain a renewability provision:

(1) The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state that the coverage is guaranteed renewable or noncancellable. This provision shall not apply to policies that do not contain a renewability provision and under which the right to nonrenew is reserved solely to the policyholder; and

(2) A long-term care insurance policy or certificate, other than one where the insurer does not have the right to change the premium, shall include a statement that premium rates may change.

(b) Riders and Endorsements. Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under the individual long-term care insurance policy, all riders or endorsements added to an individual long-term care insurance policy after date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the individual insured. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, except if the increased benefits or coverage are required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy, rider, or endorsement.

(c) Payment of Benefits. A long-term care insurance policy that provides for the payment of benefits based on standards described as “usual and customary”, “reasonable and customary”, or words of similar import shall include a definition of these terms and an explanation of the terms in its accompanying outline of coverage.

(d) Limitations. If a long-term care insurance policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy or certificate and shall be labeled as “Preexisting Condition Limitations”.

(e) Other Limitations or Conditions on Eligibility for Benefits. A long-term care insurance policy or certificate containing any limitations or conditions for eligibility other than those prohibited in RSA 415-D:5 IV(b), (c) and (d) shall set forth a description of the limitations or conditions, including any required number of days of confinement, in a separate paragraph of the policy or certificate and shall label such paragraph “Limitations or Conditions on Eligibility for Benefits”.

(f) Disclosure of Tax Consequences. With regard to life insurance policies that provide an accelerated benefit for long-term care, a disclosure statement is required at the time of application for the policy or rider and at the time the accelerated benefit payment request is submitted that receipt of these accelerated benefits may be taxable, and that assistance should be sought from a personal tax advisor. The disclosure statement shall be prominently displayed on the first page of the policy or rider and any other related documents. This paragraph shall not apply to qualified long-term care insurance contracts.

(g) Benefit Triggers. Activities of daily living and cognitive impairment shall be used to measure an insured’s need for long-term care and shall be described in the policy or certificate in a separate paragraph and shall be labeled “Eligibility for the Payment of Benefits”. Any additional benefit triggers shall also be explained in this section. If these triggers differ for different benefits, explanation of the trigger shall accompany each benefit description. If an attending physician or other specified person must certify a certain level of functional dependency in order to be eligible for benefits, this too shall be specified.

(h) A qualified long-term care insurance contract shall include a disclosure statement in the policy and in the outline of coverage, as contained in Ins 3601.32(e)3., that the policy is intended to be a qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.

(i) A nonqualified long-term care insurance contract shall include a disclosure statement in the policy and in the outline of coverage, as contained in Ins 3601.32(e)3., that the policy is not intended to be a qualified long-term care insurance contract.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.08 Required Disclosure of Rating Practices to Consumers {#sec-ins-3601.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.08}

(a) This section shall apply as follows:

(1) Except as provided in (2) below, this section applies to any long-term care policy or certificate issued in this state on or after the effective date of this rule; and

(2) For certificates issued on or after the effective date of this amended rule under a group long-term care insurance policy as defined in RSA 415-D:3 IV(a), which policy was in force at the time this amended rule became effective, the provisions of this section shall apply on the policy anniversary following 12 months after the effective date of this amended rule.

(b) Other than policies for which no applicable premium rate or rate schedule increases can be made, insurers shall provide all of the information listed in this paragraph to the applicant at the time of application or enrollment, unless the method of application does not allow for delivery at that time. In such a case, an insurer shall provide all of the information listed below to the applicant no later than at the time of delivery of the policy or certificate:

(1) A statement that the policy may be subject to rate increases in the future;

(2) An explanation of potential future premium rate revisions, and the policyholder’s or certificateholder’s option in the event of a premium rate revision;

(3) The premium rate or rate schedules applicable to the applicant that will be in effect until a request is made for an increase;

(4) A general explanation for applying premium rate or rate schedule adjustments that shall include:

a. A description of when premium rate or rate schedule adjustments will be effective (e.g., next anniversary date, next billing date, etc.); and

b. The right to a revised premium rate or rate schedule as provided in paragraph (3) if the premium rate or rate schedule is changed; and

(5) a. Information regarding each premium rate increase on this policy form or similar policy forms over the past 10 years for this state or any other state that, at a minimum, identifies:

The policy forms for which premium rates have been increased;
The calendar years when the form was available for purchase; and
The amount or percent of each increase. The percentage may be expressed as a percentage of the premium rate prior to the increase, and may also be expressed as minimum and maximum percentages if the rate increase is variable by rating characteristics;

b. The insurer may, in a fair manner, provide additional explanatory information related to the rate increases;

c. An insurer shall have the right to exclude from the disclosure premium rate increases that only apply to blocks of business acquired from other nonaffiliated insurers or the long-term care policies acquired from other nonaffiliated insurers when those increases occurred prior to the acquisition;

d. If an acquiring insurer files for a rate increase on a long-term care policy form acquired from nonaffiliated insurers or a block of policy forms acquired from nonaffiliated insurers on or before the later of the effective date of this section or the end of a 24 month period following the acquisition of the block or policies, the acquiring insurer may exclude that rate increase from the disclosure. However, the nonaffiliated selling company shall include the disclosure of that rate increase in accordance with clause a. of this subparagraph; and

e. If the acquiring insurer in clause d. above files for a subsequent rate increase, even within the 24 month period, on the same policy form acquired from nonaffiliated insurers or block of policy forms acquired from nonaffiliated insurers referenced in clause d., the acquiring insurer shall make all disclosures required by this subparagraph (5), including disclosure of the earlier rate increases referenced in clause d.

(c) An applicant shall sign an acknowledgement at the time of application, unless the method of application does not allow for signature at that time, that the insurer made the disclosure required under (b)(1) and (5) above. If, due to the method of application, the applicant cannot sign an acknowledgement at the time of application, the applicant shall sign no later than at the time of delivery of the policy or certificate.

(d) An insurer shall use the forms in Appendices B and F to comply with the requirements of (b) and (c) of this section.

(e) An insurer shall provide notice of an upcoming premium rate schedule increase to all policyholders or certificateholders, if applicable, at least 45 days prior to the implementation of the premium rate schedule increase by the insurer. The notice shall:

(1) Include the information required by paragraph (b) when the rate increase is implemented;

(2) Include available benefit reduction and other rate increase mitigation options; and

(3) Address the guaranteed renewable nature of the policy so that the insured shall understand that the premium rates may increase again in the future.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; amd by #10782, eff 2-13-152; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.09 Initial Filing Requirements {#sec-ins-3601.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.09}

(a) This section applies to any long-term care policy issued in this state on or after the effective date of this rule.

(b) An insurer shall provide the information listed in this paragraph to the commissioner 30 days prior to making a long-term care insurance form available for sale:

(1) A copy of the disclosure documents required in Ins 3601.08; and

(2) An actuarial certification consisting of at least the following:

a. A statement that the initial premium rate schedule is sufficient to cover anticipated costs under moderately adverse experience and that the premium rate schedule is reasonably expected to be sustainable over the life of the form with no future premium increases anticipated;

b. A statement that the policy design and coverage provided have been reviewed and taken into consideration;

c. A statement that the underwriting and claims adjudication processes have been reviewed and taken into consideration;

d. A complete description of the basis for contract reserves that are anticipated to be held under the form, to include:

Sufficient detail or sample calculations provided so as to have a complete depiction of the reserve amounts to be held;
A statement that the assumptions used for reserves contain reasonable margins for adverse experience;
A statement that the net valuation premium for renewal years does not increase (except for attained-age rating where permitted); and
A statement that the difference between the gross premium and the net valuation premium for renewal years is sufficient to cover expected renewal expenses; or if such a statement cannot be made, a complete description of the situations where this does not occur;

(i) An aggregate distribution of anticipated issues may be used as long as the underlying gross premiums maintain a reasonably consistent relationship;

(ii) If the gross premiums for certain age groups appear to be inconsistent with this requirement, the commissioner may request a demonstration under (c) based on a standard age distribution; and

e. 1. A statement that the premium rate schedule is not less than the premium rate schedule for existing similar policy forms also available from the insurer except for reasonable differences attributable to benefits; or

A comparison of the premium schedules for similar policy forms that are currently available from the insurer with an explanation of the differences.

(c) (1) The commissioner may request an actuarial demonstration that benefits are reasonable in relation to premiums. The actuarial demonstration shall include either premium and claim experience on similar policy forms, adjusted for any premium or benefit differences, relevant and credible data from other studies, or both; and

(2) In the event the commissioner asks for additional information under this provision, the period in (b) above does not include the period during which the insurer is preparing the requested information.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.10 Prohibition Against Post-Claims Underwriting {#sec-ins-3601.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.10}

(a) All applications for long-term care insurance policies or certificates, except those that are guaranteed issue, shall contain clear and unambiguous questions designed to ascertain the health condition of the applicant.

(b) (1) If an application for long-term care insurance contains a question that asks whether the applicant has had medication prescribed by a physician, it shall also ask the applicant to list the medication that has been prescribed; and

(2) If the medications listed in the application were known by the insurer, or should have been known at the time of application, to be directly related to a medical condition for which coverage would otherwise be denied, then the policy or certificate shall not be rescinded for that condition.

(1) The following language shall be set out conspicuously and in close conjunction with the applicant's signature block on an application for a long-term care insurance policy or certificate:

“Caution: If your answers on this application are incorrect or untrue, [company] has the right to deny benefits or rescind your policy.”;

(2) The following language, or language substantially similar to the following, shall be set out conspicuously on the long-term care insurance policy or certificate at the time of delivery:

“Caution: The issuance of this long-term care insurance [policy] [certificate] is based upon your responses to the questions on your application. A copy of your [application] [enrollment form] [is enclosed] [was retained by you when you applied]. If your answers are incorrect or untrue, the company has the right to deny benefits or rescind your policy. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers are incorrect, contact the company at this address: [insert address]”;

(3) Prior to issuance of a long-term care policy or certificate to an applicant age 80 or older, the insurer shall obtain one of the following:

a. A report of a physical examination;

b. An assessment of functional capacity;

c. An attending physician's statement; or

d. Copies of medical records;

(4) A copy of the completed application or enrollment form (whichever is applicable) shall be delivered to the insured no later than at the time of delivery of the policy or certificate unless it was retained by the applicant at the time of application; and

(5) Every insurer or other entity selling or issuing long-term care insurance benefits shall maintain a record of all policy or certificate rescissions, both state and countrywide, except those that the insured voluntarily effectuated and shall annually furnish this information to the insurance commissioner in the format prescribed by the National Association of Insurance Commissioners in Appendix A.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.11 Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies {#sec-ins-3601.11 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.11}

(a) A long-term care insurance policy or certificate shall not, if it provides benefits for home health care or community care services, limit or exclude benefits:

(1) By requiring that the insured or claimant would need care in a skilled nursing facility if home health care services were not provided;

(2) By requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services, or both, in a home, community, or institutional setting before home health care services are covered;

(3) By limiting eligible services to services provided by registered nurses or licensed practical nurses;

(4) By requiring that a nurse or therapist provide services covered by the policy that can be provided by a home health aide, or other licensed or certified home care worker acting within the scope of his or her licensure or certification;

(5) By excluding coverage for personal care services provided by a home health aide;

(6) By requiring that the provision of home health care services be at a level of certification or licensure greater than that required by the eligible service;

(7) By requiring that the insured or claimant have an acute condition before home health care services are covered;

(8) By limiting benefits to services provided by Medicare-certified agencies or providers; or

(9) By excluding coverage for adult day care services.

(b) A long-term care insurance policy or certificate, if it provides for home health or community care services, shall provide total home health or community care coverage that is a dollar amount equivalent to at least one-half of one year's coverage available for nursing home benefits under the policy or certificate, at the time covered home health or community care services are being received. This requirement shall not apply to policies or certificates issued to residents of continuing care retirement communities.

(c) Home health care coverage may be applied to the nonhome health care benefits provided in the policy or certificate when determining maximum coverage under the terms of the policy or certificate.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.12 Requirement to Offer Inflation Protection {#sec-ins-3601.12 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.12}

(a) No insurer may offer a long-term care insurance policy unless the insurer also offers to the policyholder in addition to any other inflation protection the option to purchase a policy that provides for benefit levels to increase with benefit maximums or reasonable durations which are meaningful to account for reasonably anticipated increases in the costs of long-term care services covered by the policy. Insurers shall offer to each policyholder, at the time of purchase, the option to purchase a policy with an inflation protection feature no less favorable than one of the following:

(1) Increases benefit levels annually in a manner so that the increases are compounded annually at a rate of not less than 5 percent;

(2) Guarantees the insured individual the right to periodically increase benefit levels without providing evidence of insurability or health status so long as the option for the previous period has not been declined. The amount of the additional benefit shall be no less than the difference between the existing policy benefit and that benefit compounded annually at a rate of at least 5 percent for the period beginning with the purchase of the existing benefit and extending until the year in which the offer is made; or

(3) Covers a specified percentage of actual or reasonable charges and does not include a maximum specified indemnity amount or limit.

(b) Where the policy is issued to a group, the required offer in (a) above shall be made to the group policyholder; except, if the policy is issued to a group defined in RSA 415-D:3 IV(d) other than to a continuing care retirement community, the offering shall be made to each proposed certificateholder.

(c) The offer in (a) above shall not be required of life insurance policies or riders containing accelerated long-term care benefits.

(d) (1) Insurers shall include the following information in or with the outline of coverage:

a. A graphic comparison of the benefit levels of a policy that increases benefits over the policy period with a policy that does not increase benefits. The graphic comparison shall show benefit levels over at least a 20 year period; and

b. Any expected premium increases or additional premiums to pay for automatic or optional benefit increases; and

(2) An insurer may use a reasonable hypothetical, or a graphic demonstration, for the purposes of this disclosure.

(e) Inflation protection benefit increases under a policy which contains these benefits shall continue without regard to an insured's age, claim status, or claim history, or the length of time the person has been insured under the policy.

(f) An offer of inflation protection that provides for automatic benefit increases shall include an offer of a premium which the insurer expects to remain constant. The offer shall disclose in a conspicuous manner that the premium may change in the future unless the premium is guaranteed to remain constant.

(g) (1) Inflation protection as provided in (a)(1) of this section shall be included in a long-term care insurance policy unless an insurer obtains a rejection of inflation protection signed by the policyholder as required in this paragraph. The rejection may be either in the application or on a separate form; and

(2) The rejection shall be considered a part of the application and shall state:

“I have reviewed the outline of coverage and the graphs that compare the benefits and premiums of this policy with and without inflation protection. Specifically, I have reviewed Plans _______, and I reject inflation protection.”

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.13 Requirements for Application Forms and Replacement Coverage {#sec-ins-3601.13 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.13}

(a) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has another long-term care insurance policy or certificate in force or whether a long-term care policy or certificate is intended to replace any other accident and sickness or long-term care policy or certificate presently in force. A supplementary application or other form to be signed by the applicant and producer, except where the coverage is sold without a producer, containing the questions may be used. With regard to a replacement policy issued to a group defined by RSA 415-D:3, IV(a), the following questions may be modified only to the extent necessary to elicit information about health or long-term care insurance policies other than the group policy being replaced, provided that the certificateholder has been notified of the replacement:

(1) Do you have another long-term care insurance policy or certificate in force (including health care service contract, health maintenance organization contract)?

(2) Did you have another long-term care insurance policy or certificate in force during the last 12 months?

a. If so, with which company?

b. If that policy lapsed, when did it lapse?

(3) Are you covered by Medicaid?

(4) Do you intend to replace any of your medical or health insurance coverage with this policy (certificate)?

(b) Producers shall list any other health insurance policies they have sold to the applicant:

(1) List policies that are still in force; and

(2) List policies sold in the past 5 years that are no longer in force.

(c) Solicitations Other than Direct Response. Upon determining that a sale will involve replacement, an insurer, other than an insurer using direct response solicitation methods, or its producer, shall furnish the applicant, prior to issuance or delivery of the individual long-term care insurance policy, a notice regarding replacement of accident and sickness or long-term care coverage. One copy of the notice shall be retained by the applicant and an additional copy signed by the applicant shall be retained by the insurer. The required notice shall be provided in the following manner:

“NOTICE TO APPLICANT REGARDING REPLACEMENT

OF INDIVIDUAL ACCIDENT AND SICKNESS OR LONG-TERM CARE INSURANCE

[Insurance company's name and address]

SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE

According to [your application] [information you have furnished], you intend to lapse or otherwise terminate existing accident and sickness or long-term care insurance and replace it with an individual long-term care insurance policy to be issued by [company name] Insurance Company. Your new policy provides 30 days within which you may decide, without cost, whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

You should review this new coverage carefully, comparing it with all accident and sickness or long-term care insurance coverage you now have, and terminate your present policy only if, after due consideration, you find that purchase of this long-term care coverage is a wise decision.

STATEMENT TO APPLICANT BY PRODUCER OR OTHER REPRESENTATIVE

(Use additional sheets, as necessary)

I have reviewed your current medical or health insurance coverage. I believe the replacement of insurance involved in this transaction materially improves your position. My conclusion has taken into account the following considerations, which I call to your attention:

Health conditions that you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.
State law provides that your replacement policy or certificate may not contain new preexisting conditions or probationary periods. The insurer will waive any time periods applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
If you are replacing existing long-term care insurance coverage, you may wish to secure the advice of your present insurer or its producer regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, re-read it carefully to be certain that all information has been properly recorded.

(Signature of Producer or Other Representative)

[Typed Name and Address of Producer]

The above "Notice to Applicant" was delivered to me on:

_______________________________ _________________________”

(Applicant's Signature) (Date)

(d) Direct Response Solicitations. Insurers using direct response solicitation methods shall deliver a notice regarding replacement of accident and sickness or long-term care coverage to the applicant upon issuance of the policy. The required notice shall be provided in the following manner:

“NOTICE TO APPLICANT REGARDING REPLACEMENT

OF ACCIDENT AND SICKNESS OR LONG-TERM CARE INSURANCE

[Insurance company's name and address]

SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.

According to [your application] [information you have furnished], you intend to lapse or otherwise terminate existing accident and sickness or long-term care insurance and replace it with the long-term care insurance policy delivered herewith issued by [company name] Insurance Company. Your new policy provides 30 days within which you may decide, without cost, whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

Health conditions which you may presently have (preexisting conditions), may not be immediately or fully covered under the new policy. This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.
State law provides that your replacement policy or certificate may not contain new preexisting conditions or probationary periods. Your insurer will waive any time periods applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
If you are replacing existing long-term care insurance coverage, you may wish to secure the advice of your present insurer or its producer regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
[To be included only if the application is attached to the policy.] If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to [company name and address] within 30 days if any information is not correct and complete, or if any past medical history has been left out of the application.”

(e) Where replacement is intended, the replacing insurer shall notify, in writing, the existing insurer of the proposed replacement. The existing policy shall be identified by the insurer, name of the insured and policy number or address including zip code. Notice shall be made within 5 working days from the date the application is received by the insurer or the date the policy is issued, whichever is sooner.

(f) Life insurance policies that accelerate benefits for long-term care shall comply with this section if the policy being replaced is a long-term care insurance policy. If the policy being replaced is a life insurance policy, the insurer shall comply with the replacement requirements of Ins 302. If a life insurance policy that accelerates benefits for long-term care is replaced by another such policy, the replacing insurer shall comply with both the long-term care and the life insurance replacement requirements.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.14 Reporting Requirements {#sec-ins-3601.14 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.14}

(a) Every insurer shall maintain records for each producer of that producer’s amount of replacement sales as a percent of the producer’s total annual sales and the amount of lapses of long-term care insurance policies sold by the producer as a percent of the producer’s total annual sales.

(b) Every insurer shall report annually by June 30 the 10 percent of its producers with the greatest percentages of lapses and replacements as measured by (a) above. (See Appendix G)

(c) Reported replacement and lapse rates do not alone constitute a violation of insurance laws or necessarily imply wrongdoing. The reports are for the purpose of reviewing more closely producer activities regarding the sale of long-term care insurance.

(d) Every insurer shall report annually by June 30 the number of lapsed policies as a percent of its total annual sales and as a percent of its total number of policies in force as of the end of the preceding calendar year. (See Appendix G)

(e) Every insurer shall report annually by June 30 the number of replacement policies sold as a percent of its total annual sales and as a percent of its total number of policies in force as of the preceding calendar year. (See Appendix G)

(f) Every insurer shall report annually by June 30, for qualified long-term care insurance contracts, the number of claims denied for each class of business, expressed as a percentage of claims denied. (See Appendix E)

(g) For purposes of this section:

(1) “Policy” means only long-term care insurance;

(2) Subject to paragraph (3), “claim” means a request for payment of benefits under an in force policy regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met;

(3) “Denied” means the insurer refuses to pay a claim for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition; and

(4) “Report” means on a statewide basis.

(h) Reports required under this section shall be filed with the commissioner.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.15 Long-Term Care Insurance {#sec-ins-3601.15 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.15}

Licensing. A producer is not authorized to sell, solicit, or negotiate with respect to long

term care insurance except as authorized by RSA 402-J.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.16 Discretionary Powers of Commissioner {#sec-ins-3601.16 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.16}

The commissioner may, upon written request and after an administrative hearing, issue an order to modify or suspend a specific provision or provisions of this rule with respect to a specific long-term care insurance policy or certificate upon a written finding that:

(a) The modification or suspension would be in the best interest of the insureds;

(b) The purposes to be achieved could not be effectively or efficiently achieved without the modification or suspension; and

(c) (1) The modification or suspension is necessary to the development of an innovative and reasonable approach for insuring long-term care; or

(2) The policy or certificate is to be issued to residents of a life care or continuing care retirement community or some other residential community for the elderly and the modification or suspension is reasonably related to the special needs or nature of such a community; or

(3) The modification or suspension is necessary to permit long-term care insurance to be sold as part of, or in conjunction with, another insurance product.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.17 Reserve Standards {#sec-ins-3601.17 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.17}

(a) (1) When long-term care benefits are provided through the acceleration of benefits under group or individual life policies or riders to such policies, policy reserves for the benefits shall be determined in accordance with RSA 410. Claim reserves shall also be established in the case when the policy or rider is in claim status; and

(2) Reserves for policies and riders subject to this paragraph should be based on the multiple decrement model utilizing all relevant decrements except for voluntary termination rates. Single decrement approximations are acceptable if the calculation produces essentially similar reserves, if the reserve is clearly more conservative, or if the reserve is immaterial. The calculations may take into account the reduction in life insurance benefits due to the payment of long-term care benefits. However, in no event shall the reserves for the long-term care benefit and the life insurance benefit be less than the reserves for the life insurance benefit assuming no long-term care benefit;

(3) In the development and calculation of reserves for policies and riders subject to this paragraph, due regard shall be given to the applicable policy provisions, marketing methods, administrative procedures and all other considerations which have an impact on projected claim costs, including, but not limited to, the following:

a. Definition of insured events;

b. Covered long-term care facilities;

c. Existence of home convalescence care coverage;

d. Definition of facilities;

e. Existence or absence of barriers to eligibility;

f. Premium waiver provision;

g. Renewability;

h. Ability to raise premiums;

i. Marketing method;

j. Underwriting procedures;

k. Claims adjustment procedures;

l. Waiting period;

m. Maximum benefit;

n. Availability of eligible facilities;

o. Margins in claim costs;

p. Optional nature of benefit;

q. Delay in eligibility for benefit;

r. Inflation protection provisions; and

s. Guaranteed insurability option; and

(4) Any applicable valuation morbidity table shall be certified as appropriate as a statutory valuation table by a member of the American Academy of Actuaries.

(b) When long-term care benefits are provided other than as in (a) above, reserves shall be determined in accordance with RSA 410.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.18 Loss Ratio {#sec-ins-3601.18 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.18}

(a) This section shall apply to all long-term care insurance policies or certificates except those covered under Ins 3601.09 and Ins 3601.19.

(b) Benefits under long-term care insurance policies shall be deemed reasonable in relation to premiums provided the expected loss ratio is at least 60 percent calculated in a manner which provides for adequate reserving of the long-term care insurance risk. In evaluating the expected loss ratio, due consideration shall be given to all relevant factors, including:

(1) Statistical credibility of incurred claims experience and earned premiums;

(2) The period for which rates are computed to provide coverage;

(3) Experienced and projected trends;

(4) Concentration of experience within early policy duration;

(5) Expected claim fluctuation;

(6) Experience refunds, adjustments or dividends;

(7) Renewability features;

(8) All appropriate expense factors;

(9) Interest;

(10) Experimental nature of the coverage;

(11) Policy reserves;

(12) Mix of business by risk classification; and

(13) Product features such as long elimination periods, high deductibles, and high maximum limits.

(c) Paragraph (b) above shall not apply to life insurance policies that accelerate benefits for long-term care. A life insurance policy that funds long-term care benefits entirely by accelerating the death benefit is considered to provide reasonable benefits in relation to premiums paid, if the policy complies with all of the following provisions:

(1) The interest credited internally to determine cash value accumulations, including long-term care, if any, are guaranteed not to be less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy;

(2) The portion of the policy that provides life insurance benefits meets the nonforfeiture requirements of RSA 409;

(3) The policy meets the disclosure requirements of RSA 415-D:8, VI, VII, and VIII;

(4) Any policy illustration that meets the applicable requirements of Ins 309; and

(5) An actuarial memorandum is filed with the insurance department that includes:

a. A description of the basis on which the long-term care rates were determined;

b. A description of the basis for the reserves;

c. A summary of the type of policy, benefits, renewability, general marketing method, and limits on ages of issuance;

d. A description and a table of each actuarial assumption used. For expenses, an insurer shall include percent of premium dollars per policy and dollars per unit of benefits, if any;

e. A description and a table of the anticipated policy reserves and additional reserves to be held in each future year for active lives;

f. The estimated average annual premium per policy and the average issue age;

g. A statement as to whether underwriting is performed at the time of application. The statement shall indicate whether underwriting is used and, if used, the statement shall include a description of the type or types of underwriting used, such as medical underwriting or functional assessment underwriting. Concerning a group policy, the statement shall indicate whether the enrollee or any dependent will be underwritten and when underwriting occurs; and

h. A description of the effect of the long-term care policy provision on the required premiums, nonforfeiture values, and reserves on the underlying life insurance policy, both for active lives and those in long-term care claim status.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.19 Premium Rate Schedule Increases {#sec-ins-3601.19 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.19}

(a) This section shall apply to all requests for premium rate schedule increases.

(b) An insurer shall provide notice of a pending premium rate schedule increase, including an exceptional increase, to the commissioner at least 30 days prior to the notice to the policyholders and shall include:

(1) Information required by Ins 3601.08;

(2) Certification by a qualified actuary that:

a. If the requested premium rate schedule increase is implemented and the underlying assumptions are realized, then no further premium rate schedule increases are anticipated;

b. The premium rate filing is in compliance with the provisions of this section;

(3) An actuarial memorandum justifying the rate schedule change request that includes:

a. Lifetime projections of earned premiums and incurred claims based on the filed premium rate schedule increase; and the method and assumptions used in determining the projected values, including reflection of any assumptions that deviate from those used for pricing other forms currently available for sale;

Annual values for the 5 years preceding the 3 years following the valuation date shall be provided separately;
The projections shall include the development of the lifetime loss ratio;
The projections shall demonstrate compliance with paragraph (c) below; and
For exceptional increases:

(i) The projected experience should be limited to the increases in claims expenses attributable to the approved reasons for the exceptional increase; and

(ii) In the event the commissioner determines, as provided in Ins 3601.03(b)(4); that offsets may exist, the insurer shall use appropriate net projected experience;

b. Disclosure of how reserves have been incorporated in this rate increase whenever the rate increase will trigger contingent benefit upon lapse;

c. Disclosure of the analysis performed to determine why a rate adjustment is necessary, which pricing assumptions were not realized and why, and what other actions taken by the company have been relied on by the actuary;

d. A statement that policy design, underwriting, and claims adjudication practices have been taken into consideration; and

e. In the event that it is necessary to maintain consistent premium rates for new certificates and certificates receiving a rate increase, the insurer will need to file composite rates reflecting projections of new certificates;

(4) A statement that renewal premium rate schedules are not greater than new business premium rate schedules except for differences attributable to benefits, unless sufficient justification is provided to the commissioner;

(5) Sufficient information for review and approval of the premium rate schedule increase by the commissioner; and

(6) In assessing the reasonableness of the assumptions proposed, the commissioner may use the services of an independent actuary and may charge the insurer for the cost of these services. The commissioner may also accept a review done by or for another state or states for the same or substantially the same policy form where any differences in benefits and premiums are not material and such review was completed within 18 months of the date of the premium rate schedule filing and substantially complies with these standards.

(1) Exceptional increases shall provide that 70 percent of the present value of projected additional premiums from the exceptional increase will be returned to policyholders in benefits;

(2) Premium rate schedule increases shall be calculated such that the sum of the accumulated value of incurred claims, without the inclusion of active life reserves, and the present value of future projected incurred claims, without the inclusion of active life reserves, will not be less than the sum of the following:

a. For policies issued on or after May 1, 2004:

The accumulated value of the initial earned premium times the difference between 2 percent and the greater of the original anticipated loss ratio when the product was originally filed and 60 percent;
Eighty-five percent of the accumulated value of prior premium rate schedule increases on an earned basis;
The present value of future projected initial earned premiums times the difference between 2 percent and the greater of the original anticipated loss ratio when the product was originally filed and 60 percent; and
Eighty-five percent of the present value of future projected premiums not in sub-clause 3. above on an earned basis; and

b. For policies issued prior to May 1, 2004:

The accumulated value of earned premium, using rates that had been approved and implemented prior to January 1, 2016, times the difference between 2 percent and the greater of the original anticipated loss ratio when the product was originally filed and 62 percent;
Eighty percent for individual policies and 75 percent for group policies of the accumulated value of premium rate increases approved and proposed for implementation on or after January 1, 2016;
The present value of future projected earned premium using rates that had been approved and implemented prior to January 1, 2016, times the difference between 2 percent and the greater of the original anticipated loss ratio when the product was originally filed and 62 percent; and
Eighty percent for individual policies and 75 percent for group policies of the present value of future projected premiums not in sub-clause 3. above on an earned basis;

(3) In the event that a policy form has both exceptional and other increases, the values in sub-clauses (c)(2)a.2. and 4. above will also include 70 percent for exceptional rate increase amounts;

(4) All present and accumulated values used to determine rate increases shall use the maximum valuation interest rate for contract reserves. The actuary shall disclose as part of the actuarial memorandum the use of any appropriate averages;

(5) All calculated accumulated values shall use the actual experience of the product, except for the interest rate as specified in subparagraph (4) above, in as close a manner to that used in the original development of rates as possible. This shall not preclude the inclusion of multiple policy forms into one rate increase determination if such pooling enhances the credibility of the combined accumulated experience; and

(6) All calculated present values shall use reasonable estimates of future premium payments and claim payments. Such estimates shall be based on reasonable assumptions, which may include a margin for moderately adverse experience, as characterized herein.

(d) For any increase that is greater than 20 percent, the insurer shall be required to implement a series of scheduled increases to ensure that no policyholder will realize an annual rate increase of more than 20%. The entire scheduled series, or methodology for establishing a series, shall be approved as part of the rate filing justifying the premium rate schedule increase. For the purposes of Ins 3601.08(e), any schedule series implemented pursuant to this paragraph shall be considered one premium rate schedule increase. The insurer shall not be permitted to implement any further increases on the subject policy during the period of such scheduled increases. The insurer shall not be permitted to implement any further increases within the period during which scheduled increases previously approved are being implemented.

(e) For each rate increase that is implemented, the insurer shall file for review by the commissioner updated projections, as defined in (b)(3)a. above, every 2 years during the period over which scheduled increases are being implemented and include a comparison of actual results to projected values. For group insurance policies that meet the conditions in paragraph (l) below, the projections required by this paragraph shall be provided to the policyholder in lieu of filing with the commissioner.

(f) If any premium rate in the revised premium rate schedule is greater than 200 percent of the comparable rate in the initial premium schedule, lifetime projections, as defined in paragraph (b)(3)a. above, shall be filed for review by the commissioner every 5 years following the end of the required period in paragraph (e) above. For group insurance policies that meet the conditions in paragraph (l) below, the projections required by this paragraph shall be provided to the policyholder in lieu of filing with the commissioner.

(g) (1) If the commissioner has determined that the actual experience following a rate increase does not adequately match the projected experience and that the current projections demonstrate that incurred claims will not exceed proportions of premiums specified in paragraph (c), the commissioner may require the insurer to implement any of the following:

a. Premium rate schedule adjustments; or

b. Other measures to reduce the difference between the projected and actual experience; and

(2) In determining whether the actual experience adequately matches the projected experience, consideration should be given to clause (b)(3)e. above, if applicable.

(h) If the majority of the policies or certificates to which the increase is applicable are eligible for the contingent benefit upon lapse, the insurer shall file:

(1) A plan, subject to commissioner approval, for improved administration or claims processing designed to eliminate the potential for further deterioration of the policy form requiring further premium rate schedule increases, or both, or to demonstrate that appropriate administration and claims processing have been implemented or are in effect; otherwise the commissioner may impose the condition in paragraph (i) of this section; and

(2) The original anticipated lifetime loss ratio, and the premium rate schedule increase that would have been calculated according to paragraph (c) had the greater of the original anticipated lifetime loss ratio or 58 percent been used in the calculations described in sub-clauses (c)(2)a.1. and 3. above.

(i) (1) For a rate increase filing that meets the following criteria, the commissioner shall review, for all policies included in the filing, the projected lapse rates and past lapse rates during the 12 months following each increase to determine if significant adverse lapsation has occurred or is anticipated:

a. The rate increase is not the first rate increase requested for the specific policy form or forms;

b. The rate increase is not an exceptional increase; and

c. The majority of the policies or certificates to which the increase is applicable are eligible for the contingent benefit upon lapse; and

(2) In the event significant adverse lapsation has occurred, is anticipated in the filing, or is evidenced in the actual results as presented in the updated projections provided by the insurer following the requested rate increase, the commissioner may determine that a rate spiral exists. Following the determination that a rate spiral exists, the commissioner may require the insurer to offer, without underwriting, to all in force insureds subject to the rate increase the option to replace existing coverage with one or more reasonably comparable products being offered by the insurer or its affiliates.

a. The offer shall:

Be subject to the approval of the commissioner;
Be based on actuarially sound principles, but not be based on attained age; and
Provide that maximum benefits under any new policy accepted by an insured shall be reduced by comparable benefits already paid under the existing policy; and

b. The insurer shall maintain the experience of all the replacement insureds separate from the experience of insureds originally issued the policy forms. In the event of a request for a rate increase on the policy form, the rate increase shall be limited to the lesser of:

The maximum rate increase determined based on the combined experience; and
The maximum rate increase determined based only on the experience of the insureds originally issued the form plus 10 percent.

(j) If the commissioner determines that the insurer has exhibited a persistent practice of filing inadequate initial premium rates for long-term care insurance, the commissioner may, in addition to the provisions of paragraph (i) of this section, prohibit the insurer from either of the following:

(1) Filing and marketing comparable coverage for a period of up to 5 years; or

(2) Offering all other similar coverages and limiting marketing of new applications to the products subject to recent premium rate schedule increases.

(k) Paragraphs (a) through (j) shall not apply to policies for which the long-term care benefits provided by the policy are incidental, as defined in Ins 3601.03(c), if the policy complies with all of the following provisions:

(1) The interest credited internally to determine cash value accumulations, including long-term care, if any, rate guaranteed not to be less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy;

(2) The portion of the policy that provides insurance benefits other than long-term care coverage meets the nonforfeiture requirements as applicable in any of the following:

a. RSA 409; and

b. RSA 409-A;

(3) The policy meets the disclosure requirements of RSA 415-D:8, VI, VII, and VIII;

(4) The portion of the policy that provides insurance benefits other than long-term care coverage meets the requirements as applicable in policy illustrations as required by Ins 309;

(5) An actuarial memorandum is filed with the insurance department that includes:

a. A description of the basis on which the long-term care rates were determined;

b. A description of the basis for the reserves;

c. A summary of the type of policy, benefits, renewability, general marketing method, and limits on ages of issuance;

d. A description and a table of each actuarial assumption used. For expenses, an insurer shall include percent of premium dollars per policy and dollars per unit of benefits, if any;

e. A description and a table of the anticipated policy reserves and additional reserves to be held in each future year for active lives;

f. The estimated average annual premium policy and the average issue age;

h. A description of the effect of the long-term care policy provision on the required premiums, nonforfeiture values and reserves on the underlying insurance policy, both for active lives and those in long-term care status.

(l) Paragraphs (g) and (i) shall not apply to group insurance policies as defined in RSA 415-D:3, IV(a) where:

(1) The policies insure 250 or more persons and the policyholder has 5,000 or more eligible employees of a single employer; or

(2) The policyholder, and not the certificateholders, pays a material portion of the premium, which shall not be less than 20 percent of the total premium for the group in the calendar year prior to the year a rate increase is filed.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #10782, eff 2-13-15; amd by #12651, eff 10-29-18; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.20 Filing Requirement {#sec-ins-3601.20 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.20}

Prior to an insurer or similar organization offering group long-term care insurance to a resident of this state pursuant to RSA 415-D:4, it shall file with the commissioner evidence that the group policy or certificate thereunder has been approved by a state having statutory or regulatory long-term care insurance requirements substantially similar to those adopted in this state.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.21 Filing Requirements for Advertising {#sec-ins-3601.21 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.21}

(a) Every insurer, health care service plan or other entity providing long-term care insurance or benefits in this state shall provide a copy of any long-term care insurance advertisement intended for use in this state whether through written, radio or television medium to the commissioner for review or approval by the commissioner. In addition, all advertisements shall be retained by the insurer, health care service plan or other entity for at least 3 years from the date the advertisement was first used.

(b) The commissioner may exempt from these requirements any advertising form or material when, in the commissioner's opinion, this requirement may not be reasonably applied.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; amd by #12595, eff 7-30-18; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.22 Standards for Marketing {#sec-ins-3601.22 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.22}

(a) Every insurer, health care service plan or other entity marketing long-term care insurance coverage in this state, directly or through its producers, shall:

(1) Establish marketing procedures and producer training requirements to assure that:

a. Any marketing activities, including any comparison policies, by its producers or other producers will be fair and accurate; and

b. Excessive insurance is not sold or issued;

(2) Display prominently by type, stamp or other appropriate means, on the first page of the outline of coverage and policy the following:

“Notice to buyer: This policy may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations.”;

(3) Provide copies of the disclosure forms required in Ins 3601.08 (Appendices B and F) to the applicant;

(4) Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for long-term care insurance already has accident and sickness or long-term care insurance and the types and amounts of any such insurance, except that in the case of qualified long-term care insurance contracts, an inquiry into whether a prospective applicant or enrollee for long-term care insurance has accident and sickness insurance is not required;

(5) Every insurer or entity marketing long-term care insurance shall establish auditable procedures for verifying compliance with this paragraph;

(6) If the state in which the policy or certificate is to be delivered or issued for delivery has a senior insurance counseling program approved by the commissioner, the insurer shall, at solicitation, provide written notice to the prospective policyholder and certificateholder that the program is available and the name, address and telephone number of the program;

(7) For long-term care health insurance policies and certificates, use the terms “noncancellable” or “level premium” only when the policy or certificate conforms to Ins 3601.05(a)(3) and (4); and

(8) Provide an explanation of contingent benefit upon lapse provided for in Ins 3601.27(d)(3) and, if applicable, the additional contingent benefit upon lapse provided to policies with fixed or limited premium paying periods in Ins 3601.27(d)(4).

(b) In addition to the practices prohibited in RSA 417, the following acts and practices are prohibited:

(1) Twisting. Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any insurance policy or to take out a policy of insurance with another insurer;

(4) Misrepresentation. Misrepresenting a material fact in selling or offering to sell a long-term care insurance policy.

(c) (1) With respect to the obligations set forth in this paragraph, the primary responsibility of an association, as defined in RSA 415-D:3, IV(b), when endorsing or selling long-term care insurance shall be to educate its members concerning long-term care issues in general so that its members can make informed decisions. Associations shall provide objective information regarding long-term care insurance policies or certificates endorsed or sold by such associations to ensure that members of such associations receive a balanced and complete explanation of the features in the policies or certificates that are being endorsed or sold;

(2) The insurer shall file with the department the following material:

a. The policy and certificate;

b. A corresponding outline of coverage; and

c. All advertisements requested by the department;

(3) The association shall disclose in any long-term care insurance solicitation:

a. The specific nature and amount of the compensation arrangements (including all fees, commissions, administrative fees and other forms of financial support) that the association receives from endorsement or sale of the policy or certificate to its members; and

b. A brief description of the process under which the policies and the insurer issuing the policies were selected;

(4) If the association and the insurer have interlocking directorates or trustee arrangements, the association shall disclose that fact to its members;

(5) The board of directors of associations selling or endorsing long-term care insurance policies or certificates shall review and approve the insurance policies as well as the compensation arrangements made with the insurer;

(6) The association shall also:

a. At the time of the association's decision to endorse, engage the services of a person with expertise in long-term care insurance not affiliated with the insurer to conduct an examination of the policies, including its benefits, features, and rates and update the examination thereafter in the event of material change;

b. Actively monitor the marketing efforts of the insurer and its producers;

c. Review and approve all marketing materials or other insurance communications used to promote sales or sent to members regarding the policies or certificates; and

d. Subparagraphs a. through c. shall not apply to qualified long-term care insurance contracts;

(7) No group long-term care insurance policy or certificate may be issued to an association unless the insurer files with the state insurance department the information required in this section;

(8) The insurer shall not issue a long-term care policy or certificate to an association or continue to market such a policy or certificate unless the insurer certifies annually that the association has complied with the requirements set forth in this paragraph; and

(9) Failure to comply with the filing and certification requirements of this section constitutes an unfair trade practice in violation of RSA 417.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.23 Suitability {#sec-ins-3601.23 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.23}

(a) This section shall not apply to life insurance policies that accelerate benefits for long-term care.

(b) Every insurer, health care service plan, or other entity marketing long-term care insurance (the “issuer”) shall:

(1) Develop and use suitability standards to determine whether the purchase or replacement of long-term care insurance is appropriate for the needs of the applicant;

(2) Train its producers in the use of its suitability standards; and

(3) Maintain a copy of its suitability standards and make them available for inspection upon request by the commissioner.

(c) (1) To determine whether the applicant meets the standards developed by the issuer, the producer and issuer shall develop procedures that take the following into consideration:

a. The ability to pay for the proposed coverage and other pertinent financial information related to the purchase of the coverage;

b. The applicant's goals or needs with respect to long-term care and the advantages and disadvantages of insurance to meet these goals or needs; and

c. The values, benefits and costs of the applicant's existing insurance, if any, when compared to the values, benefits and costs of the recommended purchase or replacement;

(2) The issuer and, where a producer is involved, the producer shall make reasonable efforts to obtain the information set out in subparagraph (1) above. The efforts shall include presentation to the applicant, at or prior to application, the “Long-Term Care Insurance Personal Worksheet”. The personal worksheet used by the issuer shall contain, at a minimum, the information in the format contained in Appendix B, in not less than 12 point type. The issuer may request the applicant to provide additional information to comply with its suitability standards. A copy of the issuer's personal worksheet shall be filed with the commissioner;

(3) A completed personal worksheet shall be returned to the issuer prior to the issuer's consideration of the applicant for coverage, except the personal worksheet need not be returned for sales of employer group long-term care insurance to employees and their spouses; and

(4) The sale or dissemination outside the company or agency by the issuer or producer of information obtained through the personal worksheet in Appendix B is prohibited.

(d) The issuer shall use the suitability standards it has developed pursuant to this section in determining whether issuing long-term care insurance coverage to an applicant is appropriate.

(e) Producers shall use the suitability standards developed by the issuer in marketing long-term care insurance.

(f) At the same time as the personal worksheet is provided to the applicant, the disclosure form entitled “Things You Should Know Before You Buy Long-Term Care Insurance” shall be provided. The form shall be in the format contained in Appendix C, in not less than 12 point type.

(g) If the issuer determines that the applicant does not meet its financial suitability standards, or if the applicant has declined to provide the information, the issuer may reject the application. In the alternative, the issuer shall send the applicant a letter similar to Appendix D. However, if the applicant had declined to provide financial information, the issuer may use some other method to verify the applicant's intent. Either the applicant's returned letter or a record of the alternative method of verification shall be made part of the applicant's file.

(h) The issuer shall report annually to the commissioner the total number of applications received from residents of this state, the number of those who declined to provide information on the personal worksheet, the number of applicants who did not meet the suitability standards, and the number of those who chose to confirm after receiving a suitability letter.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.24 Prohibition Against Preexisting Conditions and Probationary Periods in Replacement Policies or Certificates {#sec-ins-3601.24 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.24}

If a long-term care insurance policy or certificate replaces another long-term care policy or certificate, the replacing insurer shall waive any time periods applicable to preexisting conditions and probationary periods in the new long-term care policy for similar benefits to the extent that similar exclusions have been satisfied under the original policy.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.25 Availability of New Services or Providers {#sec-ins-3601.25 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.25}

(a) An insurer shall notify policyholders of the availability of a new long-term policy series that provides coverage for new long-term care services or providers material in nature and not previously available through the insurer to the general public. The notice shall be provided within 12 months of the date of the new policy series is made available for sale in this state.

(b) Notwithstanding paragraph (a) above, notification is not required for any policy issued prior to the effective date of this section or to any policyholder or certificateholder who is currently eligible for benefits, within an elimination period or on a claim, or who previously had been in claim status, or who would not be eligible to apply for coverage due to issue age limitations under the new policy. The insurer may require that policyholders meet all eligibility requirements, including underwriting and payment of the required premium to add such new services or providers.

(1) By adding a rider to the existing policy and charging a separate premium for the new rider based on the insured's attained age;

(2) By exchanging the existing policy or certificate for one with an issue age based on the present age of the insured and recognizing past insured status by granting premium credits toward the premiums for the new policy or certificate. The premium credits shall be based on premiums paid or reserves held for the prior policy or certificate;

(3) By exchanging the existing policy or certificate for a new policy or certificate in which consideration for past insured status shall be recognized by setting the premium for the new policy or certificate at the issue age of the policy or certificate being exchanged. The cost for the new policy or certificate may recognize the difference in reserves between the new policy or certificate and the original policy or certificate; or

(4) By an alternative program developed by the insurer that meets the intent of this section if the program is filed with and approved by the commissioner.

(d) An insurer is not required to notify policyholders of a new proprietary policy series created and filed for use in a limited distribution channel. For purpose of this paragraph, "limited distribution channel" means through a discrete entity, such as a financial institution or brokerage, for which specialized products are available that are not available for sale to the general public. Policyholders that purchased such a new proprietary policy shall be notified when a new long-term care policy series that provides coverage for new long-term care services or providers material in nature is made available to that limited distribution channel.

(e) Policies issued pursuant to this section shall be considered exchanges and not replacements. These exchanges shall not be subject to Ins 3601.13 and Ins 3601.23 and the reporting requirements of Ins 3601.14(a) to (e).

(f) Where the policy is offered through an employer, labor organization, professional, trade or occupational association, the required notification in paragraph (a) above shall be made to the offering entity. However, if the policy is issued to a group defined in RSA 415-D:3, IV, the notification shall be made to each certificateholder.

(g) Nothing in this section shall prohibit an insurer from offering any policy, rider, certificate or coverage change to any policyholder or certificateholder. However, upon request any policyholder may apply for currently available coverage that includes the new services or providers. The insurer may require that policyholders meet all eligibility requirements, including underwriting and payment of the required premium to add such new services or providers.

(h) This section does not apply to life insurance policies or riders containing accelerated long-term care benefits.

(i) This section shall become effective on or after the effective date of this amended rule.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.26 Right to Reduce Coverage and Lower Premiums {#sec-ins-3601.26 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.26}

(a) (1) Every long-term care insurance policy and certificate shall include a provision that allows the policyholder or certificateholder to reduce coverage and lower the policy or certificate premium in at least one of the following ways:

a. Reducing the maximum benefit; or

b. Reducing the daily, weekly or monthly benefit amount; and

(2) The insurer may also offer other reduction options that are consistent with the policy or certificate design or the carrier's administrative processes.

(b) The provision shall include a description of the ways in which coverage may be reduced and the process for requesting and implementing a reduction in coverage.

(c) The age to determine the premium for the reduced coverage shall be based on the age used to determine the premium for the coverage currently in force.

(d) The insurer may limit any reduction in coverage to plans or options available for that policy form and to those for which benefits will be available after consideration of claims paid or payable.

(e) If a policy or certificate is about to lapse, the insurer shall provide a written reminder to the policyholder or certificateholder of his or her right to reduce coverage and premiums in the notice required by Ins 3601.06(a)(3).

(f) This section does not apply to life insurance policies or riders containing accelerated long-term care benefits.

(g) The requirements of paragraphs (a) through (f) above shall apply to any long-term care policy issued in this state on or after the adoption of this amended rule.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.27 Nonforfeiture Benefit Requirement {#sec-ins-3601.27 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.27}

(a) This section does not apply to life insurance policies or riders containing accelerated long-term care benefits.

(b) To comply with the requirement to offer a nonforfeiture benefit pursuant to the provisions of RSA 415-D:10:

(1) A policy or certificate offered with nonforfeiture benefits shall have coverage elements, eligibility, benefit triggers and benefit length that are the same as coverage to be issued without nonforfeiture benefits. The nonforfeiture benefit included in the offer shall be the benefit described in paragraph (e) below; and

(2) The offer shall be in writing if the nonforfeiture benefit is not otherwise described in the outline of coverage or other materials given to the prospective policyholder.

(c) If the offer required to be made under RSA 415-D:10 is rejected, the insurer shall provide the contingent benefit upon lapse described in this section. Even if this offer is accepted for a policy with a fixed or limited premium paying period, the contingent benefit on lapse in paragraph (d)(4) below shall still apply.

(d) (1) After rejection of the offer required under RSA 415-D:10, for individual and group policies without nonforfeiture benefits, the insurer shall provide a contingent benefit upon lapse;

(2) In the event a group policyholder elects to make the nonforfeiture benefit an option to the certificateholder, a certificate shall provide either the nonforfeiture benefit or the contingent benefit upon lapse;

(3) A contingent benefit on lapse shall be triggered every time an insurer increases the premium rates to a level which results in a cumulative increase of the annual premium equal to or exceeding the percentage of the insured's initial annual premium set forth below based on the insured's issue age, and the policy or certificate lapses within 120 days of the due date of the premium so increased. Unless otherwise required, policyholders shall be notified at least 30 days prior to the due date of the premium reflecting the rate increase:

Triggers for a Substantial Premium Increase

Issue Age

Percent Increase Over

Initial Premium

29 and under

200%

30-34

190%

35-39

170%

40-44

150%

45-49

130%

50-54

110%

55-59

90%

70%

66%

62%

58%

54%

50%

48%

46%

44%

42%

40%

38%

36%

34%

32%

30%

28%

26%

24%

22%

20%

19%

18%

17%

16%

15%

14%

13%

12%

11%

90 and over

10%

(4) A contingent benefit on lapse shall also be triggered for policies with a fixed or limited premium paying period every time an insurer increases the premium rates to a level that results in a cumulative increase of the annual premium equal to or exceeding the percentage of the insured's initial annual premium set forth below based on the insured's issue age, the policy or certificate lapses within 120 days of the due date of the premium so increased, and the ratio in Ins 3601.27(d)(6)b. is 40 percent or more. Unless otherwise required, policyholders shall be notified at least 30 days prior to the due date of the premium reflecting the rate increase:

Triggers for a Substantial Premium Increase

Issue Age

Percent Increase

Over Initial Premium

Under 65

50%

65-80

30%

Over 80

10%

This provision shall be in addition to the contingent benefit provided by subparagraph (3) above and where both are triggered, the benefit provided shall be at the option of the insured;

(5) Notwithstanding the requirements delineated above, a contingent nonforfeiture benefit on lapse shall also be triggered every time an insurer increases premium rates in the policyholder’s 21st duration or later.

(6) On or before the effective date of a substantial premium increase as defined in subparagraph (3) above, the insurer shall:

a. Offer to reduce policy benefits provided by the current coverage without the requirement of additional underwriting so that required premium payments are not increased;

b. Offer to convert the coverage to a paid-up status with a shortened benefit period in accordance with the terms of paragraph (e) below. This option may be elected at any time during the 120-day period referenced in subparagraph (d)(3) above; and

c. Notify the policyholder or certificateholder that a default or lapse at any time during the 120-day period referenced in subparagraph (d)(3) shall be deemed to be the election of the offer to convert in paragraph (b) above, unless the automatic option in clause (7)c. below applies; and

(7) On or before the effective date of a substantial premium increase as defined in subparagraph (4) or (5) above, the insurer shall:

a. Offer to reduce policy benefits provided by the current coverage without the requirement of additional underwriting so that required premium payments are not increased;

b. Offer to convert the coverage to a paid-up status where the amount payable for each benefit is 90 percent of the amount payable in effect immediately prior to lapse times the ratio of the number of completed months of paid premiums divided by the number of months in the premium paying period. This option may be elected at any time during the 120-day period referenced in subparagraph (4) above; and

c. Notify the policyholder or certificateholder that a default or lapse at any time during the 120-day period referenced in subparagraph (4) above shall be deemed to be the election of the

offer to convert in clause b. above if the ratio is 40 percent or more;

(e) Benefits continued as nonforfeiture benefits, including contingent benefits upon lapse, in accordance with subparagraph (d)(3) but not subparagraph (d)(4), are described in this paragraph:

(1) For purposes of this paragraph, attained age rating is defined as a schedule of premiums starting from the issue date which increases age at least one percent per year prior to age 50, and at least 3 percent per year beyond age 50;

(2) For purposes of this paragraph, the nonforfeiture benefit shall be of a shortened benefit period providing paid-up long-term care insurance coverage after lapse. The same benefits (amounts and frequency in effect at the time of lapse but not increased thereafter) will be payable for a qualifying claim, but the lifetime maximum dollars or days of benefits shall be determined as specified in subparagraph (3) below;

(3) The standard nonforfeiture credit will be equal to 100 percent of the sum of all premiums paid, including the premiums paid prior to any changes in benefits. The insurer may offer additional shortened benefit period options, as long as the benefits for each duration equal or exceed the standard nonforfeiture credit for that duration. However, the minimum nonforfeiture credit shall not be less than 30 times the daily nursing home benefit at the time of lapse. In either event, the calculation of the nonforfeiture credit is subject to the limitation of paragraph (f);

(4) a. The nonforfeiture benefit shall begin not later than the end of the third year following the policy or certificate issue date. The contingent benefit upon lapse shall be effective during the first 3 years as well as thereafter.

b. Notwithstanding clause a. above, for a policy or certificate with attained age rating, the nonforfeiture benefit shall begin on the earlier of:

The end of the tenth year following the policy or certificate issue date; or
The end of the second year following the date the policy or certificate is no longer subject to attained age rating; and

(5) Nonforfeiture credits may be used for all care and services qualifying for benefits under the terms of the policy or certificate, up to the limits specified in the policy or certificate.

(f) All benefits paid by the insurer while the policy or certificate is in premium paying status and in the paid up status will not exceed the maximum benefits that would be payable if the policy or certificate had remained in premium paying status.

(g) There shall be no difference in the minimum nonforfeiture benefits as required under this section for group and individual policies.

(h) Premiums charged for a policy or certificate containing nonforfeiture benefits or a contingent benefit on lapse shall be subject to the loss ratio requirements of Ins 3601.18 or Ins 3601.19, whichever is applicable, treating the policy as a whole.

(i) To determine whether contingent nonforfeiture upon lapse provisions are triggered under (d)(3) or (d)(4) above, a replacing insurer that purchased or otherwise assumed a block or blocks of long-term care insurance policies from another insurer shall calculate the percentage increase based on the initial annual premium paid by the insured when the policy was first purchased from the original insurer.

(j) A nonforfeiture benefit for qualified long-term care insurance contracts that are level premium contracts shall be offered that meets the following requirements:

(1) The nonforfeiture provision shall be appropriately captioned;

(2) The nonforfeiture provision shall provide a benefit available in the event of a default in the payment of any premiums and shall state that the amount of the benefit may be adjusted subsequent to being initially granted only as necessary to reflect changes in claims, persistency, and interest as reflected in changes in rates for premium paying contracts approved by the commissioner for the same contract form; and

(3) The nonforfeiture provision shall provide at least one of the following:

a. Reduced paid-up insurance;

b. Extended term insurance;

c. Shortened benefit period; or

d. Other similar offerings approved by the commissioner.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12 (from Ins 3601.25); amd by #10782, eff 2-13-15; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.28 Standards for Benefit Triggers {#sec-ins-3601.28 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.28}

(a) A long-term care insurance policy shall condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits shall not be more restrictive than requiring either a deficiency in the ability to perform not more than 3 of the activities of daily living or the presence of cognitive impairment.

(b) (1) Activities of daily living shall include at least the following as defined in Ins 3601.04 and in the policy;

a. Bathing;

b. Continence;

c. Dressing;

d. Eating;

e. Toileting; and

f. Transferring; and

(2) Insurers may use activities of daily living to trigger covered benefits in addition to those contained in (b)(1) above as long as they are defined in the policy.

(c) An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate; however the provisions shall not restrict, and are not in lieu of, the requirements contained in (a) and (b) above.

(d) For purposes of this section the determination of a deficiency shall not be more restrictive than:

(1) Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

(2) If the deficiency is due to the presence of a cognitive impairment, supervision or verbal cueing by another person is needed in order to protect the insured or others.

(e) Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers.

(f) Long-term care insurance policies shall include a clear description of the process for appealing and resolving benefit determinations.

(g) The requirements set forth in this section shall be applicable 12 months after the effective date of this rule and shall apply as follows:

(1) Except as provided in (2) below, the provisions of this section apply to a long-term care policy issued in this state on or after the effective date of this amended rule; and

(2) For certificates issued on or after the effective date of this section, under a group long-term care insurance policy, as defined in RSA 415-D:3, IV(a), that was in force at the time this amended rule became effective, the provisions of this section shall not apply.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12 (from Ins 3601.26); ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.29 Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts {#sec-ins-3601.29 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.29}

(a) For purposes of this section the following definitions apply:

(1) "Qualified long-term care services" means services that meet the requirements of Section 7702B(c)(1) of the Internal Revenue Code of 1986, as amended, as follows: necessary diagnostic, preventive, therapeutic, curative, treatment, mitigation and rehabilitative services, and maintenance or personal care services which are required by a chronically ill individual, and are provided pursuant to a plan of care prescribed by a licensed health care practitioner;

(2) a. "Chronically ill individual" has the meaning prescribed for this term by Section 7702B(c)(2) of the Internal Revenue Code of 1986, as amended. Under this provision, a chronically ill individual means any individual who has been certified by a licensed health care practitioner as:

Being unable to perform (without substantial assistance from another individual) at least 2 activities of daily living for a period of at least 90 days due to a loss of functional capacity; or
Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment; and

b. The term “chronically ill individual” shall not include an individual otherwise meeting these requirements unless within the preceding 12 month period a licensed health care practitioner has certified that the individual meets these requirements;

(3) “Licensed health care practitioner” means a physician, as defined in Section 1861 (r)(1) of the Social Security Act, a registered professional nurse, licensed social worker, or other individual who meets requirements prescribed by the Secretary of the Treasury; and

(4) “Maintenance or personal care services” means any care the primary purpose of which is the provision of needed assistance with any of the disabilities as a result of which the individual is a chronically ill individual (including the protection from threats to health and safety due to severe cognitive impairment).

(b) A qualified long-term care insurance contract shall pay only for qualified long-term care services received by a chronically ill individual provided pursuant to a plan of care prescribed by a licensed health care practitioner.

(c) A qualified long-term care insurance contract shall condition the payment of benefits on a determination of the insured's inability to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity or to severe cognitive impairment.

(d) Certifications regarding activities of daily living and cognitive impairment required pursuant to paragraph (c) above shall be performed by the following licensed or certified professionals: physicians, registered professional nurses, licensed social workers, or other individuals who meet requirements prescribed by the Secretary of the Treasury.

(e) Certifications required pursuant to paragraph (c) above may be performed by a licensed health care professional at the direction of the carrier as is reasonably necessary with respect to a specific claim, except that when a licensed health care practitioner has certified that an insured is unable to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity and the insured is in claim status, the certification may not be rescinded and additional certifications may not be performed until after the expiration of the 90 day period.

(f) Qualified long-term care insurance contracts shall include a clear description of the process of appealing and resolving disputes with respect to benefit determinations.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12 (from Ins 3601.27); ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.30 Appealing an Insurer’s Determination That the Benefit Trigger Is Not Met {#sec-ins-3601.30 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.30}

(a) For purposes of this section, "authorized representative" is authorized to act as the covered person's personal representative within the meaning of 45 CFR 164.502(g) promulgated by the Secretary under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act and means the following:

(1) A person to whom a covered person has given express written consent to represent the covered person in an external review;

(2) A person authorized by law to provide substituted consent for a covered person; or

(3) A family member of the covered person or the covered person's treating health care professional only when the covered person is unable to provide consent.

(b) If an insurer determines that the benefit trigger of a long-term care insurance policy has not been met, it shall provide a clear, written notice to the insured and the insured's authorized representative, if applicable, of all of the following:

(1) The reason that the insurer determined that the insured's benefit trigger has not been met;

(2) The insured's right to internal appeal in accordance with paragraph (c), and the right to submit new or additional information relating to the benefit trigger denial with the appeal request; and

(3) The insured's right, after exhaustion of the insurer's internal appeal process to have the benefit trigger determination reviewed under the independent review process in accordance with paragraph (d) below.

(c) Internal Appeal. The insured or the insured’s authorized representative may appeal the insurer's adverse benefit trigger determination by sending a written request to the insurer, along with any additional supporting information, within 120 calendar days after the insured and the insured’s authorized representative, if applicable, receives the insurer’s benefit determination notice. The internal appeal shall be considered by an individual or group of individuals designated by the insurer, provided that the individual or individuals making the internal appeal decision may not be the same individual or individuals who made the initial benefit determination. The internal appeal shall be completed and written notice of the internal appeal decision shall be sent to the insured and the insured's authorized representative, if applicable, within 30 calendar days of the insurer's receipt of all necessary information upon which a final determination can be made, and:

(1) If the insurer's original determination is upheld upon internal appeal, the notice of the internal appeal decision shall describe any additional internal appeal rights offered by the insurer. Nothing herein shall require the insurer to offer any internal appeal rights other than those described in this paragraph;

(2) If the insurer's original determination is upheld after the internal appeal process has been exhausted, and new or additional information has not been provided to the insurer, the insurer shall provide a written description of the insured's right to request an independent review of the benefit determination as described in paragraph (d) below to the insured and the insured's authorized representative, if applicable;

(3) As part of the written description of the insured's right to request an independent review, an insurer shall include the following, or substantially equivalent, language:

“We have determined that the benefit eligibility criteria (“benefit trigger”) of your [policy][certificate] has not been met. You may have the right to an independent review of our decision conducted by long-term care professionals who are not associated with us. Please send a written request for independent review to us at [address]. You must inform us, in writing, of your election to have this decision reviewed within 120 days of receipt of this letter. Listed below are the names and contact information of the independent review organizations approved or certified by your state insurance commissioner's office to conduct long-term care insurance benefit eligibility reviews. If you wish to request an independent review, please choose one of the listed organizations and include its name with your request for independent review. If you elect independent review, but do not choose an independent review organization with your request, we will choose one for the independent review organizations for you and refer the request for independent review to it.”;

(4) If the insurer does not believe the benefit trigger decision is eligible for independent review, the insurer shall inform the insured and the insured's authorized representative, if applicable, and the commissioner in writing and include in the notice the reasons for its determination of independent review ineligibility; and

(5) The appeal process described in this paragraph is not deemed to be a “new service or provider” as referenced in Ins 3601.25, and therefore does not trigger the notice requirements of that section.

(d) Independent Review of Benefit Trigger Determination:

(1) Request. The insured or the insured’s authorized representative may request an independent review of the insurer’s benefit trigger determination after the internal appeal process outlined in paragraph (c) above has been exhausted. A written request for independent review may be made by the insured or the insured’s authorized representative to the insurer within 120 calendar days after the insurer’s written notice of the final internal appeal decision is received by the insured and the insured's authorized representative, if applicable;

(2) Cost. The cost of the independent review shall be borne by the insurer; and

(3) Independent Review Process:

a. Within 5 business days of receiving a written request for independent review, the insurer shall refer the request to the independent review organization that the insured or the insured's authorized representative has chosen from the list of certified or approved organizations the insurer has provided to the insured. If the insured or the insured's authorized representative does not choose an approved independent review organization to perform the review, the insurer shall choose an independent review organization approved or certified by the state. The insurer shall vary its selection of authorized independent review organizations on a rotating basis;

b. The insurer shall refer the request for independent review of a benefit trigger determination to an independent review organization, subject to the following:

The independent review organization shall be on a list of certified or approved independent review organizations that satisfy the requirements of a qualified long-term care insurance independent review organization contained in this section;
The independent review organization shall not have any conflicts of interest with the insured, the insured's authorized representative, if applicable, or the insurer; and
Such review shall be limited to the information or documentation provided to and considered by the insurer in making its determination, including any information or documentation considered as part of the internal appeal process;

c. If the insured or the insured's authorized representative has new or additional information not previously provided to the insurer, whether submitted to the insurer or the independent review organization, such information shall first be considered in the internal review process, as set forth in paragraph (c) above, and:

While this information is being reviewed by the insurer, the independent review organization shall suspend its review, and the time period for review is suspended until the insurer completes its review;
The insurer shall complete its review of the information and provide written notice of the results of the review to the insured and the insured's authorized representative, if applicable, and the independent review organization within 5 business days of the insurer's receipt of such new or additional information; and
If the insurer maintains its denial after such review, the independent review organization shall continue its review and render its decision within the time period specified in clause i. below. If the insurer overturns its decision following its review, the independent review request shall be considered withdrawn;

d. The insurer shall acknowledge in writing to the insured and the insured’s authorized representative, if applicable, and the commissioner that the request for independent review has been received, accepted, and forwarded to an independent review organization for review. Such notice will include the name and address of the independent review organization;

e. Within 5 business days of receipt of the request for independent review, the independent review organization assigned pursuant to this paragraph shall notify the insured and the insured’s authorized representative, if applicable, the insurer, and the commissioner that it has accepted the independent review request and identify the type of licensed health care professional assigned to the review. The assigned independent review organization shall include in the notice a statement that the insured or the insured's authorized representative may submit in writing to the independent review organization within 7 days following the date of receipt of the notice additional information and supporting documentation that the independent review organization should consider when conducting its review;

f. The independent review organization shall review all of the information and documents received pursuant to clause e. above that has been provided to the independent review organization. The independent review organization shall provide copies of any documentation or information provided by the insured or the insured's authorized representative to the insurer for its review, if it is not part of the information or documentation submitted by the insurer to the independent review organization. The insurer shall review the information and provide its analysis of the new information in accordance with clause h. below;

g. The insured or the insured’s authorized representative may submit, at any time, new or additional information not previously provided to the insurer but pertinent to the benefit trigger denial. The insurer shall consider such information and affirm or overturn its benefit trigger determination. If the insurer affirms its benefit trigger determination, the insurer shall promptly provide such new or additional information to the independent review organization for its review, along with the insurer’s analysis of such information;

h. If the insurer overturns its benefit trigger determination:

The insurer shall provide notice to the independent review organization and the insured and the insured’s authorized representative, if applicable, and the commissioner of its decision; and
The independent review process shall immediately cease;

i. The independent review organization shall provide the insured and the insured’s authorized representative, if applicable, the insurer, and the commissioner with written notice of its decision, within 30 calendar days from receipt of the referral referenced in clause b. above. If the independent review organization overturns the insurer’s decision, it shall:

Establish the precise date within the specific period of time under review that the benefit trigger was deemed to have been met;
Specify the specific period of time under review for which the insurer declined eligibility but during which the independent review organization deemed the benefit trigger to have been met; and
For tax-qualified long-term care insurance contracts, provide a certification (made only by a licensed health care practitioner as defined in section 7702B(c)(4) of the Internal Revenue Code) that the insured is a chronically ill individual;

j. The decision of the independent review organization with respect to whether the insured met the benefit trigger will be final and binding on the insurer;

k. The independent review organization’s determination shall be used solely to establish liability for benefit trigger decisions and is intended to be admissible in any proceeding only to the extent it establishes the eligibility of benefits payable;

l. Nothing in this section shall restrict the insured's right to submit a new request for benefit trigger determination after the independent review decision, should the independent review organization uphold the insurer’s decision;

m. The insurance department shall utilize the criteria set forth in Appendix H, Guidelines for Long-Term Care Independent Review Entities, in certifying or approving entities to review long-term care insurance benefit trigger decisions; and

n. The commissioner shall maintain and periodically update a list of approved independent review organizations.

(e) Certification of Long-Term Care Insurance Independent Review Organizations. The commissioner shall certify or approve a qualified long-term care insurance independent review organization, provided the independent review organization demonstrates to the satisfaction of the commissioner that it is unbiased and meets the following qualifications:

(1) Have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured’s functional or cognitive impairment (e.g., physical therapy, occupational therapy, neurology, physical medicine, and rehabilitation) to conduct the review;

(2) Neither it nor any of its licensed health care professionals may, in any manner, be related to or affiliated with an entity that previously provided medical care to the insured;

(3) Utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured;

(4) Neither it nor its licensed health care professional who conducts the reviews may receive compensation of any type that is dependent on the outcome of the review;

(5) Be state approved or certified to conduct such reviews, if the state requires such approvals or certifications;

(6) Provide a description of the fees to be charged by it for independent reviews of a long-term care insurance benefit trigger decision. Such fees shall be reasonable and customary for the type of long-term care insurance benefit trigger decision under review;

(7) Provide the name of the medical director or health care professional responsible for the supervision and oversight of the independent review procedure; and

(8) Have on staff or contract with a licensed health care practitioner, as defined by section 7702B(c)(4) of the Internal Revenue Code of 1986, as amended, who is qualified to certify that an individual is chronically ill for purposes of a qualified long-term care insurance contract.

(f) Maintenance of Records and Reporting Obligations by Independent Review Organizations. Each certified independent review organization shall comply with the following:

(1) Maintain written documentation establishing the date it receives a request for independent review, the date each review is conducted, the resolution, the date such resolution was communicated to the insurer and the insured, and the name and professional status of the reviewer conducting such review in an easily accessible and retrievable format for the year in which it received the information, plus 2 calendar years;

(2) Be able to document measures taken to appropriately safeguard the confidentiality of such records and prevent unauthorized use and disclosures in accordance with applicable federal and state law;

(3) Report annually to the commissioner, by June 1, in the aggregate and for each long-term care insurer of all of the following:

a. The total number of requests received for independent review of long-term care benefit trigger decisions;

b. The total number of reviews conducted and the resolution of such reviews (i.e., the number of reviews which upheld or overturned the long-term care insurer’s determination that the benefit trigger was not met);

c. The number of reviews withdrawn prior to review;

d. The percentage of reviews conducted within the prescribed timeframe set forth in clause (d)(3)i. above; and

(4) Report immediately to the commissioner any change in its status which would cause it to cease meeting any of the qualifications required of an independent review organization performing independent reviews of long-term care benefit trigger decisions.

(g) Additional Rights. Nothing contained in this section shall limit the ability of an insurer to assert any rights an insurer may have under the policy related to:

(1) An insured’s misrepresentation;

(2) Changes in the insured’s benefit eligibility; and

(3) Terms, conditions, and exclusions of the policy, other than failure to meet the benefit trigger.

(h) Applicability. The requirements of this rule apply to a benefit trigger request made on or after the adoption of this rule under a long-term care insurance policy.

(i) Conflict with Other Laws. RSA 420-J:5-a, RSA 420-J:5-b; RSA 420-J:5-c, and Ins 2703 shall not be applicable for the purposes of external review requirements for long term care insurance.

History

#8036, eff 5-1-04; ss by #10154, eff 6-25-12 (from Ins 3601.27); ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.31 Prompt Payment of Clean Claims {#sec-ins-3601.31 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.31}

(a) For purposes of this section:

(1) “Claim” means a request for payment of benefits under an in-force policy, regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met; and

(2) “Clean claim” means a claim that has no defect or impropriety, including any lack of required substantiating documentation, such as satisfactory evidence of expenses incurred, or particular circumstance requiring special treatment that prevents timely payment from being made on the claim.

(b) Within 30 business days after receipt of a claim for benefits under a long-term care insurance policy or certificate, the insurer shall pay such claim, if it is a clean claim, or send a written notice acknowledging the date of receipt of the claim and one of the following:

(1) The insurer is declining to pay all or part of the claim and the specific reason(s) for denial; or

(2) That additional information is necessary to determine if all or any part of the claim is payable and the specific additional information that is necessary.

(c) Within 30 business days after receipt of all the requested additional information, an insurer shall pay a claim for benefits under a long-term care insurance policy or certificate if it is a clean claim, or send a written notice that the insurer is declining to pay all or part of the claim, and the specific reason or reasons for denial.

(d) If an insurer fails to comply with paragraph (b) or (c) above, such insurer shall pay interest at the rate of one percent per month on the amount of the claim that should have been paid but that remains unpaid 45 business days after the receipt of the claim with respect to paragraph (b) or all requested additional information with respect to paragraph (c). The interest payable pursuant to this paragraph shall be included in any late reimbursement without requiring the person who filed the original claim to make any additional claim for such interest.

(e) The provisions of Ins 3601.31 shall not apply where the insurer has a reasonable basis supported by specific information that such claim was fraudulently submitted.

(f) Any violation of this rule by an insurer, if committed flagrantly and in conscious disregard of the provisions of this rule or with such frequency as to constitute a general business practice, shall be considered a violation of RSA 417.

(g) The provisions of Ins 3601.31 supersede any other claim payment requirement found in RSA 415:6-h, RSA 415:18-k, RSA 420-A:17-d, and RSA 420-J:8-a.

History

#10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.32 Standard Format Outline of Coverage {#sec-ins-3601.32 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.32}

This section of the rule implements, interprets, and makes specific the provisions of RSA 415-D:8 in prescribing a standard format and the content of an outline of coverage.

(a) The outline of coverage shall be a free-standing document, using no smaller than 10 point type.

(b) The outline of coverage shall contain no material of an advertising nature.

(c) Text that is capitalized or underscored in the standard format outline of coverage may be emphasized by other means that provide prominence equivalent to the capitalization or underscoring.

(d) Use of the text and sequence of text of the standard format outline of coverage is mandatory, unless otherwise specifically indicated.

(e) Format for outline of coverage:

[COMPANY NAME]

[ADDRESS – CITY & STATE]

[TELEPHONE NUMBER]

LONG-TERM CARE INSURANCE

OUTLINE OF COVERAGE

[Policy Number or Group Master Policy and Certificate Number]

[Except for policies or certificates which are guaranteed issue, the following caution statement, or language substantially similar, shall appear as follows in the outline of coverage.]

Caution: The issuance of this long-term care insurance [policy] [certificate] is based upon your responses to the questions on your application. A copy of your [application] [enrollment form] [is enclosed] [was retained by you when you applied]. If your answers are incorrect or untrue, the company has the right to deny benefits or rescind your policy. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers are incorrect, contact the company at this address: [insert address]

This policy is [an individual policy of insurance] ([a group policy] which was issued in the [indicate jurisdiction in which group policy was issued]).
PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief description of the important features of the policy. You should compare this outline of coverage to outlines of coverage for other policies available to you. This is not an insurance contract, but only a summary of coverage. Only the individual or group policy contains governing contractual provisions. This means that the policy or group policy sets forth in detail the rights and obligations of both you and the insurance company. Therefore, if you purchase this coverage, or any other coverage, it is important that you READ YOUR POLICY (OR CERTIFICATE) CAREFULLY!
FEDERAL TAX CONSEQUENCES.

This [POLICY] [CERTIFICATE] is intended to be a federally tax-qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.

Federal Tax implications of this [POLICY] [CERTIFICATE]. This [POLICY] [CERTIFICATE] is not intended to be a federally tax-qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended. Benefits received under the [POLICY] [CERTIFICATE] may be taxable as income.

TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE CONTINUED IN FORCE OR DISCONTINUED.

(a) [For long-term care health insurance policies or certificates describe one of the following permissible policy renewability provisions:

(1) Policies and certificates that are guaranteed renewable shall contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS GUARANTEED RENEWABLE. This means you have the right, subject to the terms of your policy, [certificate] to continue this policy as long as you pay your premiums on time. [Company Name] cannot change any of the terms of your policy on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY.

(2) [Policies and certificates that are noncancellable shall contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS NONCANCELLABLE. This means that you have the right, subject to the terms of your policy, to continue this policy as long as you pay your premiums on time. [Company Name] cannot change any of the terms of your policy on its own and cannot change the premium you currently pay. However, if your policy contains an inflation protection feature where you choose to increase your benefits, [Company Name] may increase your premium at that time for those additional benefits.

(b) [For group coverage, specifically describe continuation/conversion provisions applicable to the certificate and group policy;]

TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS.

[In bold type larger than the maximum type required to be used for the other provisions of the outline of coverage, state whether or not the company has a right to change the premium, and if a right exists, describe clearly and concisely each circumstance under which the premium may change.]

TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED.

(a) [Provide a brief description of the right to return – "free look" provision of the policy.]

(b) [Include a statement that the policy either does or does not contain provisions providing for a refund or partial refund of premium upon the death of an insured or surrender of the policy or certificate. If the policy contains such provisions, include a description of them.]

THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide available from the insurance company.

(a) [For producers] Neither [insert company name] nor its producers represent Medicare, the federal government or any state government.

(b) [For direct response] [insert company name] is not representing Medicare, the federal government or any state government.

LONG-TERM CARE COVERAGE. Policies of this category are designed to provide coverage for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital, such as in a nursing home, in the community or in the home.

This policy provides coverage in the form of a fixed dollar indemnity benefit for covered long-term care expenses, subject to policy [limitations] [waiting periods] and [coinsurance] requirements. [Modify this paragraph if the policy is not an indemnity policy.]

BENEFITS PROVIDED BY THIS POLICY.

(a) [Covered services, related deductibles, waiting periods, elimination periods and benefit maximums.]

(b) [Institutional benefits, by skill level.]

(d) Eligibility for Payment of Benefits

[Activities of daily living and cognitive impairment shall be used to measure an insured's need for long-term care and shall be defined and described as part of the outline of coverage.]

[Any additional benefit triggers must also be explained. If these triggers differ for different benefits, explanation of the triggers should accompany each benefit description. If an attending physician or other specified person must certify a certain level of functional dependency in order to be eligible for benefits, this too must be specified.]

LIMITATIONS AND EXCLUSIONS.

[Describe:

(a) Preexisting conditions;

(b) Non-eligible facilities and provider;

(d) Exclusions and exceptions;

(e) Limitations.]

[This section should provide a brief specific description of any policy provisions that limit, exclude, restrict, reduce, delay, or in any other manner operate to qualify payment of the benefits described in Number 6 above.]

THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR LONG-TERM CARE NEEDS.

RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of long-term care services will likely increase over time, you should consider whether and how the benefits of this plan may be adjusted. [As applicable, indicate the following:

(a) That the benefit level will not increase over time;

(b) Any automatic benefit adjustment provisions;

(c) Whether the insured will be guaranteed the option to buy additional benefits and the basis upon which benefits will be increased over time if not by a specified amount or percentage;

(d) If there is such a guarantee, include whether additional underwriting or health screening will be required, the frequency and amounts of the upgrade options, and any significant restrictions or limitations;

(e) And finally, describe whether there will be any additional premium charge imposed, and how that is to be calculated.]

ALZHEIMER’S DISEASE AND OTHER ORGANIC BRAIN DISORDERS.

[State that the policy provides coverage for insureds clinically diagnosed as having Alzheimer's disease or related degenerative and dementing illnesses. Specifically describe each benefit screen or other policy provision which provides preconditions to the availability of policy benefits for such an insured.

PREMIUM.

[(a) State the total annual premium for the policy;

(b) If the premium varies with an applicant's choice among benefit options, indicate the portion of the annual premium that corresponds to each benefit option.]

ADDITIONAL FEATURES.

[(a) Indicate if medical underwriting is used;

(b) Describe other important features.]

CONTACT THE STATE SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM IF YOU HAVE GENERAL QUESTIONS REGARDING LONG-TERM CARE INSURANCE. CONTACT THE INSURANCE COMPANY IF YOU HAVE SPECIFIC QUESTIONS REGARDING YOUR LONG-TERM CARE INSURANCE POLICY OR CERTIFICATE.

History

#8036, eff 5-1-04, ss by 10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.33 Requirement to Deliver Shopper’s Guide {#sec-ins-3601.33 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.33}

(a) A long-term care insurance shopper’s guide in the format developed by the National Association of Insurance Commissioners, or a guide developed or approved by the commissioner, shall be provided to all prospective applicants of a long-term care insurance policy or certificate.

(1) In the case of producer solicitations, a producer shall deliver the shopper’s guide prior to the presentation of an application or enrollment form; and

(2) In the case of direct response solicitations, the shopper's guide shall be presented in conjunction with any application or enrollment form.

(b) Life insurance policies or riders containing accelerated long-term care benefits are not required to furnish the above-referenced guide, but shall furnish the policy summary required under RSA 415-D:8, VII.

History

#10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.34 Penalties {#sec-ins-3601.34 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.34}

In addition to any other penalties provided by the laws of this state, any insurer and any producer found to have violated any requirement of this state relating to the regulation of long-term care insurance or the marketing of such insurance shall be subject to a fine of up to 3 times the amount of any commissions paid for each policy involved in the violation or up to $10,000, whichever is greater.

History

#10154, eff 6-25-12; ss by #13400, eff 6-22-22

N.H. Code Admin. R. Ann. Ins 3601.35 Waiver of Rules {#sec-ins-3601.35 omnilex-key=us-nh-regs-official--agency-ins--Ins 3601.35}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX A

Rescission Reporting Form for

Long-Term Care Policies

For The State Of _____________

For The Reporting Year 20[ ]

Company Name: _______________________________________________________________

Address: _______________________________________________________________

Phone Number: _______________________________________________________________

Due: March 1 annually

Instructions:

The purpose of this form is to report all rescissions of long-term care insurance policies or certificates. Those rescissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.

Date of Date/s

Policy Policy and Name of Policy Claim/s Date of

Form # Certificate # Insured Issuance Submitted Rescission

Detailed reason for rescission:________________________________________________________________

Signature

Name and Title (please type)

Date

APPENDIX B

Long-Term Care Insurance

Personal Worksheet

This worksheet will help you understand some important information about this type of insurance. State law requires companies issuing this [policy] [certificate] [rider] to give you some important facts about premiums and premium increases and to ask you some important questions to help you and the company decide if you should buy this [policy] [certificate] [rider]. Long-term care insurance can be expensive and it may not be right for everyone.

Premium Information

The premium for the coverage you are considering will be [$_________ per [insert payment interval] or a total of [$_______ per year] [a one-time single premium of $____________].

The premium quoted in this worksheet is not guaranteed and may change during the underwriting process and in the future while this [policy] [certificate] [rider] is in force.

Type of Policy & The Company's Right to Increase Premiums on the Coverage You Choose:

[Noncancellable - The company cannot increase your premiums on this [policy] [certificate] [rider]].

[Guaranteed renewable - The company can increase your premiums on this [policy] [certificate] [rider] in the future if it increases the premiums for all [policies] [certificates] [riders] like yours in this state.]

[Paid-up - This [policy] [certificate] [rider] will be paid-up after you have paid all of the premiums specified in your [policy] [certificate] [rider]].

Premium Increase History

[Name of company] has sold long-term care insurance since [year] and has sold this [policy] [certificate] [rider] since [year].

[The company has never increased its premiums for any long-term care [policy] [certificate] [rider] it has sold in this state or any other state.]

[The company has not increased its premiums for this [policy] [certificate] [rider] or similar [policies] [certificates] [riders] in this state or any other state in the last 10 years.]

[The company has increased its premiums on this [policy] [certificate] [rider] or similar [policies] [certificates] [riders] in the last 10 years. A summary of those premium increases follows.]

(Note: The company may substitute the language below for the last sentence in the paragraph above and include the full summary as an attachment to this worksheet. “Over the past 3 years, the company has increased premiums by ___%.” “A summary of premium increases in the last 10 years is attached to this worksheet.”

Companies that have increased premiums by 30% or more in the last ten years must include the following statement: “There was a 30% or greater premium increase in _____[insert year].” “A summary of premium increases in the last 10 years is attached to this worksheet.”)

Questions About Your Income

You do not have to answer the questions that follow. They are intended to make sure you have thought about how you’ll pay premiums and the cost of care your insurance does not cover. If you do not want to answer these questions, you should understand that the company might refuse to insure you.

What resources will you use to pay your premium? □Current income from employment □Current income from investments □Other current income □Savings □Sell investments □Sell other assets □Money from my family □Other _______________

If you will be paying premiums with money received only from your own income, a rule of thumb is that you may not be able to afford this [policy] [certificate] [rider] if the premiums will be more than 7% of your income.

Could you afford to keep this [policy] [certificate] [rider] if your spouse or partner dies first?

□Yes □ No □Had not thought about it □Do not know □Does not apply

What would you do if the premiums went up, for example, by 50%?

□[Pay the higher premium □Call the company/agent □Reduce benefits □Drop the [policy] [certificate] [rider] □Do not know]

(Note: The company is not required to use the bracketed question above if the coverage is fully paid up or is noncancellable.)

What is your household annual income from all sources? (check one)

□[Less than $10,000] □$[10,000-19,999] □$[20,000-29,999] □$[30,000-50,000] □[More than $50,000]

Do you expect your income to change over the next 10 years? (check one)

□No □Yes, expect increase □Yes, expect decrease

If you plan to pay premiums from your income, have you thought about how a change in your income would affect your ability to continue to pay the premium?

□ Yes □ No □Do not know

Will you buy inflation protection? (check one)

□ Yes □ No

Inflation may increase the cost of long-term care in the future.

If you do not buy inflation protection, how will you pay for the difference between future costs and your daily benefit amount?

□From my income □From savings □From investments □Sell other assets □Money from my family □Other

The national average annual cost of long-term care in [insert year] was [insert $ amount], but this figure varies across the country. In ten years the national average annual cost would be about [insert $ amount] if costs increase 5% annually.

What [elimination period][waiting period][cash deductible] are you considering?

[Number of days ________ in [elimination period][waiting period]

Approximate cost of care for this period: $_________

($xxx per day times number of days in [elimination period] [waiting period], where “xxx” represents the most recent estimate of the national daily average cost of long-term care)]

[Cash Deductible $________]

How do you plan to pay for your care during the [elimination period] [waiting period] [deductible period]? (check all that apply)

□From my income □From my savings/investments □My family will pay

Questions About Your Savings and Investments

Not counting your home, about how much are all of your assets (your savings and investments) worth? (check one) □[Less than $20,000] □[$20,000-$29,999] □[$30,000-$49,999] □ [More than $50,000]

Do you expect the value of your assets to change over the next ten years? (check one)

□No □Yes, expect to increase □Yes, expect to decrease

If you’re buying this [policy] [certificate] [rider] to protect your assets and your assets are less than $50,000, experts suggest you think about other ways to pay for your long-term care.

Disclosure Statement

□ The answers to the questions above describe my financial situation.

□I choose not to complete this information.

(Check one.)

□ I agree that the company and/or its agent (below) has reviewed this worksheet with me including the premium, premium increase history and potential for premium increases in the future. I understand the information contained in this worksheet. (This box must be checked.)

(Note: For direct mail situations, the lead in sentence should be changed to “I agree that I have reviewed this worksheet including the premium….”)

Signed:____________________________________________________________

(Applicant) (Date)

[□I explained to the applicant the importance of answering these questions.

Signed:____________________________________________________________

(Agent) (Date)

Agent’s Printed Name:____________________________________________]

[In order for us to process your application, please return this signed worksheet to [name of company], along with your application.]

[My agent has advised me that this long-term care insurance [policy] [certificate] [rider] does not seem to be suitable for me. However, I still want the company to consider my application.

Signed:______________________________________________________________]

(Applicant) (Date)

(Note: Choose the appropriate sentences depending on whether this is a direct mail or agent sale.)

Someone from the company may contact you to discuss your answers and the suitability of this [policy] [certificate] [rider] for you.

APPENDIX C

Things You Should Know Before You Buy

Long-Term Care Insurance

Long-Term *A long-term care insurance policy may pay most of the costs of your care in a nursing

Care home. Many policies also pay for care at home or other community settings. Since

Insurance polices can vary in coverage, you should read this policy and make sure you understand

what it covers before you buy it.

*[You should not buy this insurance policy unless you can afford to pay the premiums

every year.] [Remember that the company can increase premiums in the future.]

*The personal worksheet includes questions designed to help you and the company

determine whether this policy is suitable for your needs.

Medicare *Medicare does not pay for most long-term care.

Medicaid *Medicaid will generally pay for long-term care if you have very little income and few

assets. You probably should not buy this policy if you are now eligible for Medicaid.

*Many people become eligible for Medicaid after they have used up their own financial

resources by paying for long-term care services.

*When Medicaid pays your spouse's nursing home bills, you are allowed to keep your

house and furniture, a living allowance, and some of your joint assets.

*Your choice of long-term care services may be limited if you are receiving Medicaid. To

learn more about Medicaid, contact your local or state Medicaid agency.

Shopper’s *Make sure the insurance company or agent gives you a copy of a book called the National

Guide Association of Insurance Commissioners’ “Shopper's Guide to Long-Term Care

Insurance”. Read it carefully. If you have decided to apply for long-term care

insurance, you have the right to return the policy within 30 days and get back any

premium you have paid if you are dissatisfied for any reason or choose not to purchase

the policy.

Counseling *Free counseling and additional information about long-term care insurance are available

through your state's insurance counseling program. Contact your state insurance

department or department on aging for more information about the senior health

insurance counseling program in your state.

Facilities *Some long-term care insurance contracts provide for benefit payments in certain facilities

only if they are licensed or certified, such as in assisted living centers. However, not all

states regulate these facilities in the same way. Also, many people move into a different

state from where they purchased their long-term care insurance policy. Read the policy

carefully to determine what types of facilities qualify for benefit payments, and to

determine payment for a covered service will be made if you move to a state that has a

different licensing scheme for facilities than the one in which you purchased the policy.

APPENDIX D

Long-Term Care Insurance Suitability Letter

Dear [Applicant]:

Your recent application for long-term care insurance included a “personal worksheet,” which asked questions about your finances and your reasons for buying long-term care insurance. For your protection, state law requires us to consider this information when we review your application, to avoid selling a policy to those who may not need coverage.

[Your answers indicate that long-term care insurance may not meet your financial needs. We suggest that you review the information provided along with your application, including the booklet “Shopper’s Guide to Long-Term Care Insurance” and the page titled “Things You Should Know Before Buying Long-Term Care Insurance. ” Your state insurance department also has information about long-term care insurance and may be able to refer you to a counselor free of charge who can help you decide whether to buy this policy.]

[You chose not to provide any financial information for us to review.]

We have suspended our final review of your application. If, after careful consideration, you still believe this policy is what you want, check the appropriate box below and return this letter to us within the next 60 days. We will then continue reviewing your application and issue a policy if you meet our medical standards.

If we do not hear from you within the next 60 days, we will close your file and not issue you a policy. You should understand that you will not have any coverage until we hear back from you, approve your application and issue you a policy.

Please check one box and return in the enclosed envelope.

□ Yes, [although my worksheet indicates that long-term care insurance may not be a suitable purchase,] I wish to purchase this coverage. Please resume review of my application.

□ No. I have decided not to buy a policy at this time. _________________________________________________ ___________________________________ APPLICANT’S SIGNATURE DATE

Please return to [issuer] at [address] by [date].

APPENDIX E

Claims Denial Reporting Form

Long-Term Care Insurance

For the State of ______________________________________________

For the Reporting Year of _____________________________________

Company Name: ___________________________________________ Due: June 30 annually

Company Address: ________________________________________________________________________

Company NAIC Number: _________________________________________________________

Contact Person: __________________________________ Phone Number: _____________________

Line of Business: Individual Group

Instructions

The purpose of this form is to report all long-term care claim denials under in force long-term care insurance policies. Indicate the manner of reporting by checking one of the boxes below:

⁭ Per Claimant - counts each individual who makes one or a series of claim requests.

⁭ Per Transaction - counts each claim payment request.

“Denied” means a claim that is not paid for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition. It does not include a request for payment that is in excess of the applicable contractual limits.

Inforce Data

State

Data

Nationwide

Data

Total Number of Inforce Policies [Certificates] as of December 31^st

Claims & Denial Data

State

Data

Nationwide

Data^[1]^[1]

Total Number of Long-Term Care Claims Reported

Total Number of Long-Term Care Claims Denied/Not Paid

Number of Claims Not Paid due to Preexisting Condition Exclusion

Number of Claims Not Paid due to Waiting (Elimination) Period Not Met

Net Number of Long-Term Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)

Percentage of Long-Term Care Claims Denied of Those Reported

(Line 5 Divided by Line 1)

Number of Long-Term Care Claims Denied due to:

· Long-Term Care Services Not Covered under the Policy^[2]^[2]

· Provider/Facility Not Qualified under the Policy^[3]^[3]

· Benefit Eligibility Criteria Not Met^[4]^[4]

· Other

The nationwide data may be viewed as a more representative and credible indicator where the data for claims reported and denied for your state are small in number.
Example—home health care claim filed under a nursing home only policy.
Example—a facility that does not meet the minimum level of care requirements or the licensing requirements as outlined in the policy.
Examples—a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.

APPENDIX F

Instructions: Insurers shall provide all of the following information to the applicant regarding premium, premium adjustments, potential premium increases, and policyholder options in the event of a premium increase except as noted below. This form does not need to be provided in the event the policy does not reserve the right to increase rates.

As used in this Appendix:

“Policy” shall mean policy, certificate, or rider, as applicable.

“Premium” shall include premium schedules, as applicable.

Companies may substitute whichever term is appropriate to reflect the long-term care insurance for which the applicant is applying.

Long-Term Care Insurance

Potential Premium Increase Disclosure Form

This policy is guaranteed renewable. Companies can increase the premiums for guaranteed renewable policies in the future. The company cannot increase your premiums because you are older or your health declines. It can increase premiums based on the experience of all individuals with a policy like yours.

What Is Your Premium?

The agent/company has quoted you a premium of [$________] for this policy. This is not a final premium. The premium might change during the underwriting process or if you choose different benefits. The premium you’ll be required to pay for your policy will be [shown on the schedule page of] [will be attached to] your policy.

How Will I Know If My Premium Is Changing?

The company will send you a notice. The notice will include the new premium and when you will start paying it. It also will give you ways you could avoid paying a higher premium. One likely choice will be to keep your insurance policy, but with fewer or lower benefits than you bought. Another choice may be to stop paying premiums and have a “paid-up” policy with fewer or lower benefits than the policy you bought. You may have other choices.

*Contingent Nonforfeiture

If the premium rate for your policies goes up in the future and you didn't buy a nonforfeiture option, you may be eligible for contingent nonforfeiture. Here's how to tell if you are eligible:

You will keep some long-term care insurance coverage, if:

· Your premium after the increase exceeds your original premium by the percentage shown (or more) in the following table; and

· You lapse (not pay more premiums) within 120 days of the increase.

The amount of coverage (i.e., new lifetime maximum benefit amount) you will keep will equal the total amount of premiums you've paid since your policy was first issued. If you have already received benefits under the policy, so that the remaining maximum benefit amount is less than the total amount of premiums you've paid, the amount of coverage will be that remaining amount.

Except for this reduced lifetime maximum benefit amount, all other policy benefits will remain at the levels attained at the time of the lapse and will not increase thereafter.

Should you choose this Contingent Nonforfeiture option, your policy, with this reduced maximum benefit amount, will be considered "paid-up" with no further premiums due.

Example:

· You bought the policy at age 65 and paid the $1,000 annual premium for 10 years, so you have paid a total of $10,000 in premium.

· In the eleventh year, you receive a rate increase of 50%, or $500 for a new annual premium of $1,500, and you decide to lapse the policy (not pay any more premiums).

· Your "paid-up" policy benefits are $10,000 (provided you have at least $10,000 of benefits remaining under your policy.)

Contingent Nonforfeiture

Cumulative Premium Increase over Initial Premium

That qualifies for Contingent Nonforfeiture

(Percentage increase is cumulative from date of original issue. It does NOT represent a one-time increase.)

Issue Age

Percent Increase Over Initial Premium

29 and under

200%

30-34

190%

35-39

170%

40-44

150%

45-49

130%

50-54

110%

55-59

90%

70%

66%

62%

58%

54%

50%

48%

46%

44%

42%

40%

38%

36%

34%

32%

30%

28%

26%

24%

22%

20%

19%

18%

17%

16%

15%

14%

13%

12%

11%

90 and over

10%

[The following contingent nonforfeiture disclosure need only be included for those limited pay policies to which Ins 3601.27(d)(4) and (d)(6) of the rule are applicable].

In addition to the contingent nonforfeiture benefits described above, the following reduced "paid-up" contingent nonforfeiture benefit is an option in all policies that have a fixed or limited premium payment period, even if you selected a nonforfeiture benefit when you bought your policy. If both the reduced "paid-up" benefit AND the contingent benefit described above are triggered by the same rate increase, you can chose either of the two benefits.

You are eligible for the reduced "paid-up" contingent nonforfeiture benefit when all three conditions shown below are met:

The premium you are required to pay after the increase exceeds your original premium by the same percentage or more shown in the chart below:

Triggers for a Substantial Premium Increase

Issue Age

Percent Increase

Over Initial Premium

Under 65

50%

65-80

30%

Over 80

10%

You stop paying your premiums within 120 days of when the premium increase took effect; AND
The ratio of the number of months you already paid premiums is 40% or more than the number of months you originally agreed to pay.

If you exercise this option your coverage will be converted to reduced "paid-up" status. That means there will be no additional premiums required. Your benefits will change in the following ways:

a. The total lifetime amount of benefits your reduced paid up policy will provide can be determined by multiplying 90% of the lifetime benefit amount at the time the policy becomes paid up by the ratio of the number of months you already paid premiums to the number of months you agreed to pay them.

b. The daily benefit amounts you purchased will also be adjusted by the same ratio.

If you purchased lifetime benefits, only the daily benefit amounts you purchased will be adjusted by the applicable ratio.

Example:

· You bought the policy at age 65 with an annual premium payable for 10 years.

· In the sixth year, you receive a rate increase of 35% and you decide to stop paying premiums.

· Because you have already paid 50% of your total premium payments and that is more than the 40% ratio, your "paid up" policy benefits are .45 (.90 times .50) times the total benefit amount that was in effect when you stopped paying your premiums. If you purchased inflation protection, it will not continue to apply to the benefits in the reduced "paid-up" policy.

APPENDIX G

Long-Term Care Insurance

Replacement and Lapse Reporting Form

For the State of ________________________ For the Reporting Year of _____________________

Company Name: __________________________________ Due: June 30 annually

Company Address: _____________________________Company NAIC Number: ____________

Contact Person: _______________Phone Number: ()

Instructions:

The purpose of this form is to report on a statewide basis information regarding long-term care insurance policy replacements and lapses. Specifically, every insurer shall maintain records for each producer on that producer's amount of long-term care insurance replacement sales as a percent of the producer's total annual sales and the amount of lapses of long-term care insurance policies sold by the producer as a percent of the producer's total annual sales. The tables below should be used to report the ten percent (10%) of the insurer's producers with the greatest percentages of replacements and lapses.

Listing of the 10% of Producers with the Greatest Percentage of Replacements

Producer's Name

Number of Policies Sold By This Producer

Number of Policies Replaced By This Producer

Number of Replacements As % of Number Sold By This Producer

Listing of the 10% of Producers with the Greatest Percentage of Lapses

Producer's Name

Number of Policies Sold By This Producer

Number of Policies Lapsed by This Producer

Number of Lapses As % of Number Sold By This Producer

Company Totals

Percentage of Replacement Policies Sold to Total Annual Sales ____%

Percentage of Replacement Policies Sold to Policies In Force (as of the end of the preceding

calendar year) ____%

Percentage of Lapse Policies to Total Annual Sales _____%

Percentage of Lapse Policies to Policies in Force (as of the end of the preceding calendar year) ____%

APPENDIX H

Guidelines for Long-Term Care Independent Review Entities

In order for an organization to qualify as an independent review organization for long-term care insurance benefits trigger decisions, it shall comply with all of the following:

a. The independent review organization shall ensure that all health care professionals on its staff and with whom it contracts to provide benefit trigger determination reviews hold a current unrestricted license or certification to practice a health care profession in the United States.

b. The independent review organization shall ensure that any health care professional on its staff and with whom it contracts to provide benefit trigger determination reviews who is a physician holds a current certification by a recognized American medical specialty board in a specialty appropriate for determining an insured's functional or cognitive impairment.

c. The independent review organization shall ensure that any health care professional on its staff and with whom it contracts to provide benefit trigger determination reviews who is not a physician holds a current certification in the specialty in which that person is licensed, by a recognized American specialty board in a specialty appropriate for determining an insured's functional or cognitive impairment.

d. The independent review organization shall ensure that all health care professionals on its staff and with whom it contracts to provide benefit trigger determination reviews have no history of disciplinary actions or sanctions including, but not limited to, the loss of staff privileges or any participation restriction taken or pending by any hospital or state or federal government regulatory agency.

e. The independent review organization shall ensure that neither it, nor any of its employees, agents, or licensed health care professionals utilized for benefit trigger determination reviews receives compensation of any type that is dependent on the outcome of the review.

f. The independent review organization shall ensure that neither it, nor any of its employees, agents, or licensed health care professionals it utilizes for benefit trigger determination reviews are in any manner related to, employed by or affiliated with the insurer, insured or with a person who previously provided medical care or long term care services to the insured.

g. The independent review organization shall provide a description of the qualifications of the reviewers retained to conduct independent review of long-term care insurance benefit trigger decisions, including the reviewer's current and past employment history, practice affiliations and a description of past experience with decisions relating to long-term care, functional capacity, dependency in activities of daily living, or in assessing cognitive impairment. Specifically, with regard to reviews of tax qualified long-term care insurance contracts, it must demonstrate the ability to assess the severity of cognitive impairment requiring substantial supervision to protect the individual from harm, or with assessing deficits in the ability to perform without substantial assistance from another person at least two activities of daily living for a period of at least 90 days due to a loss of functional capacity.

h. The independent review organization shall provide a description of the procedures employed to ensure that reviewers conducting independent reviews are appropriately licensed, registered or certified; trained in the principles, procedures and standards of the independent review organization; and knowledgeable about the functional or cognitive impairments associated with the diagnosis and disease staging processes, including expected duration of such impairment, which is the subject of the independent review.

i. The independent review organization shall provide the number of reviewers retained by the independent review organization and a description of the areas of expertise available from such reviewers and the types of cases such reviewers are qualified to review (e.g., assessment of cognitive impairment or inability to perform activities of daily living due to a loss of functional capacity).

j. The independent review organization shall provide a description of the policies and procedures employed to protect confidentiality of protected health information, in accordance with federal and state law.

k. The independent review organization shall provide a description of its quality assurance program.

l. The independent review organization shall provide the names of all corporations and organizations owned or controlled by the independent review organization or which own or control the organization, and the nature and extent of any such ownership or control. The independent review organization shall ensure that neither it, nor any of its employees, agents, or licensed health care professionals utilized are not a subsidiary of, or owned or controlled by, an insurer or by a trade association of insurers of which the insured is a member.

m. The independent review organization shall provide the names and resumes of all directors, officers and executives of the independent review organization.

History

#13400, eff 6-22-22

Part Ins 3602 New Hampshire Long-Term Care Partnership Program

N.H. Code Admin. R. Ann. Ins 3602.01 Purpose {#sec-ins-3602.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.01}

The purpose of this part is to implement filing, notice, and exchange requirements for the New Hampshire long-term care partnership program.

History

#9654, eff 2-16-10; ss by #12472, eff 2-16-18

N.H. Code Admin. R. Ann. Ins 3602.02 Applicability and Scope {#sec-ins-3602.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.02}

This part shall be applicable to all long-term care insurance policies and to any policy or certificate that will be marketed and sold under the New Hampshire long-term care partnership program.

History

#9654, eff 2-16-10; ss by #12472, eff 2-16-18

N.H. Code Admin. R. Ann. Ins 3602.03 Definitions {#sec-ins-3602.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.03}

(a) "Commissioner" means the commissioner of the New Hampshire insurance department.

(b) "Exchange" means an exchange of a long-term care policy or certificate that was issued on or after February 8, 2006, including an exchange of a non-certified partnership policy or certificate, for a New Hampshire partnership policy or certificate.

(d) "New Hampshire long-term care partnership program" means a program established under the Federal Deficit Reduction Act of 2005 and approved under Medicaid State Plan Amendment 07-009.

(e) "Non-certified partnership policy or certificate" means insurance coverage under a long-term care policy or certificate that was issued in New Hampshire on or after February 8, 2006, and contains all necessary provisions, including the necessary inflation protection requirements, to qualify as New Hampshire partnership coverage pursuant to §1917(b)(1)(C)(iii) of the Social Security Act, 42 U.S.C. §1396p(b)(1)(C)(iii), but where the policy or certificate form has not yet been approved by the New Hampshire insurance department as a New Hampshire partnership policy or certificate.

(f) "New Hampshire partnership policy or certificate" means long-term care coverage that qualifies as a partnership policy or certificate pursuant to §1917(b)(1)(C)(iii) of the Social Security Act, 42 U.S.C. §1396p (b)(1)(C)(iii) and has been filed and approved by the insurance department as a partnership policy or certificate under the New Hampshire long-term care partnership program.

History

#9654, eff 2-16-10; ss by #12472, eff 2-16-18

N.H. Code Admin. R. Ann. Ins 3602.04 Notification, Offer of Exchange {#sec-ins-3602.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.04}

(a) Except as provided in (b), within 365 calendar days from the date that an insurer begins to advertise, market, offer, or sell coverage under the New Hampshire long-term care partnership program, the insurer shall offer, on a one-time basis to all policyholders or certificateholders that were issued long-term care insurance on or after February 8, 2006, the option to exchange existing long term-care coverage for a New Hampshire partnership policy or certificate as follows:

(1) An insurer shall advise policyholders by written notice of their right to exchange their current long-term care policy for a partnership policy;

(2) This notice shall include a provision giving the policyholder up to 90 calendar days from the date of the notice to make their intention to exchange known to the insurance company; and

(3) If the policy is a group long-term care policy and an exchange is permitted by the policyholder, each certificateholder shall be given notice of the option to exchange the certificate for a certificate providing partnership coverage within 90 calendar days of the mailing of the notice by the insurer.

(b) Within 90 calendar days from the date that an insurer begins to advertise, market, offer, or sell coverage under the New Hampshire long-term care partnership program, the insurer shall deliver to any policyholder or certificateholder who was issued a non-certified partnership policy or certificate, an endorsement approved under Ins 3602.07(b) together with a notice that informs the policyholder or certificateholder that the policy or certificate qualifies as a New Hampshire partnership policy or certificate.

History

#9654, eff 2-16-10; ss by #12472, eff 2-16-18

N.H. Code Admin. R. Ann. Ins 3602.05 Exchanges {#sec-ins-3602.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.05}

(a) The insurer shall exchange long-term care coverage that was purchased on or after February 8, 2006 for partnership coverage in one of the following ways:

(1) For all non-certified partnership policies or certificates, by adding an endorsement that all the provisions required to qualify the policy as a New Hampshire partnership policy have been met and the policy is a New Hampshire partnership policy; or

(2) By exchanging an existing policy or certificate for a new partnership policy or certificate or by adding a rider or endorsement to an existing policy or certificate.

(b) The following provisions shall apply to any exchange:

(1) If the new coverage has an actuarial value of benefits equal to or lesser than the actuarial value of benefits of the existing coverage, based on uniform assumptions as determined on the date of issue for a new insured, then:

a.. The new policy or certificate shall not be underwritten; and

b. The rate charged for the new policy or certificate shall be determined using the original issue age and risk class of the insured that was used to determine the rate of the existing policy;

(2) If the new coverage has an actuarial value of benefits exceeding the actuarial value of benefits of the existing coverage, based on uniform assumptions, as determined on the date of issue for a new insured, then:

a. The insurer shall apply its new business, long-term care underwriting guidelines to the increased benefits only; and

b. The rate charged for the new policy or certificate shall be determined using the method set forth in subparagraph (b)(1)b. above for the existing benefits, increased by the rate for the increased benefits using the current attained age and risk class of the insured for the increased benefits only;

(3) Any exchange offer shall be made to all policyholders and certificateholders on a nondiscriminatory basis;

(4) Except for an exchange of a non-certified partnership policy or certificate pursuant to (a)(1) of this section, an exchange offer shall be deferred for any policyholder or certificateholder who is currently within an elimination period under the policy or is receiving benefits under the policy. Such deferral shall continue so long as the eligibility for benefits or elimination period exists;

(5) In addition to the requirements of this part, all exchanges shall comply with the requirements of Ins 3601, provided however that Ins 3601.23 shall not apply to the exchange of a non-certified partnership policy or certificate for a New Hampshire partnership policy or certificate when the new coverage has an actuarial value of benefits equal to or lesser than the actuarial value of benefits of the original non-certified partnership policy or certificate;

(6) The new coverage offered shall be on a New Hampshire partnership policy or certificate form that is approved for sale in the general market;

(7) The insurer shall issue the disclosure notice as set forth in Ins 3602.06(a)(2); and

(8) The insured shall not lose any rights, benefits, or built-up value that have accrued under the original policy with respect to the benefits provided under the original policy, including, but not limited to, rights established because of the lapse of time related to pre-existing condition exclusions, elimination periods, or incontestability clauses.

History

#9654, eff 2-16-10; ss by #12472, eff 2-16-18

N.H. Code Admin. R. Ann. Ins 3602.06 Standards and Reporting Requirements for Approved Long-Term Care Partnership Policies and Certificates {#sec-ins-3602.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.06}

(a) The following standards shall apply to all insurers that issue or deliver New Hampshire partnership policies or certificates:

(1) In addition to the required filing and approval pursuant to this part, any policy or certificate marketed or represented to be a New Hampshire partnership policy or certificate shall comply with the following requirements:

a. The insured individual shall be a resident of New Hampshire when coverage first becomes effective under the policy. If the policy or certificate is exchanged pursuant to Ins 3602.05, the individual shall have been a resident of New Hampshire when coverage first became effective under the original policy;

b. The coverage shall be intended to be a qualified long-term care insurance coverage under the provisions of Ins 3601.05 (a)(5); and

c. The policy or certificate shall be issued with and shall retain inflation coverage that meets the inflation standards specified in Ins 3601.12;

(2) The following notices shall be required:

a. A disclosure notice that explains the benefits associated with the policy or certificate and indicates that, at the time issued, the policy qualified as a New Hampshire partnership policy. The required disclosure notice shall appear verbatim as follows:

“Partnership Status Disclosure Notice for Long-Term Care

Partnership Policies/Certificates

IMPORTANT INFORMATION REGARDING THE NEW HAMPSHIRE

LONG-TERM CARE PARTNERSHIP PROGRAM

Note: It is very important that you keep this Disclosure Notice with your Long-Term Care Insurance Policy or Certificate.

Insured Name: ___________________________________________

Policy Name: ____________________________________________

Date of Issue: ____________________________________________

The long-term care insurance policy/certificate that you have purchased currently qualifies for the New Hampshire Long-Term Care Partnership Program.

Insurance companies voluntarily agree to participate in the Partnership Program by offering long-term care insurance coverage that meets certain State and Federal requirements. Policies that qualify as Partnership Policies protect your assets through a feature known as an "asset disregard" under the New Hampshire Medicaid program.

Asset Disregard "Asset Disregard" means that an amount of your assets equal to the amount of long-term care insurance benefits you have received under your Partnership Policy will not be counted for the purpose of determining your eligibility for Medicaid. This generally allows you to keep additional assets equal to the insurance benefits received under your Partnership Policy without affecting your eligibility for Medicaid. All other Medicaid eligibility criteria will still apply. This "Asset Disregard" is only available if you have a Partnership Policy. The purchase of a Partnership Policy guarantees that if you qualify for the Medicaid program, you can retain additional assets as described above. However, the purchase of a Partnership Policy does not automatically qualify you for the Medicaid program.

Partnership Policy/Certificate Status. Your long-term care insurance policy is a Partnership Policy under the New Hampshire Long-Term Care Partnership Program as of your policy's effective date.

What Could Disqualify Your Policy from the Partnership Program. If you make any changes to your policy/certificate, such changes could affect whether your policy continues to be a Partnership Policy. Before you make any changes, you should consult with [name of insurance company] to determine the effect of the proposed change. In addition, if you move to a state that does not maintain a Partnership Program or does not recognize your policy as a Partnership Policy, you may not receive beneficial treatment such as asset disregard under the Medicaid program in that state.

The information contained in this notice is based on New Hampshire and Federal laws in effect the date your policy was issued. These laws are subject to change.

Additional Information. If you have any questions regarding your insurance policy/certificate please contact [insert name of insurer]. If you have questions regarding current laws governing Medicaid eligibility, you should contact the:

New Hampshire Department of Health and Human Services

Division of Family Assistance

Brown Building, 129 Pleasant Street, Concord, NH (street address)

129 Pleasant Street, Concord, NH 03301-3857 (mailing address)

Telephone: 603-271-9700 or 800-852-3345, ext. 9700”

b. The following requirements and procedures shall apply to (2)a. above:

The insurer shall provide the insured’s name, the policy name, and the date of issue in the spaces provided in the disclosure notice;
The text in the notice shall be in at least 12-point type and shall follow the order of the information presented in (2)a.; and
An insurer may modify the format but shall not change the order of the mandated text from that specified in (2)a., if the insurer files the form for review and approval by the commissioner in compliance with Ins 401.13;

c. When an insurer is made aware that a policyholder or certificateholder has initiated action that will result in the loss of partnership status, the insurer shall provide an explanation of how such action impacts the insured in writing. The insurer shall also advise the policyholder or certificateholder on how to retain partnership status if possible;

d. If a partnership policy subsequently loses partnership status, the insurer shall explain to the policyholders or certificateholders in writing within 60 calendar days of the loss the reason for the loss of status;

e. All insurers shall provide upon request and without charge to any insured under a New Hampshire partnership policy or certificate, or to any New Hampshire resident insured under a long-term care insurance policy or certificate that is afforded reciprocity pursuant to the standards established under 42 U.S.C. §1396p(b)(1)(C)(iii), a written summary of policy information that shall include the following:

The name of the insured;
The policy or certificate number;
The effective date of coverage;
The state in which the policy or certificate was issued;
The age of the insured at the time the coverage was issued;
In regard to any inflation coverage, the following information:

(i) Whether the policy was issued with or without inflation coverage;

(ii) A description of any inflation coverage currently in effect; and

(iii) Whether any inflation coverage provided is simple inflation coverage or compound inflation coverage;

f. Whether the policy is intended to meet the standards of a tax qualified long-term care policy;

g. The cumulative dollar amount of insurance benefits paid to the insured only, excluding any payments for cash surrender, return of premium death benefit, or waiver of premium. The date such cumulative dollar amount was calculated shall also be provided;

h. The total dollar amount of insurance benefits remaining available under the policy, and the date such total remaining benefits were calculated;

i. The date the form was completed; and

j. The name, address, telephone, and email address of the person completing the form; and

(3) Under §1917(b)(5)(B)(iii) of the Social Security Act 42 U.S.C. §1396p(b)(5)(B)(iii), the commissioner, in implementing the New Hampshire long-term care partnership program, shall certify that long-term care insurance policies and certificates covered under the partnership program meet certain consumer protection requirements, and policies. The consumer protection requirements shall be as set forth in §1917(b)(5)(A) of the Social Security Act and principally include certain specified provisions of the National Association of Insurance Commissioners long-term care model act 640 and model regulation 641, as updated in 2017 and available as referenced in Appendix II. In providing this certification, the commissioner shall require the certification by insurers made in accordance with Appendix III Long-Term Care Partnership Program Insurer Certification Form.

(b) In accordance with §1917(b)(1)(C)(iii)(VI) and (v) of the Social Security Act, all issuers of partnership policies or certificates shall provide regular reports to the secretary of the Federal Department of Health and Human Services (secretary) in accordance with 45 CFR Part 144, Subpart B.

(1) Notification regarding when insurance benefits provided under partnership policies or certificates have been paid and the amount of such benefits paid; and

(2) Notification regarding when such policies or certificates otherwise terminate.

History

#9654, eff 2-16-10; ss by #12472, eff 2-16-18

N.H. Code Admin. R. Ann. Ins 3602.07 Inflation Protection Requirements for Long-Term Care Partnership Policies and Certificates. {#sec-ins-3602.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.07}

Pursuant to §1917(b)(1)(C)(iii)(IV) of the Social Security Act 42 U.S.C. §1396p(b)(1)(C)(iii)(IV), an insurer shall not issue a policy or certificate marketed or represented as a partnership policy unless the policy or certificate complies with the following inflation protection requirements:

(a) For a person who is less than 61 years of age, as of the date of purchase, the policy or certificate shall provide compound annual inflation protection from the date of purchase as follows:

(1) At the time of purchase, insurers shall offer to each applicant the option to purchase compound annual inflation protection that automatically increases each year on a compounded basis at a rate of not less than 5.0 percent annually throughout the interval of coverage. The inflation protection shall automatically increase benefits each year on a compounded basis;

(2) If the applicant declines the offer of inflation protection specified in (1) above, then the insurer shall offer and the applicant shall purchase and retain compound annual inflation protection until the insured attains age 61 or goes on claim status, whichever comes first. The inflation protection is required to automatically increase benefits each year on a compounded basis at a rate that the insured elects, which may be in a range from one percent to 4 percent or tied to the consumer price index for all urban consumers (CPI-U); and

(3) A person who is less than 61 years of age that has purchased a long-term care partnership policy or certificate with the required compound inflation protection specified in this paragraph may, upon attaining 61 years of age, choose to amend the compound inflation protection provision in the policy or certificate in accordance with the requirements specified in (b) below.

(b) For a person who is at least 61 years of age but less than 76 years of age as of the date of purchase, the policy or certificate shall provide an acceptable level of inflation protection from the date of purchase as follows:

(1) Regardless of the insured's health status, the insurer shall offer and the insured shall purchase and retain inflation protection until the insured attains age 76 or goes on claim status, whichever comes first;

(2) Acceptable coverage shall include automatic annual inflation protection, either simple or compound, paid with either level or stepped premium;

(3) Inflation protection as required by this paragraph shall be in a range of from one percent to 5 percent or tied to the consumer price index for all urban consumers (CPI-U); and

(4) A person who is less than 76 years of age that has purchased a long-term care partnership policy or certificate with the required inflation protection specified in this paragraph may, upon attaining 76 years of age, choose to amend the inflation protection provision in the policy or certificate in accordance with the requirements specified in (c) below.

(c) For any person who has attained the age of 76, inflation protection may be provided but is not required. However, the long-term care inflation protection option specified in Ins 3601.12 relating to Requirement to Offer Inflation Protection shall be offered to any applicant for a partnership policy who has attained the age of 76.

(d) An option to purchase inflation protection at a future time shall not constitute compliance with the inflation protection requirements set forth in (a) and (b) above.

(e) The inflation protection provisions in this section shall not be available under the following policies:

(1) Riders for group and individual annuities and life insurance policies that provide long-term care insurance; and

(2) Life insurance policies:

a. That accelerate the death benefit for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement;

b. That provide the option of a lump-sum payment for those benefits; and

c. Where neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care.

History

#9654, eff 2-16-10; ss by #12472, eff 2-16-18

N.H. Code Admin. R. Ann. Ins 3602.08 Filing Requirements for Long-Term Care Partnership Policies {#sec-ins-3602.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.08}

(a) Each New Hampshire partnership policy or certificate, including any long-term care partnership endorsement issued or delivered, shall comply with the following requirements before being issued or delivered:

(1) Each New Hampshire partnership policy, certificate, or endorsement shall be filed with the department and approved by the commissioner in accordance with the requirements and procedures set forth in Ins 401.13; and

(2) Each New Hampshire partnership policy, certificate, or endorsement filing shall include a Long-Term Care Partnership Program Insurer Certification Form, as specified in Appendix III, which shall comply with the following requirements and procedures:

a. The text in the certification form shall be in at least 10-point type and shall follow the order of the information presented in Appendix III. The text in the certification form as specified in Appendix III shall be mandatory; and

b. An insurer may modify the format but shall not change the order of the mandated text from that specified in Appendix III, if the insurer files the certification form for review and approval by the commissioner in compliance with Ins 401.13.

(b) A previously approved non-certified partnership policy or certificate form shall be approved as a New Hampshire partnership policy or certificate form upon the filing and approval of:

(1) The Long-Term Care Partnership Program Insurer Certification Form set forth in Appendix III;

(2) An endorsement identifying the policy as a New Hampshire partnership policy; and

(3) The previously approved policy or policy and certificate if the policy is a group policy.

(c) Insurers shall notify the commissioner, via an informational System for Electronic Rate and From Filing (SERFF) filing, within 15 calendar days of beginning to advertise, market, offer, or sell partnership policies under the New Hampshire long-term care partnership program.

History

#9654, eff 2-16-10; ss by #12472, eff 2-16-18

N.H. Code Admin. R. Ann. Ins 3602.09 Waiver or Suspension of Rules {#sec-ins-3602.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 3602.09}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX I

Rule

Specific State Statute the Rule Implements

Ins 3601.01

RSA 400-A:15, I; RSA 415-D:1

Ins 3601.02

RSA 400-A:15, I; RSA 415-D:2

Ins 3601.03

RSA 400-A:15, I; RSA 415-D:3

Ins 3601.04

RSA 400-A:15, I; RSA 415-D:5

Ins 3601.05

RSA 400-A:15, I; RSA 415-D:5 through 10

Ins 3601.06

RSA 400-A:15, I; RSA 415-D:10

Ins 3601.07

RSA 400-A:15, I; RSA 415-D:5

Ins 3601.08

RSA 400-A:15, I; RSA 415-D:3, 5 and 6

Ins 3601.09

RSA 400-A:15, I; RSA 415-D:11

Ins 3601.10

RSA 400-A:15, I; RSA 415-D:5

Ins 3601.11

RSA 400-A:15, I; RSA 415-D:5 and 8

Ins 3601.12

RSA 400-A:15, I; RSA 415-D:8

Ins 3601.13

RSA 400-A:15, I; RSA 415-D:6 and 7

Ins 3601.14

RSA 400-A:15, I; RSA 415-D:12

Ins 3601.15

RSA 400-A:15, I; RSA 402-J; RSA 415-D:12

Ins 3601.16

RSA 400-A:14; RSA 400-A:15, I; 415-D:1 and 12

Ins 3601.17

RSA 400-A:15, I; RSA 410; 415-D:12

Ins 3601.18

RSA 400-A:15, I; RSA 415-D:3, VI; RSA 415-D:5, IV(e)

Ins 3601.19

RSA 400-A:15, I; RSA 415-D:3 and 8; RSA 415-D:3; RSA 415-D:8

Ins 3601.20

RSA 415-D:4, 11 and 12

Ins 3601.21

RSA 400-A:15, I; RSA 415-D:1 and 3, V; RSA 415-D:12

Ins 3601.22

RSA 400-A:15, I; RSA 415-D:1 and 3, V; RSA 415-D:5, 8, 11 and 12

Ins 3601.23

RSA 400-A:15, I; RSA 415-D:1 and 3, VIII; RSA 415-D:5

Ins 3601.24

RSA 400-A:15, I; RSA 415-D:5

Ins 3601.25

RSA 400-A:15, I; RSA 415-D:5; 415-D:8

Ins 3601.26

RSA 400-A:15, I; RSA 415-D:5; 415-D:8

Ins 3601.27

RSA 400-A:15, I; RSA 415-D:10

Ins 3601.28

RSA 400-A:15, I; RSA 415-D:5

Ins 3601.29

RSA 400-A:15, I; RSA 415-D:5

Ins 3601.30

RSA 400-A:15, I; RSA 415-D:3, VIII; RSA 415-D:5, II; RSA 415-D:8

Ins 3601.31

RSA 400-A:15, I; RSA 415-D:3, VIII; RSA 415-D:5, II; RSA 415-D:8, IX

Ins 3601.32

RSA 400-A:15, I; RSA 415-D:8

Ins 3601.33

RSA 400-A:15, I; RSA 415-D:5, VII

Ins 3601.34

RSA 400-A:15, I and III

Ins 3601.35

RSA 400-A:15, I; RSA 541-A:22, IV

Appendix A

RSA 400-A:15, I; RSA 415-D:1; RSA 415-D:5; RSA 415-D:8

Appendix B

RSA 400-A:15, I; RSA 415-D:1; RSA 415-D:5; RSA 415-D:8

Appendix C

RSA 400-A:15, I; RSA 415-D:1; RSA 415-D:5; RSA 415-D:8

Appendix D

RSA 400-A:15, I; RSA 415-D:1; RSA 415-D:5; RSA 415-D:8

Appendix E

RSA 400-A:15, I; RSA 415-D:1; RSA 415-D:5; RSA 415-D:8

Appendix F

RSA 400-A:15, I; RSA 415-D:1; RSA 415-D:5; RSA 415-D:8

Appendix G

RSA 400-A:15, I; RSA 415-D:1; RSA 415-D:5; RSA 415-D:6; RSA 415-D:8

Appendix H

RSA 400-A:15, I; RSA 415-D:1; RSA 415-D:5; RSA 415-D:8

Ins 3602.01

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:1,12; 42 U.S.C. §1396p

Ins 3602.02

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:2,12; 42 U.S.C. §1396p

Ins 3602.03

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:3,12; 42 U.S.C. §1396p

Ins 3602.04

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:5,12; 42 U.S.C. §1396p

Ins 3602.05

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:5, 6, 9, 11,12; 42 U.S.C. §1396p

Ins 3602.06

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:5, 8, 11,12; 42 U.S.C. §1396p

Ins 3602.07

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:5,12; 42 U.S.C. §1396p

Ins 3602.08

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:5, 11, 12; 42 U.S.C. §1396p

Ins 3602.09

RSA 400-A:15, I

Appendix I

42 U.S.C. §1396p; RSA 167:4, IV(d); RSA 415-D:5,8,12

Appendix II

42 U.S.C. §1396p; RSA 167:4, IV(d); RSA 415-:5,6,9,10,11,12

Appendix III

RSA 400-A:15, I; RSA 167:4, IV(d); RSA 415-D:5, 6, 9, 10, 11,12;

APPENDIX II

Rule

Title

Obtain at:

Ins 3602.06(a)(3)

Appendix III

NAIC 2017 Long-Term Care Insurance Model Act; published by NAIC as MDL-640

Available for no cost on-line at: http://www.naic.org/store/free/MDL-640.pdf

Ins 3602.06(a)(3)

Appendix III

NAIC 2017 Long-Term Care Insurance Model Regulation; published by NAIC as MDL-641

Available for no cost on-line at: http://www.naic.org/store/free/MDL-641.pdf

Appendix III

Long-Term Care Partnership Program Insurer Certification Form

Section 1917(b)(5)(B)(iii) of the Social Security Act, 42 U.S.C. §1396p(b)(5)(B)(iii), authorizes the New Hampshire insurance commissioner upon implementing a qualified state long-term care partnership program ("qualified partnership") to certify that long-term care insurance policies (including certificates issued under a group insurance contract) covered under the qualified partnership meet certain consumer protection requirements, and policies so certified are deemed to satisfy such requirements. These consumer protection requirements are set forth in §1917(b)(5)(A) of the Social Security Act, 42 U.S.C. §1396p(b)(5)(A) and principally include certain specific provisions of the long-term care insurance model regulation and long-term care insurance model act promulgated by the National Association of Insurance Commissioners, referred to herein as the "Model Regulation 641" and "Model Act 640" respectively, and available as referenced in Appendix II.

In order to provide the Insurance Commissioner with information necessary to provide a certification for policies, this issuer certification form requests information and a certification from issuers of long-term care insurance policies with respect to policy forms that may be covered under the qualified partnership program of the state.

An insurance company may request certification of policies from time to time and, accordingly, may supplement this issuer certification form, e.g., as it introduces new long-term insurance policy forms for issuance.

I. GENERAL INFORMATION

A. Name, address and telephone number of issuer:

B. Name, address, telephone number, and email address (if available) of an employee of issuer who will be the contact person for information relating to this form:

C. Policy form number(s) (or other identifying information, such as certificate series) for policies covered by this issuer certification form:

Copies of each of the above referenced policy forms, including any riders and endorsements, shall be provided.

II. QUESTIONS REGARDING APPLICABLE PROVISIONS OF THE MODEL REGULATION 641 AND MODEL ACT 640

Please answer each of the questions below with respect to the policy forms identified in section I.C. above. For purposes of answering the questions below, any provision of the Model Regulation 641 or Model Act 640 listed below shall be treated as including any other provision of the Model Regulation 641 or Model Act 640 necessary to implement the provision.

Are the following requirements of the Model Regulation 641 met with respect to all policies (including certificates issued under a group insurance contract) intended to be covered under the qualified partnership program that are issued on each of the policy forms identified in Section I.C. above?

Yes___

No___

N/A___

Section 6A (relating to guaranteed renewal or noncancellability), other than paragraph (5) thereof, and the requirements of section 6B of the Model Act 640 relating to such section 6A.

Yes___

No___

N/A___

Section 6B (relating to prohibitions on limitations and exclusions) other than paragraph (7) thereof.

Yes___

No___

N/A___

Section 6C (relating to extension of benefits).

Yes___

No___

N/A___

Section 6D (relating to continuation or conversion of coverage).

Yes___

No___

N/A___

Section 6E (relating to discontinuance and replacement of policies).

Yes___

No___

N/A___

Section 7 (relating to unintentional lapse).

Yes___

No___

N/A___

Section 8 (relating to disclosure), other than sections 8F, 8G, 8H, and 8I thereof.

Yes___

No___

N/A___

Section 9 (relating to required disclosure of rating practices to consumer).

Yes___

No___

N/A___

Section 11 (relating to prohibitions against post-claims underwriting).

Yes___

No___

N/A___

Section 12 (relating to minimum standards).

Yes___

No___

N/A___

Section 14 (relating to application forms and replacement coverage).

Yes___

No___

N/A___

Section 15 (relating to reporting requirements).

Yes___

No___

N/A___

Section 22 (relating to filing requirements for advertising).

Yes___

No___

N/A___

Section 23 (relating to standards for marketing).

Yes___

No___

N/A___

Section 24 (relating to suitability).

Yes___

No___

N/A___

Section 25 (relating to prohibition against preexisting conditions and probationary periods in replacement policies or certificates).

Yes___

No___

N/A___

Section 28 (the provisions relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in section 7702B(g)(4) of the Internal Revenue Code of 1986, 26 U.S.C. 7702BJ(g)(4).

Yes___

No___

N/A___

Section 33 (relating to standard format outline of coverage).

Yes___

No___

N/A___

Section 34 (relating to requirement to deliver shopper's guide).

Are the following requirements of the Model Act 640 met with respect to all policies (including certificates issued under a group insurance contract) intended to be covered under the qualified partnership program that are issued on each of the policy forms identified in section I.C. above?

Yes___

No___

N/A___

Section 6C (relating to preexisting conditions).

Yes___

No___

N/A___

Section 6D (relating to prior hospitalization).

Yes___

No___

N/A___

Section 8 (provisions relating to contingent nonforfeiture benefits).

Yes___

No___

N/A___

Section 6F (relating to right to return).

Yes___

No___

N/A___

Section 6G (relating to outline of coverage).

Yes___

No___

N/A___

Section 6H (relating to requirements for certificates under group plans).

Yes___

No___

N/A___

Section 6J (relating to policy summary).

Yes___

No___

N/A___

Section 6K (relating to monthly reports on accelerated death benefits).

Yes___

No___

N/A___

Section 7 (relating to incontestability period).

In order for a policy to be covered under the qualified partnership program of the state, the answers to all questions above should be "yes" (or "N/A" where all requirements with respect to a provision are not applicable). If answers differ between policy forms (e.g., a requirement would be answered "Yes" for one form and "N/A" for another), you should use separate issuer certification forms for such policies.

III. CERTIFICATION

I hereby certify that the policy forms and endorsements identified in section C. above meet all of the requirements of the National Association of Insurance Commissioners' Long-Term Care Model Act 640 and Model Regulation 641 that are specified in 42 U.S.C. §1396p(b)(1)(C)(iii) and further certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct, and complete.

Date Name and Title of Officer of the Issuer

Signature of Officer of the Issuer

History

#12472, eff 2-16-18

Chapter Ins 3700 Standards for Safeguarding Customer Information

Part Ins 3701 Standards

N.H. Code Admin. R. Ann. Ins 3701.01 Purpose and Scope {#sec-ins-3701.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.01}

(a) This rule establishes standards for developing and implementing administrative, technical and physical safeguards to protect the security, confidentiality and integrity of customer information, pursuant to Sections 501, 505(b), and 507 of the Gramm-Leach-Bliley Act, codified at 15 U.S.C. 6801, 6805(b) and 6807.

(b) Section 501(a) provides that it is the policy of the Congress that each financial institution has an affirmative and continuing obligation to respect the privacy of its customers and to protect the security and confidentiality of those customers’ nonpublic personal information. Section 501(b) requires the state insurance regulatory authorities to establish appropriate standards relating to administrative, technical and physical safeguards:

(1) To ensure the security and confidentiality of customer records and information;

(2) To protect against any anticipated threats or hazards to the security or integrity of such records; and

(3) To protect against unauthorized access to or use of records or information that could result in substantial harm or inconvenience to a customer.

(c) Section 505(b)(2) calls on state insurance regulatory authorities to implement the standards prescribed under Section 501(b) by rule with respect to persons engaged in providing insurance.

(d) Section 507 provides, among other things, that a state rule may afford persons greater privacy protections than those provided by subtitle A of Title V of the Gramm-Leach-Bliley Act. This rule requires that the safeguards established pursuant to this rule shall apply to nonpublic personal information, including nonpublic personal financial information and nonpublic personal health information.

History

#7964, eff 1-1-04; ss by #8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.02 Definitions {#sec-ins-3701.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.02}

For purposes of this rule, the following definitions apply:

(a) “Customer” means a customer of the licensee as the term customer is defined in Ins 3001.04 (i).

(b) “Customer information” means nonpublic personal information as defined in Ins 3001.04 (s) about a customer, whether in paper, electronic or other form, that is maintained by or on behalf of the licensee.

(c) “Customer information systems” means the electronic or physical methods used to access, collect, store, use, transmit, protect or dispose of customer information.

(d) “Licensee” means a licensee as that term is defined in Ins 3001.04 (q), except that “licensee” shall not include: a purchasing group; or an unauthorized insurer in regard to the excess line business conducted pursuant to RSA 406-B.

(e) “Service provider” means a person that maintains, processes or otherwise is permitted access to customer information through its provision of services directly to the licensee.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.03 Information Security Program {#sec-ins-3701.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.03}

Each licensee shall implement a comprehensive written information security program that includes administrative, technical and physical safeguards for the protection of customer information. The administrative, technical and physical safeguards included in the information security program shall be appropriate to the size and complexity of the licensee and the nature and scope of its activities.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.04 Objectives of Information Security Program {#sec-ins-3701.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.04}

A licensee’s information security program shall be designed to:

(a) Ensure the security and confidentiality of customer information;

(b) Protect against any anticipated threats or hazards to the security or integrity of the information; and

(c) Protect against unauthorized access to or use of the information that could result in substantial harm or inconvenience to any customer.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.05 Examples of Methods of Development and Implementation {#sec-ins-3701.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.05}

The actions and procedures described in Ins 3701.06 through Ins 3701.09 are examples of methods of implementation of the requirements of Ins 3701.03 and Ins 3701.04. These examples are non-exclusive illustrations of actions and procedures that licensees may follow to implement Ins 3701.03 and Ins 3701.04.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.06 Assess Risk {#sec-ins-3701.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.06}

The licensee:

(a) Identifies reasonably foreseeable internal or external threats that could result in unauthorized disclosure, misuse, alteration or destruction of customer information or customer information systems;

(b) Assesses the likelihood and potential damage of these threats, taking into consideration the sensitivity of customer information; and

(c) Assesses the sufficiency of policies, procedures, customer information systems and other safeguards in place to control risks.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.07 Manage and Control Risk {#sec-ins-3701.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.07}

The licensee:

(a) Designs its information security program to control the identified risks, commensurate with the sensitivity of the information, as well as the complexity and scope of the licensee’s activities;

(b) Trains staff, as appropriate, to implement the licensee’s information security program; and

(c) Regularly tests or otherwise regularly monitors the key controls, systems and procedures of the information security program. The frequency and nature of these tests or other monitoring practices are determined by the licensee’s risk assessment.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.08 Oversee Service Provider Arrangements {#sec-ins-3701.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.08}

The licensee:

(a) Exercises appropriate due diligence in selecting its service providers; and

(b) Requires its service providers to implement appropriate measurers designed to meet the objectives of this rule, and, where indicated by the licensee’s risk assessment, takes appropriate steps to confirm that its service providers have satisfied these obligations.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.09 Adjust the Program {#sec-ins-3701.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.09}

The licensee monitors, evaluates and adjusts, as appropriate, the information security program in light of any relevant changes in technology, the sensitivity of its customer information, internal or external threats to information, and the licensee’s own changing business arrangements, such as mergers and acquisitions, alliances and joint ventures, outsourcing arrangements and changes in customer information systems.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3701.10 Violations {#sec-ins-3701.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 3701.10}

Violations of any of the provisions of this part shall be subject to the penalties of RSA 400-A:15 III.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

Part Ins 3702 Customer Notice

N.H. Code Admin. R. Ann. Ins 3702.01 Purpose and Scope {#sec-ins-3702.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3702.01}

This part establishes the standards for the notice to customers of a security breach involving the unauthorized access or use of the customer's information.

History

#7964, eff 1-1-04; ss by #8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3702.02 Definitions {#sec-ins-3702.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3702.02}

For the purposes of this part, definitions shall be the same as those delineated at Ins 3701.02 with the following exceptions:

(a) "Customer information" means nonpublic personal information as defined in RSA 359-C:19, IV. (a) and (b) about a customer, in electronic form, that is maintained by or on behalf of the licensee.

(b) "Unauthorized access to customer information" means the unauthorized acquisition of customer information that compromises the security, confidentiality or integrity of the customer information.

History

#8901, eff 7-1-07; ss by #8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3702.03 Standards for Providing Notice {#sec-ins-3702.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3702.03}

(a) When a licensee becomes aware of an incident of unauthorized access to customer information, the licensee shall immediately conduct an investigation to promptly determine the likelihood that the information has been or will be misused.

(b) If a licensee determines that misuse of its customer information has occurred or is reasonably likely to occur or if a determination cannot be made, it shall notify:

(1) The department as soon as possible; and

(2) The affected customer or customers as soon as possible with written notice to each affected customer in no later than 30 days and in compliance with paragraph (c) of this section.

(1) Five days after the licensee submits the notice to the department for review; or

(2) Receipt from the department of approval of the written notice that has been filed.

(d) Customer notice may be delayed if a law enforcement agency determines that notification will interfere with a criminal investigation and provides the licensee with a written request for the delay. However, the licensee shall notify its customer or customers pursuant to (b) above as soon as the law enforcement agency informs the licensee that notification will no longer interfere with the investigation.

History

#8901, eff 7-1-07; ss by #8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3702.04 Affected Customers {#sec-ins-3702.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3702.04}

(a) If a licensee, based upon its investigation, can determine from its logs or other data precisely which customers' information has been improperly accessed, it may limit notification to those customers with regard to whom the licensee determines that misuse of their information has occurred or is reasonably possible.

(b) If the licensee is unable to identify which specific customers' information has been accessed, it shall notify all customers by substitute notice in accordance with RSA 359-C:20 III. (d).

History

#8901, eff 7-1-07; ss by #8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3702.05 Content of Customer Notice {#sec-ins-3702.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3702.05}

(a) Customer notice shall be given in a clear and conspicuous manner. The notice shall describe the incident in general terms, the type of customer information that was the subject of the unauthorized access or use and the approximate date of the breach.

(b) The notice shall include a telephone number that customers may call for further information and assistance.

(1) A general description of what the licensee has done to protect the customers' information from further unauthorized access;

(2) A reminder to customers of the need to remain vigilant over the next year or two to promptly report incidents of suspected identify theft to the licensee and the appropriate authorities;

(3) A recommendation that the customer review bank and creditor statements and immediately report any suspicious activity to the appropriate authorities;

(4) A description of fraud alerts and an explanation of how the customer may place a fraud alert in the customer's consumer reports to put the customer's creditors on notice that the customer may be a victim of fraud;

(5) A recommendation that the customer periodically obtain credit reports from each nationwide credit reporting agency and have information relating to fraudulent transactions deleted; and

(6) An explanation of how the customer may obtain a credit report free of charge.

History

#8901, eff 7-1-07; ss by #8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3702.06 Delivery of {#sec-ins-3702.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3702.06}

Customer Notice.

(a) Customer notice shall be delivered in any manner designed to ensure that a customer can be expected to receive it. The licensee may choose to contact all customers affected by telephone provided the licensee maintains a log of each such notification, or by U.S. mail, or by electronic mail if the customer has agreed to receive communications electronically.

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

N.H. Code Admin. R. Ann. Ins 3702.07 Violations {#sec-ins-3702.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3702.07}

Violations of any of the provisions of this part shall be subject to the penalties of RSA 400-A:15 III.

APPENDIX

RULE

STATUTE IMPLEMENTED

Ins 3701.01

RSA 400-A:15, I.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.02

RSA 400-A:15, I.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.03

RSA 400-A:15, I.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.04

RSA 400-A:15, I.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.05

RSA 400-A:15, I.; 359-C:20, I. (b); 359-C:20, V.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.06

RSA 400-A:15, I.; 359-C:20, V.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.07

RSA 400-A:15, I.; 359-C:20, V.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.08

RSA 400-A:15, I.; 359-C:20, V.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.09

RSA 400-A:15, I.; 359-C:20, V.; 15 USC 6805(b)(2), (a)(6)

Ins 3701.10

RSA 400-A:15, I.; 359-C:20, V.; 15 USC 6805(b)(2), (a)(6)

Ins 3702.01

RSA 400-A:15 I.; 15 USC 6805(b)(2), (a)(6)

Ins 3702.02

RSA 400-A:15 I.; 15 USC 6805(b)(2), (a)(6)

Ins 3702.03

RSA 400-A:15 I.; 359-C:20 V.; 15 USC 6805(b)(2), (a)(6)

Ins 3702.04

RSA 400-A:15 I.; 359-C:20 V.; 15 USC 6805(b)(2), (a)(6)

Ins 3702.05

RSA 400-A:15 I.; 359-C:20 V.; 15 USC 6805(b)(2), (a)(6)

Ins 3702.06

RSA 400-A:15 I.; 359-C:20 V.; 15 USC 6805(b)(2), (a)(6)

Ins 3702.07

RSA 400-A:15 I.; 359-C:20 V.; 15 USC 6805(b)(2), (a)(6)

History

#8901, eff 7-1-07, EXPIRED: 7-1-15
#11015, eff 1-8-16

Chapter Ins 3900 Other Insurances

Part Ins 3901 Group Disability Insurance Claim Processing Standards

N.H. Code Admin. R. Ann. Ins 3901.01 Purpose and Scope {#sec-ins-3901.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3901.01}

In accordance with RSA 415-A and the U.S. Department of Labor Benefit Claims Procedure Regulation, 29 CFR 2560.503, this section establishes the minimum requirements for carriers pertaining to the processing of claims for disability benefits by participants and claimants. These requirements shall apply to every group policy provided by the carrier that contains disability benefits.

History

#8020, eff 3-1-04; ss by #10122, eff 5-1-12

N.H. Code Admin. R. Ann. Ins 3901.02 Definitions {#sec-ins-3901.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3901.02}

(a) "Adverse benefit determination" means a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or claimant's eligibility to participate in a plan, and including a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

(b) "Health care professional" means a physician or other health care provider who is licensed, accredited, or certified to perform specified health services consistent with state law.

(c) "Relevant to a claimant's claim" means, when used in reference to a document, record or other information, that the document, record or other information:

(1) Was relied upon in making the benefit determination;

(2) Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;

(3) Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination; or

(4) Constitutes a statement of policy or guidance with respect to the carrier's policy concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

History

#8020, eff 3-1-04; ss by #10122, eff 5-1-12

N.H. Code Admin. R. Ann. Ins 3901.03 Claims Procedures {#sec-ins-3901.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3901.03}

(a) Health carriers that offer disability benefits shall establish and maintain reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations, hereinafter collectively referred to as claims procedures. The claims procedures shall be deemed by the department to be reasonable only if:

(1) They contain a description of all procedures, including any procedures for obtaining prior approval as a prerequisite for obtaining a benefit, such as preauthorization procedures or utilization review procedures and the applicable time frames as part of a summary plan description;

(2) They do not contain any provision, and are not administered in a way, that unduly inhibits or hampers the initiation or processing of claims for benefits. A provision or practice that requires payment of a fee or costs as a condition to making a claim or to appealing an adverse benefit determination would be considered by the department to unduly inhibit the initiation and processing of claims for benefits, as would the denial of a claim for failure to obtain a prior approval under circumstances that would make obtaining such prior approval impossible or where application of the prior approval process could seriously jeopardize the life or health of the claimant;

(3) They do not preclude an authorized representative of a claimant from acting on behalf of such claimant in pursuing a benefit claim or appeal of an adverse benefit determination. Nevertheless, a plan may establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a claimant; and

(4) They contain administrative processes and safeguards designed to ensure and to verify that benefit claim determinations are made in accordance with governing policy documents and that, where appropriate, the provisions in the policy have been applied consistently with respect to similarly situated claimants.

(b) Appeal of adverse benefit determinations. The claims procedures of group disability coverage for appealing adverse benefit determinations shall be deemed by the department to be reasonable only if:

(1) They do not contain any provision, and are not administered in a way, that requires a claimant to file more than two appeals of an adverse benefit determination prior to bringing a civil action;

(2) To the extent that a carrier offers voluntary levels of appeal, including voluntary arbitration or any other form of dispute resolution, the procedures provide that:

a. The carrier waives any right to assert that a claimant has failed to exhaust administrative remedies because the claimant did not elect to submit a benefit dispute to any such voluntary level of appeal provided by the carrier;

b. The carrier agrees that any statute of limitations or other defense based on timeliness is tolled during the time that any such voluntary appeal is pending;

c. The claims procedures provide that a claimant may elect to submit a benefit dispute to such voluntary level of appeal only after exhaustion of the appeals permitted by this rule;

d. The carrier provides to any claimant, upon request, sufficient information relating to the voluntary level of appeal to enable the claimant to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal, including a statement that the decision of a claimant as to whether or not to submit a benefit dispute to the voluntary level of appeal will have no effect on the claimant's rights to any other benefits under the plan and information about the applicable rules, the claimant's right to representation, the process for selecting the decision maker, and the circumstances, if any, that may affect the impartiality of the decision maker, such as any financial or personal interests in the result or any past or present relationship with any party to the review process; and

e. No fees or costs are imposed on the claimant as part of the voluntary level of appeal.

(3) The claims procedures do not contain any provision for the mandatory arbitration of adverse benefit determinations, except to the extent that the plan or procedures provide that:

a. The arbitration is conducted as one of the two appeals referenced in paragraph (b)(1) of this section; and

b. The claimant is not precluded from challenging the decision under any applicable law.

(c) Notification of benefit determination. The claims procedures of group disability coverage for notifying a claimant of a benefit determination shall be deemed reasonable by the department only if:

(1) Timing of notification.

a. When a claim is wholly or partially denied, the carrier's procedures require it to notify the claimant of the carrier's adverse benefit determination within a reasonable period of time, but not later than 45 days after the carrier's receipt of the claim. This period may be extended for up to 30 days, provided that the carrier both determines that such an extension is necessary due to matters beyond its control and notifies the claimant, prior to the expiration of the initial 45-day period, of the circumstances requiring the extension of time and the date by which the carrier expects to render a decision. If, prior to the end of the first 30-day extension period, the carrier determines that, due to matters beyond the control of the carrier, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to an additional 30 days, provided that the carrier notifies the claimant, prior to the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date as of which the carrier expects to render a decision. In the case of any extension, the notice of extension shall specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues, and the claimant shall be afforded at least 45 days within which to provide the specified information; and

b. In calculating time periods for benefit determinations, the period of time within which a benefit determination is required to be made shall begin at the time a claim is filed in accordance with the reasonable procedures of a carrier, without regard to whether all the information necessary to make a benefit determination accompanies the filing. In the event that a period of time is extended due to a claimant's failure to submit information necessary to decide a claim, the period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

(2) Contents of notification. The carrier shall provide a claimant with written or, if requested by the claimant, electronic notification of any adverse benefit determination. The notification shall set forth, in a manner calculated to be understood by the claimant:

a. The specific reason or reasons for the adverse determination;

b. Reference to the specific policy provisions on which the determination is based;

c. A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary;

d. A description of the carrier's review procedures and the time limits applicable to such procedures, including a statement of the claimant's right to bring a civil action following an adverse benefit determination on review;

e. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, the carrier shall either provide a copy of the specific rule, guideline, protocol, or other similar criterion, or explain when the rule, guideline, protocol, or other similar criterion that was relied upon in making the adverse determination will be provided; and

f. If the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, the carrier shall either provide an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant's medical circumstances, or state that such explanation will be provided free of charge upon request.

(d) Appeal of adverse benefit determinations. Every carrier that offers group disability insurance shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the carrier, and under which there will be a full and fair review of the claim and the adverse benefit determination. The claims procedures of a group disability policy will not be deemed by the department to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless the claims procedures:

(1) Provide a claimant with at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination;

(2) Provide for a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the carrier who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual;

(3) Provide that, in deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment;

(4) Provide for the identification of medical or vocational experts whose advice was obtained on behalf of the carrier in connection with a claimant's adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination;

(5) Provide that the health care professional engaged for purposes of a consultation shall be an individual who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual;

(6) Provide claimants with the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits;

(7) Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claimant's claim for benefits to include specific information relating to any denial of benefits; and

(8) Provide for a review that takes into account all comments, documents, records and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

(e) Timing of notification of benefit determination on review.

(1) The carrier shall notify a claimant of the outcome of the review conducted under Ins 3901.03(d) within a reasonable period of time, but not later than 45 days after receipt of the claimant's request for review by the carrier, unless the carrier determines that special circumstances (such as the need to hold a hearing, if the carrier's procedures provide for a hearing) require an extension of time for processing the claim. If the carrier determines that an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 45-day period. In no event shall such extension exceed a period of 45 days from the end of the initial period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the carrier expects to render the determination on review; and

(2) Calculating time periods. The period of time within which a benefit determination on review is required to be made shall begin at the time an appeal is filed in accordance with the procedures the carrier has established pursuant to Ins 3901.03(a), without regard to whether all the information necessary to make a benefit determination on review accompanies the filing. In the event that a period of time is extended due to a claimant's failure to submit information necessary to decide a claim, the period for making the benefit determination on review shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

(f) Manner and content of notification of benefit determination on review. The carrier shall provide a claimant with written or, if requested by the claimant, electronic notification of its benefit determination on review. The notification shall set forth, in a manner calculated to be understood by the claimant:

(1) The specific reason or reasons for the adverse determination;

(2) Reference to the specific policy provisions on which the benefit determination is based;

(3) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits; and

(4) A statement describing any voluntary appeal procedures offered by the plan and the claimant's right to obtain the information about such procedures and a statement of the claimant's right to bring a legal action.

(5) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, the carrier shall provide the claimant with either the specific rule, guideline, protocol, or other similar criterion; or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and shall agree to provide a copy of the rule, guideline, protocol, or other similar criterion free of charge to the claimant upon request;

(6) If the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, the carrier shall provide either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request; and

(7) The carrier shall include in the notice of adverse benefit determination the 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 US department of labor office or the New Hampshire insurance department."

History

#8020, eff 3-1-04; ss by #10122, eff 5-1-12

N.H. Code Admin. R. Ann. Ins 3901.04 Failure to Establish and Follow Reasonable Claims Procedures {#sec-ins-3901.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3901.04}

In the case of the failure of a carrier to establish or follow its claims and appeals procedures, a claimant shall be deemed by the department to have exhausted the administrative remedies available under the plan and shall be entitled to pursue any available legal remedies on the basis that the carrier has failed to provide a reasonable claims procedure that would yield a decision on the merits of the claim.

History

#8020, eff 3-1-04; ss by #10122, eff 5-1-12

N.H. Code Admin. R. Ann. Ins 3901.05 Effective Date {#sec-ins-3901.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3901.05}

This section shall apply to claims filed under a plan on or after March 1, 2004.

History

#8020, eff 3-1-04; ss by #10122, eff 5-1-12

Part Ins 3902 Individual Supplemental Unemployment Insurance

N.H. Code Admin. R. Ann. Ins 3902.01 Purpose {#sec-ins-3902.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.01}

The purpose of this part is to permit the sale of individual supplementary insurance against the loss of income due to the involuntary loss of employment and to establish standards governing such coverage.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.02 Scope {#sec-ins-3902.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.02}

This part shall apply to all licensed insurers authorized to insure casualty risks.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.03 Definitions {#sec-ins-3902.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.03}

(a) “Individual supplemental unemployment insurance” means individual insurance that provides supplemental benefits, paid directly to an insured, for protection against the loss of income due to the involuntary loss of employment.

(b) “Loss of income” means loss of income as the result of any loss of employment resulting in qualification for unemployment benefits.

(c) “Involuntary loss of employment” means any loss of employment that qualifies an individual for unemployment benefits whether or not the loss of employment is considered involuntary or voluntary as part of the relevant unemployment statutory scheme.

(d) “Unemployment benefits” means the cash benefits paid in accordance with state unemployment benefit law, Chapter 282-A, or any federal unemployment cash benefits that are administered by the state.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.04 Benefits {#sec-ins-3902.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.04}

(a) Benefits shall be paid weekly for any involuntary loss of employment, so long as:

(1) The insured has been approved to receive unemployment benefits; and

(2) Any waiting period or exclusionary period has elapsed.

(b) The maximum weekly unemployment benefit payable under a supplemental unemployment insurance policy shall be 50 percent of weekly wages minus the amount of maximum weekly unemployment benefits at the time of application for coverage.

(c) For purposes of determining the maximum weekly benefit payable to the insured under (b) above, weekly wages shall be the lesser of:

(1) The weekly wages reported by the insured to the insurer at the time of initial application, or any subsequent agreed upon increase in equivalent weekly wages and corresponding increased limits; or

(2) The insured’s weekly wages as determined by state unemployment compensation records.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.05 Exclusionary Periods {#sec-ins-3902.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.05}

(a) A policy of individual supplemental unemployment insurance shall not provide for more than a 6 month exclusionary period, commencing with the initial policy’s effective date.

(b) If the insured begins a period of involuntary unemployment during an exclusionary period, the policy shall be terminated and the insurer shall provide a full refund of premiums paid.

(c) If the insured receives advance oral, written, or other notice of impending unemployment during an exclusionary period and thereafter begins a period of involuntary unemployment at the same job during the initial policy period that is directly related to that notice, the policy shall be terminated and the insurer shall provide a full refund of premium paid.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.06 Mandatory Disclosures {#sec-ins-3902.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.06}

The insurer shall disclose the following information to the insured at the time of the issuance of coverage:

(a) The premium for the initial term of the insurance coverage;

(b) The term of the insurance coverage;

(c) The number of weekly payments payable to the insured under the policy, and any limitations on the amount of such payments;

(d) A detailed description how any waiting period, exclusionary period, or elimination period affects benefits payable under the policy; and

(e) The specific requirements that shall be met if the insured wishes to cancel the policy.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.07 Mandatory Minimum Policy Provisions {#sec-ins-3902.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.07}

(a) All supplemental insurance policies shall contain the following provisions:

(1) A provision stating that the policy shall conform and operate consistently with the applicable federal and state laws and rules concerning unemployment insurance, including any amendments to those laws and rules taking effect during the term of the policy;

(2) A provision that gives the insured the right to cancel the policy within 30 days of the insured’s receipt of the policy, with full premium refund, and at no cost to the insured;

(3) A provision that terminates the policy, with a full refund of premiums paid, at no cost to the insured, if the insured becomes unemployed during any exclusionary period or receives advance oral, written, or other notice of impending unemployment during the exclusionary period, and thereafter begins a period of involuntary unemployment in the same job during the initial period that is directly related to the notice; and

(4) A provision that gives the insured the right to cancel the policy at any time after 30 days, with a refund of unearned premium.

(b) Supplemental unemployment insurance shall be subject to all laws and rules governing liability insurance sold under authority of RSA 401:1,V, including, but not limited to, the cancellation and nonrenewal provisions for liability insurance under RSA 417-B except as provided above.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.08 Repayment of Benefits {#sec-ins-3902.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.08}

No insurer shall seek repayment of benefits paid under a supplemental unemployment policy based upon a reversal of a state decision with respect to eligibility for unemployment benefits unless:

(a) The state department of employment security has made a finding of fault in accordance with its administrative rules; or

(b) The insured has been found to have made a material misrepresentation in the application for coverage that led to approval of the application, where an accurate representation would have resulted in a denial of the application.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.09 Penalties {#sec-ins-3902.09 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.09}

Any insurer who shall knowingly violate any provision of this part shall be subject to the provisions of RSA 400-A:15, III.

History

#10863, eff 8-1-15; ss by #14507, eff 2-7-26, EXPIRES: 2-7-36

N.H. Code Admin. R. Ann. Ins 3902.10 Waiver of Rules {#sec-ins-3902.10 omnilex-key=us-nh-regs-official--agency-ins--Ins 3902.10}

(1) Applying the rule provision would cause confusion or would be misleading to consumers;

(2) The rule provision is in whole or in part inapplicable to the given circumstances;

(3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or

(4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(b) No requirement prescribed by statute shall be waived unless expressly authorized by law.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

APPENDIX

Rule

Specific State Statute the Rule Implements

Ins 3901.01

RSA 415-A:6, II and 29 CFR 2560.503

Ins 3901.02

RSA 415-A:6, II and 29 CFR 2560.503

Ins 3901.03

RSA 415-A:6, II and 29 CFR 2560.503

Ins 3901.04

RSA 415-A:6, II and 29 CFR 2560.503

Ins 3901.05

RSA 415-A:6, II and 29 CFR 2560.503

Ins 3902.01

RSA 401:1-a, II

Ins 3902.02

RSA 401:1-a, II

Ins 3902.03

RSA 401:1-a, II

Ins 3902.04

RSA 401:1-a, II

Ins 3902.05

RSA 401:1-a, II

Ins 3902.06

RSA 401:1-a, II

Ins 3902.07

RSA 401:1-a, II; RSA 401:1, V

Ins 3902.08

RSA 401:1-a, II

Ins 3902.09

RSA 401:1-a, II; RSA 400-A:15, III

Ins 3902.10

RSA 400-A:15, I; RSA 541-A:22, IV

History

#14507, eff 2-7-26, EXPIRES: 2-7-36

Chapter Ins 4000 Uniform Reporting System for Health Care Claims Data Sets

Part Ins 4001 Purpose and Scope

N.H. Code Admin. R. Ann. Ins 4001.01 Purpose and Scope {#sec-ins-4001.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4001.01}

This chapter contains procedures and substantive requirements for the submission of health care data under RSA 420-G:11, II to the New Hampshire Comprehensive Health Information System by insurance companies, third-party payers, third-party administrators, pharmacy benefit managers, and carriers that provide administrative services for a plan sponsor.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

Part Ins 4002 Definitions

N.H. Code Admin. R. Ann. Ins 4002.01 Definitions {#sec-ins-4002.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4002.01}

Unless the context indicates otherwise, the following words and phrases shall have the following meanings:

(a) “Address” means street addresses, post office box numbers, apartment numbers, email addresses, web universal resource locators (URLs), and internet protocol (IP) address numbers;

(b) “Alternative payment arrangements” means those claims considered paid by the carrier or third-party administrator under a capitated services arrangement or a global payment, resulting in zero paid amounts on the claim;

(d) “Capitated services” means services rendered by a provider through a contract in which payment is based upon a fixed dollar amount for each member on a monthly basis;

(e) “Carrier” means any entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to provide, deliver, arrange for, pay for, or reimburse any of the costs of health services, or to administer on behalf of a third-party payer, and includes an insurance company, a health maintenance organization, a nonprofit health services corporation, a dental benefits administrator, a third-party administrator, or any other entity arranging for or providing health coverage, Medicare Supplemental, and Medicare Advantage plans;

(f) “Commissioner” means the New Hampshire insurance commissioner;

(g) “Dental claims file” means a data file composed of service level remittance information for all adjudicated claims for each billed dental service provided to members, including data for services provided under alternative payment arrangements with zero paid amounts;

(h) “Department (NHID)” means the New Hampshire insurance department;

(i) “Designee” means an entity with which the department or the department of health and human services have entered into an arrangement pursuant to which the entity performs data management and collecting functions and under which the entity is strictly prohibited from using or releasing the information and data obtained in such a capacity for any purposes other than those specified in the agreement;

(j) “Department of Health and Human Services (DHHS)” means the New Hampshire department of health and human services;

(k) “Direct identifier” means any information, other than case or code numbers used to create anonymous or encrypted data, that plainly discloses the identity of an individual as referenced in 45 CFR Part 164.514 (e)(2);

(l) “Encryption” means a method by which the true value of data has been disguised in order to prevent the identification of persons or groups and which does not provide the means for recovering the true value of the data;

(m) “Exchange” means a governmental agency or non-profit entity that meets the applicable standards of 42 U.S.C. section 13031 and makes qualified health plans available to qualified individuals and qualified employers in accordance with federal law;

(n) “Health care claims data” means the set of data files that are filed by carriers and third-party administrators under this chapter consisting of, or derived directly from, member eligibility, medical claims, pharmacy claims, and dental claims files, including a provider file. “Health care claims data” does not include analysis, reports, or studies containing information from health care claims data sets, if those analyses, reports, or studies have already been released in response to another request for information or as part of a general distribution of public information by the department;

(o) “Hospital” means a licensed acute or specialty care institution;

(p) “Insured” means an individual in whose name an insurance policy is issued;

(q) “Medical claims file” means a data file composed of service level remittance information for all adjudicated claims for each billed medical service provided to members, including data for services provided under alternative payment arrangements with zero paid amounts;

(r) “Members” means all individuals, employees, and dependents for which the health carrier or third-party administrator has an obligation to adjudicate, pay, or disburse claim payments. The term includes “covered lives”. For employer-sponsored group coverage, members include certificate holders and their dependents;

(s) “Member eligibility file” means a data file containing demographic information for each individual member eligible for medical, pharmacy, or dental benefits for one or more days of coverage at any time during the reporting month as well as any retrospective updates that correspond to previously submitted eligibility data. The term also includes benefits attributed and associated effective periods;

(t) “New Hampshire Comprehensive Health Information System (NHCHIS)” means the system established and operated by the department and the department of health and human services or its designee to collect, store, and analyze health care claims data;

(u) “Pharmacy benefit manager” means “pharmacy benefit manager” as defined in RSA 402-N:1;

(v) “Pharmacy claims file” means a data file composed of service level remittance information from all adjudicated claims for each billed prescription provided to members, including data for services provided under alternative payment arrangements with zero paid amounts;

(w) “Plan ID” means the 14-character Health Insurance and Oversight System (HIOS) Plan ID, standard component. The full HIOS ID is unique to each fully insured carrier, product, or plan;

(x) “Plan sponsor” means any persons, other than an insurer, who establishes or maintains a plan covering residents of the state of New Hampshire, including plans established or maintained by employers or jointly by one or more employers and one or more employee organizations, committee, joint board of trustees, or other similar group of representatives of the parties that establish or maintain the plan;

(y) “Prepaid amount” means the amount that would have been paid by the health care claims processor for a specific service if the service had not been capitated or otherwise did not result in a transfer of funds;

(z) “Provider” means a health care facility, medical, dental, or behavioral health care practitioner, health product manufacturer, health product vendor, or pharmacy;

(aa) “Provider file” means a data file listing information about the service providers identified in the medical claims, pharmacy claims, and the dental claims file as servicing billing, prescribing, or primary providers;

(ab) “Release” means to make data or information available for inspection and copying to persons other than the data submitter;

(ac) “Subcontractor” means a vendor or contractor who manages carved out categories of services, including behavioral health services, pharmacy services, or any other subcontractor that processes claims on behalf of a carrier;

(ad) “Subscriber” means the certificate holder who receives coverage from a carrier or third-party administrator. For employer-sponsored group coverage, the employee or subscriber is considered the certificate holder. For individual coverage, the policyholder is considered the certificate holder. For other types of group coverage, the certificate holder is considered the person who is the principal insured; and

(ae) “Third party administrator” means any persons licensed by the department that receives or collects charges, contributions, or premiums for, or adjusts or settles claims for, residents of the state on behalf of a plan sponsor, health care services plan, dental services plan, nonprofit hospital or medical service organization, health maintenance organization, or insurer.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

Part Ins 4003 Annual Registration Requirement

N.H. Code Admin. R. Ann. Ins 4003.01 Annual Registration Requirement {#sec-ins-4003.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4003.01}

(a) Each carrier, third party administrator and pharmacy benefit manager shall submit a completed NHCHIS registration form, available at https://nhchis.com/, to the department or its designee by March 15 of every calendar year.

(b) Carriers, third party administrators, and pharmacy benefit managers shall notify the department or its designee within 30 days of changes to any of the annual NHCHIS registration information.

(c) Carriers, third party administrators, and pharmacy benefit managers shall notify the department or its designee of any changes to the individual contact information submitted on the NHCHIS registration form as soon as possible, but no later than 30 days after a reassignment occurs.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4003.02 Contents of NHCHIS Registration Form {#sec-ins-4003.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4003.02}

The NHCHIS registration form for carriers, pharmacy benefit managers, and third-party administrators submitting data under RSA 420-G:11, II shall contain the fields required under Ins 4008.01.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4003.03 Submission of NHCHIS Registration Form {#sec-ins-4003.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4003.03}

Carriers, pharmacy benefit managers, and third-party administrators shall submit the NHCHIS registration form through the NHCHIS website.

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

Part Ins 4004 Filing Schedules

N.H. Code Admin. R. Ann. Ins 4004.01 Filing Schedules {#sec-ins-4004.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4004.01}

(a) The deadline for submitting NHCHIS data files shall be determined by the total number of members for whom claims are being paid or processed by each carrier, third party administrator, or pharmacy benefit manager.

(b) Carriers, third-party administrators, and pharmacy benefit managers that have 10,000 or more New Hampshire members shall submit required NHCHIS files monthly, no later than 30 days after the close of the reporting month.

(c) Carriers, third-party administrators, and pharmacy benefit managers that have fewer than 10,000 New Hampshire members, but do not meet the exclusion criteria in Ins 4005.02, shall submit required NHCHIS files quarterly, no later than 30 days after the end of the reporting quarter.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4004.02 First-time Filers {#sec-ins-4004.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4004.02}

(a) Carriers, third party administrators, and pharmacy benefit managers that have not previously submitted files to the department or its designee and that have never registered under this chapter shall register no later than 30 days after the first applicable requirement to submit data, using the NHCHIS registration form outlined in Ins 4003.02.

(b) First-time submitters shall provide test files within 120 days after registration. The test file size shall correspond to the size required for that carrier, third party administrator, or pharmacy benefit manager as specified in Ins 4004.01(a).

(c) No later than 150 days after registration, newly-submitting carriers, third party administrators, and pharmacy benefit managers shall submit files containing the 3 most recent calendar years of data, January through December. Year-to-date information and monthly or quarterly files shall be provided no later than 180 days after registration.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4004.03 Changes to Data Submitter’s Process, Format, or Sources {#sec-ins-4004.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4004.03}

(a) Carriers, third-party administrators, and pharmacy benefit managers, that change health plan identifiers or implement new data submission platforms through acquisitions, mergers, or reorganization shall be subject to the requirements for first-time submitters.

(b) Carriers, third-party administrators, and pharmacy benefit managers, filing under new health plan identifiers or through new production systems shall provide additional documentation pursuant to instructions from the department or its designee to ensure that NHCHIS maintains a continuous record of member enrollment and claims history before and after the changes.

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

Part Ins 4005 Required Filers and Exclusions

N.H. Code Admin. R. Ann. Ins 4005.01 Required Filers and Data Sets {#sec-ins-4005.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4005.01}

(a) In accordance with the submission schedule set forth in Ins 4004, each carrier, third party administrator, and pharmacy benefit manager shall submit to the department or its designee a complete and accurate health care claims data set.

(b) Carriers, third-party administrators, and pharmacy benefit managers shall submit health care claims data for all residents of New Hampshire and for all members who receive services under a policy issued in New Hampshire, as follows:

(1) Any policy that provides coverage to the employees of a New Hampshire employer that has a business location in New Hampshire shall be considered a policy that is issued in New Hampshire;

(2) An out-of-state employer’s branch location in New Hampshire shall be considered a New Hampshire employer, and the carrier, third-party administrator, and pharmacy benefit manager shall submit a claims data set for all members who are employed at that branch location; and

(3) Carriers, third-party administrators, and pharmacy benefit managers shall submit health care claims data for New Hampshire state and municipal employees.

(c) When more than one entity is involved in the administration of a policy, data shall be submitted in accordance with the following:

(1) A carrier shall be responsible for submitting the claims data on policies that it has written;

(2) Third-party administrators and pharmacy benefit managers shall be responsible for submitting claims data on self-insured plans that it administers;

(3) Each carrier, third-party administrator, and pharmacy benefit manager shall submit all health care claims processed by any subcontractor on its behalf, including claims related to pharmacy services, dental services, and behavioral health, mental health, and substance abuse treatment services;

(4) Each carrier, third-party administrator, and pharmacy benefit manager shall ensure that the subcontractor shall not submit duplicate claims to the department or its designee if the subcontractor falls under the definition of a carrier, meets the requirements of this section, and is required to submit data as a separate entity; and

(5) Each carrier, third-party administrator, and pharmacy benefit manager shall ensure that member and subscriber identifiers in any files processed by subcontracts are consistent with member and subscriber identifiers in the medical and pharmacy claims files and the member eligibility files.

(d) Carriers, third-party administrators, and pharmacy benefit managers shall continue to submit claims data for each month in which they meet the criteria and for the 180 days after the month in which the carrier, third-party administrator, or pharmacy benefit managers withdraws or falls below the exclusion criteria listed in Ins 4005.02.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4005.02 Exclusions from Filing Requirements {#sec-ins-4005.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4005.02}

(a) Carriers, third-party administrators, and pharmacy benefit managers shall not be required to submit health care claims data files, Health Care Effectiveness Data and Information Set (HEDIS®) data, or Consumer Assessment of Health Plans Survey (CAHPS) survey data if they meet the following criteria:

(1) For carriers that do not offer any products on the health insurance exchange for residents of New Hampshire and that did not cover more than 9,999 members in New Hampshire at any point in any medical, pharmacy, or dental coverage class during the prior calendar year; or

(2) For third-party administrators and pharmacy benefit managers that did not cover more than 9,999 members in New Hampshire at any point in any medical, pharmacy, or dental coverage class during the prior calendar year.

(b) Carriers, third-party administrators, and pharmacy benefit managers shall perform the calculation for (a) above at the entity level, meaning the level at which major governance decisions are made under a senior leadership team, regardless of the number of companies operating under separate corporate divisions. Carriers, third-party administrators, or pharmacy benefit managers experiencing a drop in membership below the de minimis threshold shall submit claims data and any corrections to membership files for a period of 180 days from the point the carrier, third-party administrator, or pharmacy benefit manager no longer meets the de minimis exemption.

(c) Carriers, third-party administrators, and pharmacy benefit managers shall not be required to submit health care claims data about coverage that is not part of a comprehensive medical insurance policy, including the following:

(1) Specific disease;

(2) Accident;

(3) Injury;

(4) Hospital indemnity;

(5) Disability;

(6) Long-term care;

(7) Vision coverage;

(8) Durable medical equipment; or

(9) Blanket health insurance.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4005.03 Opt-In by Self-Funded Private Employers {#sec-ins-4005.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4005.03}

(a) Each carrier, third-party administrator, or pharmacy benefit manager providing claims administration services to any self-funded private employer that maintains a business location in New Hampshire, including a branch location, shall, within 60 days for current clients or, for new or renewing clients, within 30 days of the date its claims administration services are retained or renewed, present to each such self-funded employer a copy of the “NHID Opt-In Form” for purposes of determining whether the employer directs the carrier, third-party administrator, or pharmacy benefit manager to submit its health care claims data pursuant to Ins 4000.

(b) The “NHID Opt-In Form” shall be presented at least once for each contractual period but need not be presented annually if the contractual period exceeds one year.

(c) Health care claims data for each self-funded private employer that directs the submission of its data shall be included as part of the carrier’s, third-party administrator’s, or pharmacy benefit manager’s data submission as indicated on the “NHID Opt-In Form” for that employer.

(d) Each carrier, third-party administrator, and pharmacy benefit manager shall provide to the department annually by March 15 an attestation of compliance with this section with respect to all accounts to which this section was applicable during the prior year. The attestation shall include a list of the self-funded private employers to whom the “NHID Opt-In Form” was presented. However, the association of a particular employer with a particular carrier, third-party administrator, or pharmacy benefit manager may be designated as proprietary information which the department shall, if so designated, hold confidential.

(e) A carrier whose submission includes all relevant data under Ins 4000, without regard to whether the data relate to a self-funded private employer, shall not be required to comply with paragraphs (a) through (d).

(f) The types of employers listed in RSA 420-G:11, IV shall not be considered self-funded private employers under this section, and the “NHID Opt-In Form” shall not be presented to any such employer.

(g) If a self-funded private employer chooses to include the health care claims data of its employees in the state’s All-Payer Claims Database (APCD), the employer, or its designee, shall:

(1) Complete and sign the “NHID Opt-In Form”; and

(2) Submit the completed form to its claims administrator.

(h) If the employer has questions about NH’s APCD or the department’s efforts to improve health care cost transparency, the employer may contact the department at 603-271-2261, or requests@ins.nh.gov, or visit https://www.insurance.nh.gov/.

History

#12044, eff 11-17-16; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

Part Ins 4006 Health Care Claims Data Set Filing

N.H. Code Admin. R. Ann. Ins 4006.01 General Requirements {#sec-ins-4006.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4006.01}

(a) Carriers, third-party administrators, and pharmacy benefit managers shall comply with all the technical specifications contained in Ins 4008 and shall include all data elements contained in Ins 4009, including required formats, definitions, and sources.

(b) Carriers, third-party administrators, and pharmacy benefit managers shall utilize a data transmission tool provided by the department or its designee to assign a unique identification code to each member’s and subscriber’s record in every file, transform direct identifiers, encrypt the files, and securely transmit the files to the department or its designee.

(c) Upon an amendment to this chapter, carriers, third-party administrators, and pharmacy benefit managers shall submit data that conforms to the updated specifications no later than 180 days after the effective date of the amendment(s) to this chapter.

(d) If the department or its designee identifies technical deficiencies in data submitted by a carrier, third-party administrator, or pharmacy benefit manager, the carrier, third-party administrator, or pharmacy benefit manager shall respond to the department within 10 days with a corrective action plan that will remove the deficiencies.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4006.02 Subscriber and Member Identification Data Elements {#sec-ins-4006.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4006.02}

(a) Carriers, third-party administrators, and pharmacy benefit managers shall:

(1) Provide a unique identification number for each member and subscriber included in the submitted files; and

(2) Maintain that unique identifier for each member and subscriber for the entire period of coverage for that individual by that carrier, third-party administrator, or pharmacy benefit manager.

(b) Subscriber and member identifiers shall be:

(1) Consistent across all files that contain information about the subscriber or member;

(2) Matched across the member eligibility, medical claims, pharmacy, and dental files, as well as behavioral health claims, as applicable, even where the claims are processed by a subcontractor such as a pharmacy benefits manager; and

(3) Consistent with the technical specifications in Ins 4008.02.

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4006.03 Included Records and Data Requirements {#sec-ins-4006.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4006.03}

(a) Carriers, third-party administrators, and pharmacy benefit managers shall report health care claims data for all members meeting the criteria set forth in Ins 4005.01(b).

(b) Records for medical, pharmacy, and dental claims file submissions shall be reported at the visit, service, or prescription level.

(c) Medical, pharmacy, and dental claims files shall contain all of a claim’s payment and adjustment activity during the reporting month regardless of the date of service on the claim.

(d) Claims where multiple parties have financial responsibility shall be included with all medical and pharmacy claims file submissions.

(e) Co-payment or co-insurance amounts shall be reported in 2 separate fields in the medical, pharmacy, and dental claims file submissions.

(f) Carriers, third-party administrators, and pharmacy benefit managers shall include records for services provided under alternative payment arrangements with zero paid amounts.

(g) Carriers, third-party administrators, and pharmacy benefit managers shall include records for services provided by out of network providers and services provided after member exceeds benefits with complete patient liability paid.

(h) Carriers, third-party administrators, and pharmacy benefit managers shall include all service lines associated with fully-processed claims that have gone through an accounts payable run and been booked to the health plan ledger in all medical, dental, and pharmacy claims file submissions.

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4006.04 Observation Period for Record Selection {#sec-ins-4006.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 4006.04}

(a) Carriers, third-party administrators, and pharmacy benefit managers shall submit a member eligibility file that contains data for each member eligible for medical, dental, or pharmacy benefits for one or more dates of coverage at any time during a reporting month as well as any retrospective updates that correspond to previously submitted eligibility data. The file shall include benefits, attributes, and associated effective periods.

(b) Carriers, third-party administrators, and pharmacy benefit managers shall include all claims adjudicated during the reporting month for all members in the member eligibility file for that month.

(c) Carriers’, third-party administrators’, and pharmacy benefit managers’ data submissions shall contain 180 days claims run out for members in all current or previously submitted files.

(d) Claims files and other records shall be maintained as required in RSA 400-B

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4006.05 Health Care Effectiveness Data and Information Set (HEDIS®) Reporting Requirements {#sec-ins-4006.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 4006.05}

(a) Each carrier that calculates using HEDIS®, a system of performance measures maintained by the national committee for quality assurance (NCQA), and submits those data to NCQA, shall report those data that pertain to members who receive their benefits under a policy or plan issued in New Hampshire.

(b) The carrier shall submit HEDIS® data to the DHHS or its designee by July 31st of each year as follows:

(1) The carrier shall submit the data utilizing the appropriate NCQA interactive data submission system (IDSS) import template; and

(2) The carrier shall also submit the results via a workbook, generated with results for each HEDIS® measure appearing on its own worksheet.

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

N.H. Code Admin. R. Ann. Ins 4006.06 Consumer Assessment of Health Plans Survey (CAHPS®) Reporting Requirements {#sec-ins-4006.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 4006.06}

(a) Each carrier that collects CAHPS® data, a survey overseen by the United States Department of Health and Human Services, agency for healthcare research and quality (AHRQ) and used by NCQA as part of HEDIS® reporting, shall report those data that are collected and that pertain to members who receive their benefits under a policy or plan issued in New Hampshire.

(b) The carrier shall submit CAHPS® data to the DHHS or its designee by July 31st of each year, as follows:

(1) The carrier shall submit the NCQA generated survey results reports; and

(2) The carrier shall also submit all results generated via the NCQA CAHPS® analysis program.

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

Part Ins 4007 Data Standards Compliance

N.H. Code Admin. R. Ann. Ins 4007.01 Data Standards Compliance {#sec-ins-4007.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4007.01}

(a) Carriers, third-party administrators, and pharmacy benefit managers shall submit files that conform to the formats and standards in this chapter, including the technical specifications in Ins 4008.

(b) Carrier, third-party administrator, and pharmacy benefit manager files shall be evaluated upon receipt by the department or its designee to assess compliance with the data quality standards in the submission instructions.

(1) Resubmit nonconforming files at the direction of the department or its designee;

(2) Resubmit a corrected and conforming version of the original submission within 10 business days of the rejection notification from the department or its designee; and

(3) Not submit partial replacement files or record specific corrections.

History

#8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36

Part Ins 4008 Technical Specifications

N.H. Code Admin. R. Ann. Ins 4008.01 Subscriber and Member Identification Data Elements {#sec-ins-4008.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4008.01}

(a) The following table lists the subscriber and member identifiers that shall be identical when reporting information about a subscriber or a member:

Table 1: Matching Requirements for Subscriber/Member

Identifiers Across Files

Data Element Name*

Subscriber and Member Identifiers

Member Eligibility

Medical Claims**

Dental Claims

Pharmacy Claims

Plan Specific Contract Number

ME009

MC008, MC20

DC008, DC202

PC008, PC204

Member Suffix or Sequence Number

ME010

MC009

DC009

PC009

Subscriber Last Name

ME101

MC101

DC101

PC101

Subscriber First Name

ME102

MC102

DC102

PC102

Subscriber Middle Initial

ME103

MC103

DC103

PC103

Member Last Name

ME104

MC104

DC104

PC104

Member First Name

ME105

MC105

DC105

PC105

Member Middle Initial

ME106

MC106

DC106

PC106

*The NHCHIS preprocessor hashes these data elements as part of the file encryption and transmission process.

**Also pertains to Behavioral Health.

(b) The NHCHIS preprocessor application will hash all subscriber and member identification codes and names before data are transmitted to the department’s designee. To ensure consistent hashing, subscriber and member identifiers shall not be encrypted or hashed on the initial extract loaded into the preprocessor:

(1) The discrete two-digit suffix shall also be used with the certificate or contract number. This data element is de-identified by the NHCHIS preprocessor application.

(2) The certificate or contract number with the two-digit suffix shall be at least 11, but no more than 30 characters in length. This data element is de-identified by the NHCHIS preprocessor application.

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20 (formerly Ins 4009.02); ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4009.01)

N.H. Code Admin. R. Ann. Ins 4008.02 Technical Specifications and Format for File Transfer {#sec-ins-4008.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4008.02}

(a) Carriers, third-party administrators, and pharmacy benefit managers shall use the values in the data tables contained in Ins 4009 or the corresponding externally maintained code tables referenced therein, and:

(1) Carriers, third-party administrators, and pharmacy benefit managers shall submit tables and descriptions for all non-conforming and plan-specific codes appearing in the submission; and

(2) The department and DHHS or its designee shall reject files with non-conforming and plan-specific codes if explanatory information is not provided in advance of the data submission.

(b) Carriers, third-party administrators, and pharmacy benefit managers shall report adjustment records with the appropriate positive or negative fields with the medical, pharmacy, and dental file submissions. Negative values shall contain the negative sign before the value. No sign shall appear before a positive value.

(c) All service lines associated with fully-processed claims that have gone through an accounts payable run and been booked to the health plan ledger shall be included on medical, pharmacy, and dental claims data submissions. Do not include service lines:

(1) Rejected due to failed edits;

(2) That are duplicates;

(3) That are from an inactive member; or

(4) Claims that are voided for point of sale adjustments.

(d) When more than one version of a fully-processed claim service line is submitted, each version of a claim service line shall be enumerated sequentially with a higher version number (MC005A/DC207/PC902) so that the latest version of that service line is the record with the highest version number (MC005A/DC207/PC9) and the same claim number + line counter. There shall be no leading zeros on the version numbers. Where a version number is not available, and a new claim ID is used, provide the former claim number in data element MC211. Similar requirements shall apply to the pharmacy claim file.

(e) Subsequent incremental claims submissions shall include all reversal and adjustment or restated versions of previously submitted claim service lines and all new, fully-processed service lines associated with the claim, provided that they have paid dates in the reporting period, and:

(1) Each version of a claim service line shall be enumerated sequentially with a higher line version number (MC005A/DC207/PC902); and

(2) Reversal versions of a claim service line shall be indicated by a claim status code = '22' (Field MC038/DC031/PC025).

(f) Capitated service claims, sometimes known as encounter claims, for capitated services shall be reported with all medical and pharmacy file submissions.

(g) If a claim contains service lines that do not contain a payment because their costs are covered on another line of the claim line, such as under a global payment arrangement, those line(s) shall be:

(1) Included in the data submission; and

(2) Clearly indicated by a claim status code = ‘04’ (Field MC038/DC031/PC025).

(h) Member eligibility data suppliers shall provide a data set that contains information on every covered plan member, regardless of whether the member utilized services during the reporting period. One record per member per month per plan shall be required. For example, if a member is covered as both a subscriber and a dependent on two different policies during the same month, 2 records shall be submitted. If a member has 2 contract numbers for 2 different coverage types, 2 member eligibility records shall be submitted. For each product type (ME018, ME019 and ME020), a separate eligibility record shall be submitted.

(i) The Provider ID (MP003) is the unique identifier for a single provider. The Provider ID should only occur once in the table. However, in the event the same provider delivered, and was reimbursed for, services rendered from two or more different physical locations, then the provider data file shall contain two separate records for that same provider reflecting each of those physical locations. One record should be provided for each unique physical location.

(j) Carriers, third-party administrators, and pharmacy benefit managers shall use the File Submission “Preprocessor” provided by the DHHS and their designee. The preprocessor hashes or de-identifies member and subscriber information before the data leaves the carrier’s, pharmacy benefit managers, and third-party administrator’s system.

(k) Carriers, third-party administrators, and pharmacy benefit managers shall report the minimum value for fully insured and self-insured products to support the department’s supplemental reporting reviews. The minimum value is defined as the percentage of the total allowed costs of benefits provided under a group health plan or health insurance coverage. The minimum value measure is outlined in Section 1302 (d)(2)I of the Affordable Care Act. Plans may use the HHS MV calculator available at http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html; may apply a safe harbor developed by HHS and the IRS; or may, for nonstandard plans, provide an actuarial certification from a member of the American Academy of Actuaries.

(l) Each member eligibility file and each medical, pharmacy, and dental claims file submission shall contain a header record and a trailer record. The header record is the first record of each separate file submission and the trailer record is the last.

(m) All carriers, third-party administrators, and pharmacy benefit managers submitting APCD files shall be provided with code in the form of a pre-processor, which generates the files in the required format and encrypts them prior to submission. The pre-processor code shall be provided to all carriers, third-party administrators, and pharmacy benefit managers as a download through a password protected portal.

(n) Carriers, third-party administrators, and pharmacy benefit managers may submit APCD files using the following methods:

(1) Secure File Transport Protocol (SFTP) is the preferred method for submitting files. This method requires logging on to the appropriate SFTP site and sending or receiving files using the SFTP client server. This protocol assumes that it is run over a secure channel, that the server has already authenticated the client, and that the identity of the client user is available to the protocol; or

(2) The web upload method allows the sending and receiving of files and messages without the installation of additional software. This method requires internet access, a username, and password. It is not the preferred method due to limitations on the size of the files that can be received, but may be utilized if it is the only method available to the healthcare claims processor.

(o) The member eligibility file, medical claims file, pharmacy claims file, dental claims file, and provider file shall be submitted as separate ASCII files, with variable field lengths and pipe delimited, and shall comply with the following standards:

(1) Each record shall be terminated with a carriage return and line feed (ASCII 13, ASCII 10);

(2) All fields shall be filled where applicable;

(3) Text and date fields shall be left blank when not applicable or if a value is not available;

(4) “Blank” means do not supply any value at all between consecutive field delimiters or last field delimiter and line terminator. Numeric fields without a value shall be filled with a single zero;

(5) Only one record per row shall be submitted. No single line item of data shall contain carriage return or line feed characters;

(6) Text fields shall not be padded with leading or trailing spaces or tabs;

(7) Numeric fields:

a. Shall not be padded with leading zeroes;

b. The integer portion of numeric fields shall not be padded with leading zeros;

c. The decimal portion of numeric fields, if required, shall be padded with trailing zeros up to the number of decimal places indicated; and

d. Positive values are assumed and need not be indicated as such. Negative values shall be indicated with a minus sign and shall appear in the left-most position of all numeric fields; and

(8) Date fields:

a. Shall be CCYYMMDD, when a value is provided, unless otherwise indicated;

b. Shall not be padded with leading or trailing spaces or tabs; and

c. Shall be left blank when not applicable or if a value is not available.

(p) Carriers, third-party administrators, and pharmacy benefit managers shall use the federal CARC/RARC codes when submitting medical or dental claim denial reason codes (MC220 & DC220), and either NCPDP or CARC/RARC codes with submitting pharmacy claim denial reason code (PC217). Internal denial reason codes shall not be accepted. Carriers, third-party administrators, and pharmacy benefit managers shall submit a crosswalk of internal codes to NHID upon request.

(q) When reporting Drug Code (MC075 & PC026) carriers, third-party administrators, and pharmacy benefit managers shall use the 11 digit NDC with no dashes. Carriers, third-party administrators, and pharmacy benefit managers shall report the 11 digit NDC anytime a HCPCS J code is reported in the Medical Claims.

History

#10877, eff 7-10-15; ss by #13136 eff 11-24-20(formerly Ins 4009.03); ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4009.02)

N.H. Code Admin. R. Ann. Ins 4008.03 Data Quality Requirements {#sec-ins-4008.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4008.03}

(a) A validation process shall be employed to ensure that the format and content of the submitted files are valid and complete. The validation process is primarily composed of three groups of audits, field level audits, quality audits, and post data consolidation reasonableness, longitudinal, and relational audits, as follows:

(1) All transmitted files are first checked to determine if they are in the correct form and have been created using the provided pre-processor. Field level audits are then employed to evaluate field length and type, code values, and the percentage at which the fields are filled;

(2) Quality audits are employed to determine if the data submitted meet a pre-determined level of reasonableness, for example, percent of institutional claims versus percent of professional claims. Default thresholds, which can be rates or ranges, have been established for approximately 200 quality audits; and

(3) After the files are loaded into staging tables, additional audits are run on the consolidated data to identify any global issues that would not be evident during the field and quality level audit process. The reasonableness, longitudinal, and relational audits confirm whether the appropriate and correct amount of data was received for the corresponding membership volume. Examples of these audits include frequency of individual field values, volume reconciliation, and cost or utilization reasonableness.

(b) Default thresholds or rates shall be applied to the field level audits for each element in the eligibility, claims files, and provider file for each quality audit. The standard acceptable threshold for field length, field type, and data value audits is 100 percent. However, there are some fields where the acceptable thresholds for data value will be set at less than 100 percent. Individual field completeness thresholds are established for each data element in the eligibility, medical, pharmacy, dental, and provider files and will vary accordingly. All of the pre-determined default thresholds can be individually adjusted if extenuating circumstances arise which might impact the data completeness or content. If a file is processed and rejected for failing to meet the field level or quality audit default thresholds, the healthcare claims processor may request an exemption to the default threshold through a standardized process. Exemptions or adjustments may be granted for data variances that cannot be corrected due to systematic issues.

(c) At least 30 days prior to the initial submission of the files, or whenever the data element content of the files is subsequently altered, each healthcare claims processor shall submit a data set for comparison to the same validation process used for actual submissions. Iterative rounds of testing may be necessary until the files conform to the submission requirements. A test file should contain data covering a period of one month.

(d) Failure to conform to any of the submission requirements shall result in the rejection and return of the applicable data file(s). All rejected and returned files shall be resubmitted in the appropriate, corrected form within 10 days, or the healthcare claims processor may request an exemption to adjust the threshold for the failing field(s). Due to the large amount and complexity of the data processed, it is more efficient to resubmit an entire file rather than to correct data within the file.

History

#10877, eff 7-10-15; ss by #13136, eff 11-24-20 (formerly Ins 4009.04); ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4009.03)

N.H. Code Admin. R. Ann. Ins 4008.04 External Code Sources {#sec-ins-4008.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 4008.04}

(a) Countries

American National Standards Institute

http://webstore.ansi.org/SdoInfo.aspx?sdoid=39&source=iso_member_body

(b) States, Zip Codes and Other Areas of the US

U.S. Postal Service

https://www.usps.com/

National Plan & Provider Enumeration System

https://nppes.cms.hhs.gov/NPPES/

(d) Health Care Provider Taxonomy

National Uniform Claim Committee (NUCC)

http://www.nucc.org

(e) International Classification of Diseases 9 & 10

American Medical Association

http://www.who.int/classifications/icd/en/

(f) HCPCS, CPTs and Modifiers

American Medical Association

http://www.ama-assn.org/

https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system

(g) Dental Procedure Codes and Identifiers

American Dental Association

http://www.ada.org/

(h) National Drug Codes and Names

U.S. Food and Drug Administration

http://www.fda.gov/drugs/informationondrugs/ucm142438.htm

(i) Standard Professional Billing Elements

Centers for Medicare and Medicaid Services

https://www.cms.gov/files/document/837p-cms-1500pdf

(j) Standard Facility Billing Elements

National Uniform Billing Committee (NUBC)

http://www.nubc.org/

(k) DRGs, APCs and POA Codes

Centers for Medicare and Medicaid Services

http://www.cms.gov/

(l) Claim Adjustment Reason Codes

X12

https://x12.org/codes/claim-adjustment-reason-codes

(m) Remittance Advice Remark Codes

X12

https://x12.org/codes/remittance-advice-remark-codes

(n) NCPDP Telecommunication Reject Codes

PrimeWest

https://www.primewest.org/ncpdp-telecommunication-reject-codes

(o) NCPDP Telecommunication Reject Codes NCPDC

https://www.ncpdp.org/resources.aspx

History

#10877, eff 7-10-15; ss by #13136, eff 11-24-20 (formerly Ins 4009.05); ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4009.04)

Part Ins 4009 Data Tables

N.H. Code Admin. R. Ann. Ins 4009.01 Member Eligibility Data Tables {#sec-ins-4009.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4009.01}

(a) Use Table 4009.07(a) to determine member eligibility file mapping and formatting.

(b) Member File Header Record Layout:

Table 4009.01(b) Member File Header Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

HD002

Payer

Text

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

CMS National Plan ID

HD004

Type of File

Text

ME Member Eligibility

HD005

Period Beginning Date

Number

Beginning of paid period for claims or beginning of month covered for eligibility

HD006

Period Ending Date

Number

End of paid period for claims or end of month covered for eligibility

HD007

Comments

Text

Submitter may use to document this submission by assigning a filename, system source, etc.

Table 4009.01(c) Member File Trailer Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

TR002

Payer

Text

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

CMS National Plan ID

TR004

Type of File

Text

ME Member Eligibility

TR005

Period Beginning Date

Number

Beginning of paid period for claims or beginning of month covered for eligibility

TR006

Period Ending Date

Number

End of paid period for claims or beginning of month covered for eligibility

TR007

Extraction Date

Date

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

(d) Member File Detailed Specification:

Table 4009.01(d) Member File Detailed Specification

Column Position

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

ME001

Payer

Text

Payer submitting payments NHID Submitter Code

ME002

National Plan ID

Text

CMS National Plan ID

ME003

Insurance Type Code/Product

Text

See Table 4009.06(a) Insurance Type/Product Code

ME004

Start Year

Number

4 (0)

Year for which eligibility is reported in this submission. CCYY format

ME005

Start Month

Number

2 (0)

Month for which eligibility is reported in this submission. MM format. Leading zero is required for reporting January through September files

ME006

Insured Group or Policy Number

Text

Group or policy number (not the number that uniquely identifies the subscriber)

ME007

Coverage Level Code

Text

Benefit Coverage Level

CHD Children Only

DEP Dependents Only

ECH Employee and Children

EMP Employee Only

ESP Employee and Spouse

FAM Family

IND Individual

SPC Spouse and Children

SPO Spouse Only

ME008

Placeholder

ME009

Plan Specific Contract Number

Text

Plan assigned contract number. If this is a Medicaid member, provide Medicaid ID

Must match the ID in the corresponding claim file (MC008, PC008 and DC008)

ME010

Member Suffix or Sequence Number

Text

Unique number of the member. This column is the unique identifying column for membership and related medical, pharmacy, and dental claims. Only 1 record per insurance product type, per eligibility month. Must match MC009, PC009 and DC009.

ME011

Placeholder

ME012

Individual Relationship Code

Text

See Table 4009.06(b) Relationship Codes

ME013

Member Gender

Text

M Male

F Female

U Unknown

O Other

ME014

Member Date of Birth

Date

Date of birth of member

ME015

Member City Name

Text

City name of member

ME016

Member State or Province

Text

As defined by the US Postal Service

ME017

Member ZIP Code

Text

ZIP Code of member – may include non- US codes. Do not include dash.

ME018

Medical Coverage

Text

Y Yes

N No

ME019

Prescription Drug Coverage

Text

Y Yes, member has prescription drug coverage in the period defined with this payer

N No, member does not have prescription drug coverage in the period defined with this payer

ME020

Dental Coverage

Text

Y Yes, member has dental coverage in the period defined with this payer

N No, member does not have dental coverage in the period defined with this payer

ME021

Race 1

Text

See Table 4009.06(c) Race 1/Race 2

ME022

Race 2

Text

See Table 4009.06(c) Race 1/Race 2

ME023

Placeholder

ME024

Hispanic Indicator

Text

Y Yes, member is Hispanic/Latino/Spanish

N No, member is not Hispanic/Latino/Spanish

U Unknown

ME025

Ethnicity 1

Text

See Table 4009.06(d): Ethnicity 1/ Ethnicity 2

ME026

Ethnicity 2

Text

See Table 4009.06(d): Ethnicity 1/ Ethnicity 2

ME027

Placeholder

ME028

Primary Insurance Indicator

Text

Y: Yes, this is the member’s primary insurance

N: No, this is not the member’s primary insurance

ME029

Coverage Type

Text

ASW Self-funded plans that are administered by a third party administrator, where the employer has purchased stop-loss, or group excess insurance coverage

ASO Self-funded plans that are administered by a third party administrator, where the employer has not purchased stop-loss, or group excess insurance coverage

STN Short-term non-renewable health insurance, as defined pursuant to RSA 415:5, III

MCD Medicaid

MCR Medicare

UND Plans underwritten by the carrier

OTH Any other plan. Carriers and third-party administrators using this code shall obtain prior approval from the N.H. Insurance Department

ME030

Market Category

Text

Three or four digit character code for identifying market category. Employer size is based on the number of eligible employees in the group as defined in Ins 4100, (Ins 4103.03(g)) for the Small Group market, INS 4104.03(i) for the Large Group market)

IND Policies sold and issued directly to individuals, other than those sold on a franchise basis, as defined pursuant to RSA 415:19, or as group conversion Policies as defined pursuant to RSA 415:18 VII(a)

FCH Policies sold and issued directly to individuals on a franchise basis as defined pursuant to RSA 415:19

GCV Policies sold and issued directly to individuals as group conversion Policies as required pursuant to RSA 415:18 VII(a)

GS1 Policies sold and issued directly to employers having exactly one employee

GS2 Policies sold and issued directly to employers having between 2 and 9 employees

GS3 Policies sold and issued directly to employers having between 10 and 25 employees

GS4 Policies sold and issued directly to employers having between 26 and 50 employees

GLG1 Policies sold and issued directly to employers having between 51 and 99 employees

GLG2 Policies sold and issued directly to employers having 100 or more employees

GSA Policies sold and issued directly to small employers through a qualified association trust

OTH Policies sold to other types of entities. Carriers and third-party administrators using this market code shall obtain prior approval from the NH Insurance Department

BLC Policies sold and issued as blanket health insurance Policies to a common carrier

BLE Policies sold and issued as blanket health insurance Policies to an employer

BLV Policies sold and issued as blanket health insurance Policies to a volunteer fire department, first aid, or other such volunteer group

BLS Policies sold and issued as blanket health insurance Policies to a sports team or a camp

BLT Policies sold and issued as blanket health insurance Policies to a travel agency, or other organization that provides travel-related services

BLU Policies sold and issued as blanket health insurance Policies to a university or college

SLG Policies sold and issued as student major medical expense large group coverage to enrolled students at an accredited college, university, or other educational institution

STS Policies sold and issued as group short term student health insurance

SMG Policies sold and issued as student major medical group health insurance

SNM Policies sold and issued as student group health insurance that is not major medical coverage

SIM Policies sold and issued as student individual major medical health insurance

SIN Policies sold and issued as student individual health insurance that is not major medical coverage

ME031

NH Health Protection Program

Text

For enrollees in the New Hampshire Health Protection Program (NHHPP), indicate if enrollee is part of the Premium Assistance Program (PAP) or Health Insurance Premium Payment (HIPP). Leave blank if enrollee is not a member of the NHHPP

ME032

Group Name

Text

Name of the group that the member is covered by. If the member is part of a group of one or non-group, indicate “I” for individual.

ME101

Subscriber Last Name

Text

ME102

Subscriber First Name

Text

ME103

Subscriber Middle Initial

Text

ME104

Member Last Name

Text

ME105

Member First Name

Text

ME106

Member Middle Initial

Text

Placeholder

ME203

Member’s Assigned PCP

Text

10U

National Provider ID of the member’s Primary Care Physician as designated by healthcare claims processor.

ME204

HIOS Plan ID

Text

The 16 character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be available for all market segments;

ME205

Plan Effective Date

Date

For the plan reported in ME204, report the date eligibility started for this member under this plan type. The purpose of this data element is to maintain an eligibility span for each member.

ME206

Minimum Value

Number

3 (0)

For the plan reported in ME204, report the Minimum Value as described in Part Ins 4008.02(k). This is reported as a percentage.

ME207

Exchange Indicator

Text

The plan reported in ME204 was available on the Exchange Marketplace in the month and year reflected in ME004 and ME005

Y: Yes

N: No

U: Unknown

ME208

High deductible health plan

Text

The plan reported in ME204 meets the IRS definition of a HDHP

Y: Yes

N: No

U: Unknown

ME209

Active enrollment

Text

The plan reported in ME204 was open for enrollment in the year and month reflected in ME004 and ME005

Y: Yes

N: No

ME210

New Coverage

Text

The plan reported in ME204 was being offered for the first time in the reporting year reflected in ME004

Y: Yes

N: No

ME211

Placeholder

ME899

Record Type

Text

ME900

Plan State

Text

State in which the plan is sold or used. State codes are maintained by the US Postal Service

ME901

Advanced Premium Tax Credit

Number

2(2)

Dollar value of Advanced Premium Tax Credit (APTC) subsidy

ME902

NAIC Number

Text

Number that the National Association of Insurance Commissioners (NAIC) assigns to each individual underwriting company.

ME903

Grandfather Plan indicator

Text

Indicates if a plan qualifies as a “Grandfathered” or “Transitional Plan” under the Affordable Care Act (ACA). Please see definition for “grandfathered” and “transitional” in HHS rules 45-CFR-147.140: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-147/section-147.140 The values of the indicator are as follows:

1= Grandfathered;

2 = Non-Grandfathered;

3 =Transitional;

4 = Not Applicable

ME904

Metal Level

Text

The metal representation of the plan reported in ME204 on the Exchange Marketplace

History

#10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.01)

N.H. Code Admin. R. Ann. Ins 4009.02 Member Claims Data Tables {#sec-ins-4009.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4009.02}

(a) Medical Eligibility File Mapping and Format Information. Use Table 4009.07(b) to determine medical eligibility file mapping and formatting.

(b) Medical Claims File Header Record Layout:

Table 4009.02(b) Medical Claims File Header Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

HD002

Payer

Text

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

CMS National Plan ID

HD004

Type of File

Text

MC Medical Claims

HD005

Period Beginning Date

Number

Beginning of paid period for claims or beginning of month covered for eligibility

HD006

Period Ending Date

Number

End of paid period for claims or end of month covered for eligibility

HD007

Comments

Text

Submitter may use to document this submission by assigning a filename, system source, etc.

Table 4009.02(c) Medical Claims File Trailer Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

TR002

Payer

Text

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

CMS National Plan ID

TR004

Type of File

Text

MC Medical Claims

TR005

Period Beginning Date

Number

Beginning of paid period for claims or beginning of month covered for eligibility

TR006

Period Ending Date

Number

End of paid period for claims or beginning of month covered for eligibility

TR007

Extraction Date

Date

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

(d) Medical Claims File Detailed Specifications:

Table 4009.02(d) Medical Claims File Detailed Specifications

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

MC001

Payer

Text

Payer submitting payments NHID Submitter Code

MC002

National Plan ID

Text

CMS National Plan ID

MC003

Insurance Type/Product Code

Text

Table 4009.6(a) Insurance Type/Product Code

MC004

Payer Claim Control Number

Text

Shall apply to the entire claim and be unique within the payer's system

MC005

Line Counter

Text

Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim

MC005A

Version Number

Number

4 (0)

Version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line.There shall be only one version number per claim line. The most recent version of the claim shall have the highest version number.

MC006

Insured Group or Policy Number

Text

Group or policy number (not the number that uniquely identifies the subscriber)

MC007

Placeholder

MC008

Plan Specific Contract Number

Text

Plan assigned contract number. Leave blank if Plan Specific Contract

If this is a Medicaid claim, provide Medicaid ID.

Shall match the ID in ME009, PC008, and DC008

MC009

Member Suffix or Sequence Number

Text

MC010

Placeholder

MC011

Individual Relationship Code

Text

See Table 4009.06(b) Relationship Codes

MC012

Member Gender

Text

M Male

F Female

U Unknown

O Other

MC013

Member Date of Birth

Date

Date of birth of member

MC014

Member City Name

Text

City name of member

MC015

Member State or Province

Text

As defined by the US Postal Service

MC016

Member ZIP Code

Text

ZIP Code of member – may include non- US codes. Do not include dash.

MC017

Paid Date (AP Date)

Date

Date the claim was adjudicated for reversals and denials

Date the provider was paid via EFT or date the paper check was mailed for paid claims.

MC018

Admission Date

Date

Required for all inpatient claims.

MC019

Admission Hour

Text

2 (0)

Required for all inpatient claims. Time is expressed in military time – HH

MC020

Admission Type

Text

Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications):

1 = Emergency

2 = Urgent

3 = Elective

4 = Newborn

5 = Trauma Center

9 = Information not available

MC021

Admission Source

Text

See Table 4009.06(h) Point of Origin Codes

MC022

Discharge Hour

Text

2 (0)

Required for all inpatient claims. Time is expressed in military time – HH

MC023

Discharge Status

Text

See Table 4009.06(c): Discharge Status

MC024

Service Provider Number

Text

Payer assigned servicing provider number by the payer for internal identification purposes

MC025

Service Provider Tax ID Number

Text

Federal taxpayer’s identification number – if the tax id is a provider’s social security number, use ‘SSN’ and ‘NA’ if unavailable

MC026

National Service Provider ID

Text

Provider NPI.

MC027

Service Provider Entity Type Qualifier

Text

HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as “Person”.

1 Person

2 Non-Person Entity

MC028

Service Provider First Name

Text

Individual first name. Leave blank if provider is a facility or organization

MC029

Service Provider Middle Name

Text

Individual middle name or initial. Leave blank if provider is a facility or organization

MC030

Servicing Provider Last Name or Organization Name

Text

Report the name of the organization or last name of the individual provider. MC027 determines if this is an organization or Individual Name reported here.

MC031

Service Provider Suffix

Text

Suffix to individual name. Leave blank if provider is a facility or organization. Should be used to capture the generation of the individual clinician (e.g., Jr. Sr., III), if applicable, rather than the clinician’s degree [e.g., ‘MD’, ‘LICSW’].

MC032

Service Provider Specialty

Text

National Uniform Claims Committee (NUCC) standard code that defines this provider for this line of service. Taxonomy values allow for the reporting of nurses, assistants and laboratory technicians, where applicable, as well as Physicians, Medical Groups, Facilities, etc.

MC033

Service Provider City Name

Text

City name of rendering provider - practice location

MC034

Service Provider State

Text

As defined by the US Postal Service

MC035

Service Provider ZIP Code

Text

ZIP Code of provider - may include non-US codes.

MC036

Type of Bill – Institutional

Text

For facility claims only submitted using UB04 forms

Type of Facility - First Digit

1 Hospital

2 Skilled Nursing

3 Home Health

4 Christian Science Hospital

5 Christian Science Extended Care

6 Intermediate Care

7 Clinic

8 Special Facility

Bill Classification - Second Digit if First Digit = 1-6

1 Inpatient (Including Medicare Part A)

2 Inpatient (Medicare Part B Only)

3 Outpatient

4 Other (for hospital referenced diagnostic services

or home health not under a plan of treatment)

5 Nursing Facility Level I

6 Nursing Facility Level II

7 Intermediate Care - Level III Nursing Facility

8 Swing Beds

Bill Classification - Second Digit if First Digit = 7

1 Rural Health

2 Hospital Based or Independent Renal Dialysis Center

3 Free Standing Outpatient Rehabilitation Facility (ORF)

5 Comprehensive Outpatient Rehabilitation Facility (ORF)

6 Community Mental Health Center

9 Other

Bill Classification – Second Digit if First Digit = 8

1 Hospice (Non Hospital Based)

2 Hospice (Hospital-Based)

3 Ambulatory Surgery Center

4 Free Standing Birthing Center

9 Other

Frequency – Third Digit

0 Non-Payment/Zero

1 Admit Through Discharge

2 Interim – First Claim

3 Interim - Continuing Claims

4 – Interim – Last Claim

5 – Late Charge Only

7 – Replacement of Prior Claim

8 – Void/Cancel of a Prior Claim

9 – Final Claim for a Home Health PPS Episode

MC037

Place of Service – Professional

Text

For professional claims only, such as those submitted using CMS1500 forms

See Table 4009.06(f) Place of Service -- Professional

MC038

Service Line Status

Text

Describes the payment status of the specific service line record

01 Processed as primary

02 Processed as secondary

03 Processed as tertiary

04 Denied

06 Approved as amended

19 Processed as primary, forwarded to additional payer(s)

20 Processed as secondary, forwarded to additional payer(s)

21 Processed as tertiary, forwarded to additional payer(s)

22 Reversal of previous payment

26 Documentation Claim – No Payment Associated

28 Repriced

MC039

Admitting Diagnosis

Text

ICD-CM Diagnosis Codes. Required on all inpatient admission claims and encounters. Do not include decimals.

MC040

E-Code

Text

ICD-CM Diagnosis Codes. Describes an injury, poisoning or adverse effect ICD-CM.

MC041

Principal Diagnosis

Text

ICD-CM Diagnosis Codes. Principal Diagnosis should be the principal diagnosis given on the claim header. Do not include decimals.

MC042

Other Diagnosis -1

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC043

Other Diagnosis -2

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC044

Other Diagnosis -3

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC045

Other Diagnosis -4

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC046

Other Diagnosis -5

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC047

Other Diagnosis -6

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC048

Other Diagnosis -7

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC049

Other Diagnosis -8

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC050

Other Diagnosis -9

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC051

Other Diagnosis -10

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC052

Other Diagnosis -11

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC053

Other Diagnosis -12

Text

ICD-CM Diagnosis Codes. Do not include decimals.

MC054

Revenue Code

Text

National Uniform Billing Committee Codes. Code using leading zeroes, left-justified, and four digits.

MC055

Procedure Code

Text

Health Care Common Procedural Coding System (HCPCS). This includes the CPT codes of the American Medical Association

MC056

Procedure Modifier – 1

Text

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

MC057

Procedure Modifier – 2

Text

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

MC058

ICD-9/10-CM Procedure Code

Text

Primary ICD-9/10-CM code given on the claim header.

MC059

Date of Service – From

Date

First date of service for this service line.

MC060

Date of Service – Thru

Date

Last date of service for this service line

MC061

Quantity

Number

12 (0)

Count of services performed.

MC062

Charge Amount

Number

10 (2)

The full, undiscounted total and service-specific charges billed by the provider. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

MC063

Paid Amount

Number

10 (2)

Includes any withhold amounts. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

MC064

Fee for Service Equivalent

Number

10 (2)

For capitated services, the fee for service equivalent amount.

MC065

Copay Amount

Number

10 (2)

The preset, fixed dollar amount for which the individual is responsible. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

MC066

Coinsurance Amount

Number

10 (2)

Coinsurance, dollar amount . Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

MC067

Deductible Amount

Number

10 (2)

Amount in dollars met by the patient/family in a deductible plan . Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

MC068

Patient Account/Control Number

Text

MC069

Discharge Date

Date

Required for all inpatient(s)

MC070

Service Provider Country Name

Text

MC071

DRG

Text

Carriers, pharmacy benefit managers,and third-party administrators shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the All Payer DRG system is available, then that system shall be used. If the All Payer DRG system is used, the carrier shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX)

MC072

DRG Version

Text

This element is the version number of the grouper used.

MC073

APC

Text

Carriers, pharmacy benefit managers,and third-party administrators shall code using CMS methodology. Precedence shall be given to APCs transmitted from the health care provider

MC074

APC Version

Text

This element is the version number of the grouper used

MC075

Drug Code

Text

NDC Code Used only when a medication is paid for as part of a medical claim. The NDC shall be the 11 digit code with no dashes. The NDC shall be reported when a HCPCS J code (MC055) is reported for hospital administered drugs.

MC076

Billing Provider Number

Text

Payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes and does not routinely change

MC077

National Billing Provider Number ID

Text

This is the NPI for the billing provider

MC078

Billing Provider Organization or Last Name

Text

MC101

Subscriber Last Name

Text

MC102

Subscriber First Name

Text

MC103

Subscriber Middle Initial

Text

MC104

Member Last Name

Text

MC105

Member First Name

Text

MC106

Member Middle Initial

Text

MC200

ICD Indicator

Text

Report the value that defines whether the diagnoses on claim are ICD9 or ICD10.

0 ICD-9

1 ICD-10

MC202

Other ICD-CM Procedure Code - 2

Text

ICD Secondary Procedure Code

MC203

Other ICD-CM Procedure Code - 3

Text

ICD Secondary Procedure Code

MC204

Other ICD-CM Procedure Code - 4

Text

ICD Secondary Procedure Code

MC205

Other ICD-CM Procedure Code - 5

Text

ICD Secondary Procedure Code

MC206

Other ICD-CM Procedure Code - 6

Text

ICD Secondary Procedure Code

MC207

Carrier Identifier

Text

If you are a TPA that processes claims and are submitting files on behalf of a carrier, indicate the carrier name here. Shalluse the full legal name of company, no acronyms. Else, leave blank.

MC208

Carrier Plan Specific Contract Number

Text

128

When a TPA processes claims on behalf of the carrier, for each claim, report the carrier specific contract number. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

MC209

Practitioner Group Practice

Text

Name of group practice to which a practitioner is affiliated if different from MC078

MC210

Coordination of Benefits/Third Party Liability Amount

Number

10 (2)

Coordination of Benefits (COB)/Third Party Liability (TPL) is the dollar amount paid from a prior payer (e.g. auto claim, workers comp, dual medical coverage). Report 0 if there is no COB/TPL amount. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

MC211

Cross Reference Claims ID

Text

The original Payer Claim Control Number (MC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim and a Version Number (MC005A) is not used.

MC212

Allowed Amount

Number

10 (2)

Report the maximum dollar amount contractually allowed and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

MC215

Service Line Type

Text

Report the code that defines the claim line status in terms of adjudication

O Original

V Void

R Replacement

B Back Out

A Amendment

MC216

Payment Arrangement Type

Text

Defines the contracted payment methodology for this claim line

1 Capitation

2 Fee for service

3 Percent of charges

4 DRG

5 Pay for Performance

6 Global Payment

7 Other

8 Bundled payment

MC217

Pay for Performance Flag

Text

Does this provider have pay-for-performance bonuses or year-end withhold returns based on performance for at least one service performed by this provider within the month?

Required when MP005 = 1, 2, or 3

Y: Yes

N: No

MC218

Claim Processing Level Indicator

Text

1 Claim Level

2 Service Line level

MC219

Denied Claim Indicator

Text

1 Fully Paid – the entire claim was paid at the allowed amount

2 Partially denied – some of the claims lines were paid at the allowed amount

3 Encounter claim – this claim records a service provided that is paid under a non Fee For Service (FFS) payment arrangement such as capitation

4 No payment – no payment made for reasons other than non FFS payment arrangement

MC220

Denial Reason

Text

Denial reason code. Required when Service Line Status (MC038) = 2 or 4. The denial reason code must correspond with federal CARC/RARC codes. See Ins 4008.04

MC221

Procedure Modifier – 3

Text

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

MC222

Procedure Modifier – 4

Text

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

MC223

HIOS Plan ID

Text

The 16 character HIOS Plan ID (Standard component), including a 5 digit issuer ID, 2 character state ID, 3 digit product number, 4 digit standard component number, and 2 digit variant component ID. This field may not be available for all market segments. Leave blank if not available

MC899

Record Type

Text

MC900

In Network Indicator

Text

A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network. Valid codes: Y=Yes, N=No

MC901

Unit of Measure

Text

Type of units reported in MC061. Codes accepted DA=days, MN=minutes, UN=units. If MC061 is not reported, MC901=NA

MC902

Claim Source

Text

What form the claim was received in:

E: Electronic

P: Paper

MC903

Claim Received Date

Date

Date that the claim was received from the provider and it shall be in CCYYMMDD format.

MC904

Insurance Group Name

Text

Name of the Insurance Group whose Insured Group or Policy Number was listed in MC006. The name shall match ME032

MC905

Prior Authorization

Text

If that claim required a prior authorization

Y: Yes

N: No

MC906

TPA Identifier

Text

If you are a carrier whose claims were processed by a TPA and you are submitting the files, please indicate the TPA here. The full legal name of company, no acronyms shall be used. Else, leave blank.

History

#10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.02)

N.H. Code Admin. R. Ann. Ins 4009.03 Pharmacy Claims Data Tables {#sec-ins-4009.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4009.03}

(a) Pharmacy Claims Mapping and Format Information. Use Table 4009.07(c) to determine pharmacy claims file mapping and formatting.

(b) Pharmacy Claims File Header Record Layout:

Table 4009.03(b) Pharmacy Claims File Header Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

HD002

Payer

Text

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

CMS National Plan ID

HD004

Type of File

Text

PC Pharmacy Claims

HD005

Period Beginning Date

Number

Beginning of paid period for claims or beginning of month covered for eligibility

HD006

Period Ending Date

Number

End of paid period for claims or end of month covered for eligibility

HD007

Comments

Text

Submitter may use to document this submission by assigning a filename, system source, etc.

Table 4009.03(c) Pharmacy Claims File Trailer Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

TR002

Payer

Text

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

CMS National Plan ID

TR004

Type of File

Text

PC Pharmacy Claims

TR005

Period Beginning Date

Number

Beginning of paid period for claims or beginning of month covered for eligibility

TR006

Period Ending Date

Number

End of paid period for claims or beginning of month covered for eligibility

TR007

Extraction Date

Date

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

(d) Pharmacy Claims Detailed File Specifications:

Table 4009.03(d) Pharmacy Claims Detailed File Specification

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

PC001

Payer

Text

Payer submitting payments NHID Submitter Code

PC002

Plan ID

Text

CMS National Plan ID

PC003

Insurance Type/Product Code

Text

Table 4009.6 (a) Insurance Type/Product Code

PC004

Payer Claim Control Number

Text

Shall apply to the entire claim and be unique within the payer's system

PC005

Line Counter

Text

Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim

PC006

Insured Group Number

Text

Group or policy number (not the number that uniquely identifies the subscriber)

PC007

Placeholder

PC008

Plan Specific Contract Number

Text

Plan assigned contract number.

If this is a Medicaid claim, provide Medicaid ID.

Shall match the ID in ME009, MC008, and DC008

PC009

Member Suffix or Sequence Number

Text

PC010

Placeholder

PC011

Individual Relationship Code

Text

See Table 4009.06(b) Relationship Codes

PC012

Member Gender

Text

M: Male

F: Female

U: Unknown

O: Other

PC013

Member Date of Birth

Date

Date of birth of member

PC014

Member City Name of Residence

Text

City name of member

PC015

Member State

Text

As defined by the US Postal Service

PC016

Member ZIP Code

Text

ZIP Code of member – may include non- US codes. Do not include dash.

PC017

Paid Date (AP Date)

Date

Paid date or the Pharmacy Benefits Manager’s billing date

PC018

Pharmacy Number

Text

Payer assigned pharmacy number. AHFS number is acceptable

PC019

Pharmacy Tax ID Number

Text

Federal taxpayer's identification number (Please provide the pharmacy chain’s federal tax identification number, if the individual retail pharmacy’s tax ID# is not available.)

PC020

Pharmacy Name

Text

Name of pharmacy

PC021

National Pharmacy ID Number

Text

Required if National Provider ID is mandated for use under HIPAA

PC022

Pharmacy Location City

Text

City name of pharmacy

PC023

Pharmacy Location State

Text

As defined by the US Postal Service

PC024

Pharmacy ZIP Code

Text

ZIP Code of pharmacy - may include non- US codes. Do not include dash

PC024A

Pharmacy Country Name

Text

Code US

PC025

Service Line Status

Text

See Table 4009.06(g) Claim Status

PC026

Drug Code

Text

NDC Code in CMS configuration with leading zeros and no hyphens.

PC027

Drug Name

Text

Text name of drug

PC028

New Prescription

Number

2 (0)

00 New prescription. 01-99 Number of refill(s)

PC029

Generic Drug Indicator

Text

01 No, branded drug

02 Yes, generic drug

PC030

Dispense as Written Code

Text

0 Not dispensed as written

1 Physician dispense as written

2 Member dispense as written

3 Pharmacy dispense as written

4 No generic available

5 Brand dispensed as generic

6 Override

7 Substitution not allowed - brand drug mandated by law

8 Substitution allowed

generic drug not available in marketplace

9 Other

PC031

Compound Drug Indicator

Text

N Non-compound drug

Y Compound drug

U Non-specified drug compound

PC032

Date Prescription Filled

Date

PC033

Quantity Dispensed

Number

Number of metric units of medication dispensed

PC034

Days’ Supply

Number

Estimated number of days the prescription will last

PC035

Charge Amount

Number

10 (2)

PC036

Paid Amount

Number

10 (2)

Includes any withhold amounts. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

PC037

Ingredient Cost/List Price

Number

10 (2)

Cost of the drug dispensed. Do not code decimal pointDo not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

PC038

Postage Amount Claimed

Number

10 (2)

Postage amount in dollars . Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

PC039

Dispensing Fee

Number

10 (2)

Dispensing fees in dollars . Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

PC040

Copay Amount

Number

10 (2)

The preset, fixed dollar amount for which the individual is responsible.Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

PC041

Coinsurance Amount

Number

10 (2)

Coinsurance amount in dollars . Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

PC042

Deductible Amount

Number

10 (2)

Deductible amount in dollars . Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

PC043

Prescription Number

Text

The number generated by the pharmacy when a new prescription is ordered for a person - a unique code assigned to a person’s prescribed medicine

PC044

Prescribing Physician First Name

Text

Physician first name

PC045

Prescribing Physician Middle Name

Text

Physician middle name

PC046

Prescribing Physician Last Name

Text

Physician last name

PC047

Prescribing Physician Number

Text

Provider NPI

PC101

Subscriber Last Name

Text

PC102

Subscriber First Name

Text

PC103

Subscriber Middle Initial

Text

PC104

Member Last Name

Text

PC105

Member First Name

Text

PC106

Member Middle Initial

Text

PC203

Carrier Identifier

Text

If you are a PBM that processes claims and are submitting files on behalf of a carrier, indicate the carrier name here. The full legal name of the company, no acronyms shall be used. Else, leave blank.

PC204

Carrier Plan Specific Contract Number

Text

128

For each claim, the carrier specific contract number when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by a PBM under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

PC211

Cross Reference Claims ID

Text

The original Payer Claim Control Number (PC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim.

PC212

Allowed amount

Number

10 (2)

Report the maximum amount contractually allowed for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider.

PC213

HIOS Plan ID

Text

PC214

Claim Processing Level Indicator

Text

1 Claim Level

2 Service Line level

PC215

Service Line Type

Text

Report the code that defines the claim line status in terms of adjudication

O Original

V Void

R Replacement

B Back Out

A Amendment

PC216

Denied Claim Indicator

Text

1 Fully Paid – the entire claim was paid at the allowed amount

2 Partially denied – some of the claims lines were paid at the allowed amount

3 Encounter claim – this claim records a service provided that is paid under a non FFS payment arrangement such as capitation

4 No payment – no payment made for reasons other than non FFS payment arrangement

PC217

Denial Reason

Text

Denial reason code. Required whenService Line Status (PC025)= 2 or 4 NCPDP denial reason codes and CARC/RARC code list. See Ins 4008.04

PC899

Record Type

Text

PC900

Mail Order Pharmacy Indicator

Text

A yes/no indicator that specifies that the pharmacy is a mail order pharmacy. Valid codes: Y=Yes, N=No

PC901

In Network Indicator

Text

A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network. Valid codes: Y=Yes, N=No

PC902

Version Number

Number

4(0)

Version number of this claim. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line

PC903

Claim Source

Text

What form the claim is being processed as:

E: Electronic

P: Paper

PC904

Claim Received Date

Date

Date that the claim was received from the provider. The date shall be in CCYYMMDD format.

PC905

Insurance Group Name

Text

Name of the Insurance Group whose Insured Group or Policy Number was listed in PC006. The name shall match ME032

PC906

Coordination of Benefits/Third Party Liability Amount

Number

2(10)

PC907

PBM Identifier

Text

If you are a carrier whose claims were processed by a PBM and you are submitting the files, please indicate the PBM here. The full legal name of the company, no acronyms shall be used. Else, leave blank

PC908

Prior Authorization

Text

If that claim required a prior authorization

Y: Yes

N: No

PC909

Drug Unit of Measure

Text

Report the code that defines the unit of measure for the drug dispensed in PC034. Valid codes are:

EA=Each;

F2=International Units;

GM=Grams;

ML=Milliliters;

MG=Milligrams;

MEQ=Milliequivalent;

MM=Millimeter;

UG=Microgram;

UU=Unit;

OT=Other

History

#10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.03)

N.H. Code Admin. R. Ann. Ins 4009.04 Dental Claims Data Tables {#sec-ins-4009.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 4009.04}

(a) Dental Claims Mapping and Format Information. Use Table 4009.07(d) to determine dental claims file mapping and formatting.

(b) Dental Claims File Header Record Layout:

Table 4009.04(b) Dental Claims Header File Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

HD002

Payer

Text

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

CMS National Plan ID

HD004

Type of File

Text

DC Dental Claims

HD005

Period Beginning Date

Number

Beginning of paid period for claims or beginning of month covered for eligibility

HD006

Period Ending Date

Number

End of paid period for claims or end of month covered for eligibility

HD007

Comments

Text

Submitter may use to document this submission by assigning a filename, system source, etc.

Table 4009.04(c) Dental Claims Trailer File Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

TR002

Payer

Text

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

CMS National Plan ID

TR004

Type of File

Text

DC Dental Claims

TR005

Period Beginning Date

Number

Beginning of paid period for claims or beginning of month covered for eligibility

TR006

Period Ending Date

Number

End of paid period for claims or beginning of month covered for eligibility

TR007

Extraction Date

Date

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

(d) Dental Claims Detailed File Specifications:

Table 4009.04(d) Dental Claims Detailed File Specifications

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

DC001

Payer

Text

Payer submitting payments

DC002

National Plan ID

Text

CMS National Plan ID

DC003

Insurance Type/Product Code

Text

Table 4009.6(a) Insurance Type/Product Code

DC004

Payer Claim Control Number

Text

Shall apply to entire claim and be unique within payer's system

DC005

Line Counter

Number

Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim

DC006

Insured Group or Policy Number

Text

Group or policy number (not the number that uniquely identifies the subscriber)

DC007

Placeholder

DC008

Plan Specific Contract Number

Text

Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber’s social security number.

If this is a Medicaid claim, provide Medicaid ID.

Shall match the ID in ME009, MC008, and PC008

DC009

Member Suffix or Sequence Number

Text

DC010

Member Social Security Number

Text

Member’s social security number. Do not include dashes. Leave blank if not available.

DC011

Individual Relationship Code

Text

See Table 4009.06(b) Relationship Codes

DC012

Member Gender

Text

M Male

F Female

U Unknown

O Other

DC013

Member Date of Birth

Date

DC014

Member City Name

Text

City name of member

DC015

Member State or Province

Text

As defined by the U.S. Postal Service

DC016

Member ZIP Code

Text

ZIP Code of member – may include non- US codes. Do not include dash.

DC017

Paid Date/AP Date

Date

DC018

Service Provider Number

Text

Payer assigned provider number

DC019

Service Provider Tax ID Number

Text

Federal taxpayer's identification number – if the tax id is a provider’s social security number use ‘SSN’ and ‘NA’ if unavailable

DC020

National Service Provider ID

Text

Required if National Provider ID is mandated for use under HIPAA (See MC 220 in Table 4009.02(d) above.)

DC021

Service Provider Entity Type Qualifier

Text

HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as “Person”.

1 Person

2 Non-Person Entity

DC022

Service Provider First Name

Text

Individual first name. Leave blank if provider is a facility or organization

DC023

Service Provider Middle Name

Text

Individual middle name or initial. Leave blank if provider is a facility or organization

DC024

Servicing Provider Last Name or Organization Name

Text

Report the name of the organization or last name of the individual provider. DC021 determines if this is an Organization or Individual Name reported here.

DC025

Service Provider Suffix

Text

Suffix to individual name. Leave blank if provider is a facility or organization

DC026

Service Provider Specialty

Text

National Uniform Claims Committee (NUCC) standard code that defines this provider for this line of service. Dictionary for specialty code values must be supplied during testing.

DC027

Service Provider City Name

Text

City name of provider

practice location

DC028

Service Provider State or Province

Text

As defined by the U.S. Postal Service

DC029

Service Provider ZIP Code

Text

ZIP Code of provider

may include non-US codes.

DC030

Place of Service - Professional

Text

See Table 4009.06(f)Place of Service -- Professional

DC031

Claim Status

Text

See Table 4009.06(g) Claim Status

DC032

CDT Code

Text

Common Dental Terminology code

DC033

Procedure Modifier - 1

Text

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

DC034

Procedure Modifier - 2

Text

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

DC035

Date of Service - From

Date

First date of service for this service line.

DC036

Date of Service - Thru

Date

Last date of service for this service line.

DC037

Charge Amount

Number

10 (2)

The full, undiscounted total and service-specific charges billed by the provider.

DC038

Paid Amount

Number

10 (2)

Includes any withhold amounts. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

DC039

Copay Amount

Number

10 (2)

The present, fixed dollar amount for which the individual is responsible.Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

DC040

Coinsurance Amount

Number

10 (2)

The dollar amount an individual is responsible for - not the percentage. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

DC041

Deductible Amount

Number

10 (2)

Deductible amount in dollars . Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

DC042

Billing Provider Number

Text

Carriers, third-party administrators, and dental claims processors shall code using the payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change

DC043

National Billing Provider Number ID

Text

This is the NPI for the billing provider

DC044

Billing Provider Last Name

Text

Full name of provider billing organization or last name of individual billing provider.

DC101

Subscriber Last Name

Text

DC102

Subscriber First Name

Text

DC103

Subscriber Middle Initial

Text

DC104

Member Last Name

Text

DC105

Member First Name

Text

DC106

Member Middle Initial

Text

DC201

Carrier Identifier

Text

If you are a TPA that processes claims and are submitting files on behalf of a carrier, indicate the carrier name here. The full legal name of company, without acronyms shall be used. Else, leave blank.

DC202

Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number

Text

128

For each claim, the carrier specific contract number or subscriber/member social security number when a TPA processes claims on behalf of the carrier. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

DC203

Practitioner Group Practice

Text

Name of group practice to which a practitioner is affiliated if different from DC044.

DC204

Tooth Number/Letter

Text

Report the tooth identifier(s) when DC032 is within the given range. Required when DC032 = D2000 thru D2999

DC205

Dental Quadrant

Text

Standard quadrant identifier from the External Code Source referenced in Ins 4008.05. Provides further detail on procedure(s)

DC206

Tooth Surface

Text

Tooth surface(s) that this service relates to. Provides further detail on procedure. See Ins 4008.04.

DC207

Claim Version

Text

Version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line. No alpha or special characters.

DC208

Diagnosis Code

Text

ICD CM Diagnosis Code when applicable

DC209

ICD Indicator

Text

Report the value that defines whether the diagnoses on claim are ICD9 or ICD10.

0 ICD-9

1 ICD-10

DC211

Cross Reference Claims ID

Text

The original Payer Claim Control Number (DC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim.

DC212

Allowed amount

Number

10 (0)

Report the maximum amount contractually allowed and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Shall be reported even when paid amount = 0 but member receives care. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070

DC213

HIOS Plan ID

Text

DC215

Service Line Type

Text

Report the code that defines the claim line status in terms of adjudication

O Original

V Void

R Replacement

B Back Out

A Amendment

DC218

Claim Processing Level Indicator

Text

1 Claim Level

2 Service Line level

DC219

Denied Claim Indicator

Text

1 Fully Paid – the entire claim was paid at the allowed amount

2 Partially denied – some of the claims lines were paid at the allowed amount

3 Encounter claim – this claim records a service provided that is paid under a non FFS payment arrangement such as capitation

4 No payment – no payment made for reasons other than non FFS payment arrangement

DC220

Denial Reason

Text

Denial reason code. Required when denied claim indicator = 2 or 4. See Ins 4008.04

DC899

Record Type

Text

DC900

In Network Indicator

Text

A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network. Valid codes: Y=Yes, N=No

DC901

Quantity

Number

12(0)

Count of services performed

DC902

Claim Source

Text

What form the claim is being processed as:

E: Electronic

P: Paper

DC903

Claim Received Date

Date

Date that the claim was received from the provider. The date shall be in CCYYMMDD format.

DC904

Insurance Group Name

Text

Name of the Insurance Group whose Insured Group or Policy Number was listed in DC006. The name shall match ME032

DC905

Coordination of Benefits/Third Party Liability Amount

Number

2(10)

DC906

TPA Identifier

Text

If you are a carrier whose claims were processed by a TPA and you are submitting the files, please indicate the TPA here. The full legal name of company, without acronyms shall be used. Else, leave blank.

DC907

Prior Authorization

Text

If that claim required a prior authorization

Y: Yes

N: No

History

#10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.04)

N.H. Code Admin. R. Ann. Ins 4009.05 Provider File Data Tables {#sec-ins-4009.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 4009.05}

(a) Provider File Header Record Layout:

Table 4009.05(a) Provider File Header Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

HD002

Payer

Text

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

CMS National Plan ID

HD004

Type of File

Text

MP Provider File

HD005

Period Beginning Date

Number

Beginning of span of coverage period

HD006

Period Ending Date

Number

End of span of coverage period

HD008

Comments

Text

Submitter may use to document this submission by assigning a filename, system source, etc.

(b) Provider File Trailer Record Layout:

Table 4009.05(b) Provider File Trailer Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

TR002

Payer

Text

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

CMS National Plan ID

TR004

Type of File

Text

MP Provider File

TR005

Period Beginning Date

Number

Beginning of span of coverage period

TR006

Period Ending Date

Number

End of span of coverage period

TR007

Extraction Date

Date

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

Table 4009.05(c) Provider File Detailed Specifications

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

MP001

Payer

Text

Payer submitting payments. NHID Submitter Code

MP002

Plan ID

Text

CMS National Plan ID or NAIC code.

MP003

Provider ID

Text

Unique identified for the provider as assigned by the reporting entity

MP004

Provider Tax ID

Text

Federal taxpayer's identification number –if the tax id is a provider’s social security number use ‘SSN’ and ‘NA’ if unavailable. Do not code punctuation.

MP005

Provider Entity

Text

Specify the value that defines the type of entity

1 Person; physician, clinician, orthodontist, and any individual that is licensed/certified to perform health care services.

2 Facility; hospital, health center, long term care, rehabilitation and any building that is licensed to transact health care services.

3 Professional Group; collection of licensed/certified health care professionals that are practicing health care services under the same entity name and Federal Tax Identification Number.

4 Retail Site; brick-and-mortar licensed/certified place of transaction that is not solely a health care entity, i.e., pharmacies, independent laboratories, vision services.

5 E-Site; internet-based order/logistic system of health care services, typically in the form of durable medical equipment, pharmacy or vision services. Address assigned should be the address of the company delivering services or order fulfillment.

6 Financial Parent; financial governing body that does not perform health care services itself but directs and finances health care service entities, usually through a Board of Directors.

7 Transportation; any form of transport that conveys a patient to/from a healthcare provider.

8 Other; any type of entity not otherwise defined that performs health care services.

MP006

Provider First Name

Text

Individual first name. Leave blank if provider is a facility or organization

MP007

Provider Middle Name or Initial

Text

MP008

Provider Last Name or Organization Name

Text

Full name of provider organization or last name of individual provider

MP009

Provider Suffix

Text

Example: Jr; Set as leave blank if provider is an organization. Do not use credentials such as MD or PhD

MP010

Provider Specialty

Text

Report the HIPAA-compliant health care provider taxonomy code. Code set is available at the National Uniform Claims Committee’s web site at http://www.nucc.org/

MP011

Provider Office Street Address

Text

Physical address – address where provider delivers health care services

MP012

Provider Office City

Text

Physical address – address where provider delivers health care services

MP013

Provider Office State

Text

Physical address – address where provider delivers health care services. Use postal service standard 2 letter abbreviations

MP014

Provider Office Zip

Text

Physical address – address where provider delivers health care services. Minimum 5 digit code. Do not include dashes

MP015

Provider DEA Number

Text

MP016

Provider NPI

Text

MP017

Provider State License Number

Text

MP018

Entity Code

Text

Enter the value that defines the entity provider type. Required when MP005 does not = 1

1 Academic Institution

2 Adult Foster Care

3 Ambulance Services

4 Hospital Based Clinic

5 Stand-Alone, Walk-In/Urgent Care Clinic

6 Other Clinic

7 Community Health Center - General

8 Community Health Center - Urgent Care

9 Government Agency

10 Health Care Corporation

11 Home Health Agency

12 Acute Hospital

13 Chronic Hospital

14 Rehabilitation Hospital

15 Psychiatric Hospital

16 DPH Hospital

17 State Hospital

21 Licensed Hospital Satellite Emergency Facility

22 Hospital Emergency Center

23 Nursing Home

24 Pharmacy

MP899

Record Type

Text

History

#10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.05)

N.H. Code Admin. R. Ann. Ins 4009.06 Data Submission Manual Code Tables {#sec-ins-4009.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 4009.06}

(a) Insurance Type/Product Code:

Table 4009.06(a) Insurance Type/Product Code

Code

Description

Other Non-Federal Programs

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan

Medicare Secondary, No-Fault Insurance including Insurance in which Auto Is Primary

Medicare Secondary Workers' Compensation

Medicare Secondary Public Health Service (PHS) or Other Federal Agency

Dental

Vision

Prescription Drugs (Commercial Coverage)

Medicare Secondary Black Lung

Medicare Secondary Veterans' Administration

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

Auto Insurance Policy

Commercial

Consolidated Omnibus Reconciliation Act (COBRA)

Medicare Conditionally Primary

Disability

Medicare – Point of Service (POS)

Exclusive Provider Organization

Federal Employees Health Benefits Program (HMO)

Federal Employees Health Benefits Program (PPO)

Health Maintenance Organization (HMO)

Health Maintenance Organization (HMO) Medicare Advantage/Risk

Indemnity

Individual Policy

Long Term Care

Long Term Policy

Life Insurance

Litigation

Medicare Part A (not to be used for commercial plans)

Medicare Part B (not to be used for commercial plans)

Medicaid

Medicare Part D

Medigap Part A

Medigap Part B

Medicare Advantage PPO

Medicare Primary (not to be used for commercial plans)

Other

Personal

Preferred Provider Organization (PPO)

Point of Service (POS)

Qualified Medicare Beneficiary

Property Insurance – Real

MedicareSupplemental Policy

Tricare

Multiple Options Health Plan

Wrap Up Policy

Dental Maintenance Organization

Automobile Medical

Liability

Other Federal Program

Title V

(b) Relationship Codes:

Table 4009.06(b) Relationship Codes

Code

Description

Spouse

Son or daughter

Father or Mother

Grandfather or Grandmother

Grandson or Granddaughter

Uncle or Aunt

Nephew or Niece

Cousin

Adopted Child

Foster Child

Son-in-Law or Daughter-in-Law

Brother-in-Law or Sister-in-Law

Mother-in-Law or Father-in-Law

Brother or Sister

Ward

Stepparent

Stepson or Stepdaughter

Self

Child

Employee/Self

Unknown

Handicapped Dependent

N.H. Code Admin. R. Ann. Ins 4009.07 Mapping and Format Information Tables {#sec-ins-4009.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 4009.07}

(a) Member Eligibility File Mapping and Format Information:

Table 4009.07(a) Member Eligibility File Mapping and Format Information

Data Element #

Element

HIPAA Reference

Transaction Set/Loop/

Segment/Qualifier/

Data Element

ME001

Payer

N/A

ME002

National Plan ID

271/2100A/NM1/XV/09

ME003

Insurance Type Code/Product

271/2110C/EB/ /04, 271/2110D/EB/ /04

ME004

Year

N/A

ME005

Month

N/A

ME006

Insured Group or Policy Number

271/2100C/REF/1L/02, 271/2100C/REF/IG/02, 271/2100C/REF/6P/02, 271/2100D/REF/1L/02, 271/2100D/REF/IG/02, 271/2100D/REF/6P/02

ME007

Coverage Level Code

271/2110C/EB/ /03, 271/2100D/EB/ /03

ME009

Plan Specific Contract Number

271/2100C/NM1/MI/09

ME010

Member Suffix or Sequence Number

N/A

ME012

Individual Relationship Code

271/2100C/INS/Y/02, 271/2100D/INS/N/02

ME013

Member Gender

271/2100C/DMG/ /03, 271/2100D/DMG/ /03

ME014

Member Date of Birth

271/2100C/DMG/D8/02, 271/2100D/DMG/D8/02

ME015

Member City Name

271/2100C/N4/ /01, 271/2100D/N4/ /01

ME016

Member State or Province

217/2100C/N4/ /02, 271/2100D/N4/ /02

ME017

Member ZIP Code

271/2100C/N4/ /03, 271/2100D/N4/ /03

ME018

Medical Coverage

N/A

ME019

Prescription Drug Coverage

N/A

ME020

Dental Coverage

N/A

ME021

Race 1

N/A

ME022

Race 2

N/A

ME023

Place holder

N/A

ME024

Hispanic Indicator

N/A

ME025

Ethnicity 1

N/A

ME026

Ethnicity 2

N/A

ME027

Place holder

N/A

ME028

Primary Insurance Indicator

N/A

ME029

Coverage Type

N/A

ME030

Market Category

N/A

ME031

NH Health Protection Program

N/A

ME032

Group Name

N/A

ME101

Subscriber Last Name

270/2100C/NM1/IL/1/3

ME102

Subscriber First Name

270/2100C/NM1/IL/1/4

ME103

Subscriber Middle Initial

270/2100C/NM1/IL/1/5

ME104

Member Last Name

270/2100D/NM1/QC/1/3

ME105

Member First Name

270/2100D/NM1/QC/1/4

ME106

Member Middle Initial

270/2100D/NM1/QC/1/5

271/2100/N3/ /01, 02

271/2100D/N3/ /01, 02

ME203

Member’s Assigned PCP

Loop 2000B SBR02 = 18 - ELSE - Loop

ME204

HIOS Plan ID

N/A

ME205

Plan Effective Date

N/A

ME206

Minimum Value

2010CA Segment N301

ME207

Exchange Indicator

N/A

ME208

High Deductible Health Plan

N/A

ME209

Active Enrollment

N/A

ME210

New Coverage

N/A

ME211

N/A

ME899

Record Type

N/A

ME900

Plan State

N/A

ME901

Advance Premium Tax Credit

N/A

ME902

NAIC Number

N/A

ME903

Grandfather Plan Indicator

N/A

ME904

Metal Value

N/A

(b) Medical Claims File Mapping and Format Information:

Table 4009.07(b) Medical Claims File Mapping and Format Information

Data Element #

Data Element Name

CMS 1450/UB-04

Form

Locator

CMS

1500

HIPAA Reference Transaction Set/Loop/

Segment/Qualifier/

Data Element

MC001

Payer

N/A

MC002

National Plan ID

N/A

835/1000A/N1/XV/04

MC003

Product/Claim Filing Indicator Code

N/A

835/2100/CLP/ /06

MC004

Payer Claim Control Number

N/A

835/2100/CLP/ /07

MC005

Line Counter

N/A

837/2400/LX/ /01

MC005A

Version Number

N/A

MC006

Insured Group or Policy Number

62 (A-C)

11C

837/2000B/SBR/ /03

MC007

Placeholder

MC008

Plan Specific Contract Number

1 a

835/2100/NM1/HN/08

MC009

Member Suffix or Sequence Number

N/A

MC010

Placeholder

MC011

Individual Relationship Code

59 (A-C)

837/2000B/SBR/ /02, 837/2000C/PAT/ /01

MC012

Member Gender

837/2010CA/DMG/03

MC013

Member Date of Birth

837/2010CA/DMG/D8/02

MC014

Member City Name

837/2010CA/N4/ /01

MC015

Member State or Province

837/2010CA/N4/ /02

MC016

Member ZIP Code

837/2010CA/N4/ /03

MC017

Paid Date (AP Date)

N/A

MC018

Admission Date

N/A

837/2300/DTP/435/03

MC019

Admission Hour

N/A

837/2300/DTP/435/03

MC020

Admission Type

N/A

837/2300/CL1/ /01

MC021

Admission Source

837/2300/CL1/ /02

MC022

Discharge Hour

837/2300/DTP/096/03

MC023

Discharge Status

N/A

837/2300/CL1/ /03

MC024

Service Provider Number

76-79

N/A

MC025

Service Provider Tax ID Number

835/2100/NM1/FI/09

MC026

National Service Provider ID

N/A

835/2100/NM1/XX/09

MC027

Service Provider Entity Type Qualifier

N/A

835/2100/NM1/82/02

MC028

Service Provider First Name

835/2100/NM1/82/04

MC029

Service Provider Middle Name

835/2100/NM1/82/05

MC030

Service Provider Last Name or Organization Name

835/2100/NM1/82/03

MC031

Service Provider Suffix

835/2100/NM1/82/07

MC032

Service Provider Specialty

N/A

837/2000A/PRV/ZZ/03

MC033

Service Provider City Name

N/A

837/2010A/N4/ /01

MC034

Service Provider State or Province

N/A

837/2010A/N4/ /02

MC035

Service Provider ZIP Code

N/A

837/2010A/N4/ /03

MC036

Type of Bill – Institutional

N/A

837/2300/CLM/ /05-1

MC037

Facility Type - Professional

N/A

835/2100/CLP/ /08

MC038

Service Line Status

N/A

835/2100/CLP/ /02

MC039

Admitting Diagnosis

N/A

837/2300/HI/BJ/02-2

MC040

E-Code

N/A

837/2300/HI/BN/03-2

MC041

Principal Diagnosis

21.1

837/2300/HI/BK/01-2

MC042

Other Diagnosis – 1

21.2

837/2300/HI/BF/02-1

MC043

Other Diagnosis – 2

21.3

837/2300/HI/BF/02-2

MC044

Other Diagnosis – 3

21.4

837/2300/HI/BF/02-3

MC045

Other Diagnosis – 4

N/A

837/2300/HI/BF/02-4

MC046

Other Diagnosis – 5

N/A

837/2300/HI/BF/02-5

MC047

Other Diagnosis – 6

N/A

837/2300/HI/BF/02-6

MC048

Other Diagnosis – 7

N/A

837/2300/HI/BF/02-7

MC049

Other Diagnosis – 8

N/A

837/2300/HI/BF/02-8

MC050

Other Diagnosis – 9

N/A

837/2300/HI/BF/02-9

MC051

Other Diagnosis –10

N/A

837/2300/HI/BF/02-10

MC052

Other Diagnosis –11

N/A

837/2300/HI/BF/02-11

MC053

Other Diagnosis –12

N/A

837/2300/HI/BF/02-12

MC054

Revenue Code

N/A

835/2110/SVC/RB/01-2,

835/2110/SVC/NU/01-2

MC055

Procedure Code

24.1-6 D

837/2400/SV202-02

835/2110/SVC/HC/01-2

MC056

Procedure Modifier – 1

24.1-6 D

837/2400/SV202-03

835/2110/SVC/HC/01-3

MC057

Procedure Modifier – 2

24.1-6 D

837/2400/SV202-04

835/2110/SVC/HC/01-3

MC058

ICD-9-CM Procedure Code

N/A

835/2110/SVC/ID/01-2

MC059

Date of Service – From

24.1-6 A

835/2110/DTM/150/02

MC060

Date of Service – Thru

N/A

24.1-6 A

835/2110/DTM/151/02

MC061

Quantity

24.1-6 G

835/2110/SVC/ /05

MC062

Charge Amount

24.1-6F

835/2110/SVC/ /02

MC063

Paid Amount

N/A

835/2110/SVC/ /03

MC064

Fee for Service Equivalent

N/A

MC065

Co-pay Amount

N/A

MC066

Coinsurance Amount

N/A

MC067

Deductible Amount

N/A

MC068

Patient Account/Control Number

N/A

837/2300/CLM/1

MC069

Discharge Date

MC070

Service Provider Country Name

N/A

MC071

DRG

N/A

837/2300/HI/DR/2

MC072

DRG Version

N/A

MC073

APC

N/A

MC074

APC Version

N/A

MC075

Drug Code

837/2400/SV2/N1/2

837/2400/SV2/N2/2

837/2400/SV2/N3/2

837/2400/SV2/N4/2

837/2400/SV2/ND/2

MC076

Billing Provider Number

N/A

MC077

National Billing Provider Number ID

N/A

MC078

Billing Provider Organization or Last Name

N/A

MC101

Subscriber Last Name

N/A

837/2110BA/NM1/IL/1/3

MC102

Subscriber First Name

N/A

837/2110BA/NM1/IL/1/4

MC103

Subscriber Middle Initial

N/A

837/2110BA/NM1/IL/1/5

MC104

Member Last Name

N/A

837/2110CA/NM1/QC/1/3

MC105

Member First Name

N/A

837/2110CA/NM1/QC/1/4

MC106

Member Middle Initial

N/A

837/2110CA/NM1/QC/1/5

MC200

ICD Indicator

N/A

Set value here based upon Loop 2300 Segment H101-01 starting with the letter A

MC202

Other ICD-CM Procedure code - 2

74 a-e

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC203

Other ICD-CM Procedure code - 3

74 a-e

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC204

Other ICD-CM Procedure code - 4

74 a-e

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC205

Other ICD-CM Procedure code - 5

74 a-e

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC206

Other ICD-CM Procedure code - 6

74 a-e

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC207

Carrier Associated with Claim

N/A

MC208

Carrier Plan Specific contract Number

N/A

MC209

Practitioner Group Practice

N/A

MC210

Coordination of Benefits/Third Party Liability Amount

835/2320 AMT02

MC211

Cross Reference Claims ID

N/A

MC212

Allowed Amount

N/A

837/2300 HCP02

MC215

Service Line Type

N/A

MC216

Payment Arrangement Type

N/A

Loop 2400 Segment HCP01

MC217

Pay for Performance Flag

N/A

MC218

Claim Processing Level Indicator

N/A

MC219

Denied Claim Indicator

N/A

Loop 2430 CAS identification

MC220

Denial Reason

N/A

Loop 2430 CAS identification

MC221

Procedure Modifier – 3

N/A

837/2430 SVD03-05

MC222

Procedure Modifier – 4

N/A

837/2430 SVD03-06

MC899

Record Type

N/A

MC900

In Network Indicator

N/A

MC901

Unit of Measure

N/A

MC902

Claim Source

N/A

MC903

Claim Received Date

N/A

MC904

Insurance Group Name

11C

N/A

MC905

Prior Authorization

837/2300 REF02

MC906

TPA Identifier

N/A

Table 4009.07(c) Pharmacy Claims File Mapping and Format Information

Data

Element

National Council for Prescription

Drug Programs Field #

PC001

Payer

N/A

PC002

Plan ID

PC003

Insurance Type/Product Code

N/A

PC004

Payer Claim Control Number

993-A7

PC005

Line Counter

A91

PC006

Insured Group Number

301-C1

PC007

Placeholder

A89

PC008

Plan Specific Contract Number

302-C2

PC009

Member Suffix or Sequence Number

303-C3

PC010

Placeholder

332-CY

PC011

Individual Relationship Code

306-C6

PC012

Member Gender

305-C5

PC013

Member Date of Birth

304-C4

PC014

Member City Name of Residence

323-CN

PC015

Member State or Province

324-CO

PC016

Member ZIP Code

325-CP

PC017

Paid Date (AP Date)

216 or 578

PC018

Pharmacy Number

202-B2

PC019

Pharmacy Tax ID Number

N/A

PC020

Pharmacy Name

833-5P

PC021

National Pharmacy ID Number

N/A

PC022

Pharmacy Location City

831-5N

PC023

Pharmacy Location State

832-6F

PC024

Pharmacy ZIP Code

835-5R

PC024A

Pharmacy Country Name

A93-IT

PC025

Service Line Status

N/A

PC026

Drug Code

407-D7

PC027

Drug Name

516-FG

PV028

New Prescription

403-D3

PC029

Generic Drug Indicator

425-DP

PC030

Dispense as Written Code

408-D8

PC031

Compound Drug Indicator

406-D6

PC032

Date Prescription Filled

401-D1

PC033

Quantity Dispensed

442-E7

PC034

Days Supply

405-D5

PC035

Charge Amount

804-5B

PC036

Paid Amount

509-F9

PC037

Ingredient Cost/List Price

506-F6

PC038

Postage Amount Claimed

428-DS

PC039

Dispensing Fee

507-F7

PC040

Copay Amount

518-FI

PC041

Coinsurance Amount

518-FI

PC042

Deductible Amount

505-F5

PC043

Prescription Number

402-D2

PC044

Prescribing Physician First Name

717

PC045

Prescribing Physician Middle Name

N/A

PC046

Prescribing Physician Last Name

716

PC047

Prescribing Physician Number

411-DB

PC101

Subscriber Last Name

716

PC102

Subscriber First Name

717

PC103

Subscriber Middle Initial

718

PC104

Member Last Name

716

PC105

Member First Name

717

PC106

Member Middle Initial

718

PC203

Carrier Associated with Claim

N/A

PC204

Carrier Plan Specific Contract Number

N/A

PC211

Cross Reference Claims ID

N/A

PC212

Allowed Amount

N/A

PC213

HIOS Plan ID

N/A

PC214

Claim Processing Level Indicator

N/A

PC215

Service Line Type

N/A

PC216

Denied Claim Indicator

N/A

PC217

Denial Reason

511-FB

PC899

Record Type

N/A

PC900

Mail Order Pharmacy Indicator

N/A

PC901

In Network Indicator

N/A

PC902

Version Number

102-A2

PC903

Claim Source

N/A

PC904

Claim Received Date

N/A

PC905

Insurance Group Name

N/A

PC906

Coordination of Benefits/Third Party Liability Amount

565-J4

PC907

PBM Identifier

N/A

PC908

Prior Authorization

N/A

PC909

Drug Unit of Measure

N/A

(d) Dental Claims File Mapping and Format Information:

Table 4009.07(d) Dental Claims File Mapping and Format Information

Data Element

Data Element Name

ADA Dental Claim

HIPAA Reference Transaction Set/Loop/

Segment/Qualifier/

Data Element

DC001

Payer

N/A

DC002

National Plan Id

N/A

DC003

Insurance Type/Product Code

N/A

835/2100/CLP/ /06

DC004

Payer Claim Control Number

N/A

835/2100/CLP/ /07

DC005

Line Counter

N/A

837/2400/LX/ /01

DC006

Insured Group or Policy Number

837/2000B/SBR/ /03

DC007

Placeholder

DC008

Plan Specific Contract Number

835/2100/NM1/MI/08

DC009

Member Suffix or Sequence Number

N/A

DC010

Placeholder

DC011

Individual Relationship Code

837/2000B/SBR/ /02, 837/20000C/PAT/ /01

DC012

Member Gender

837/2010BA/DMB/ /03, 837/2010CA/DMB/ /03

DC013

Member Date of Birth

837/2010BA/DMB/D8/02, 837/2010CA/DMB/D8/02

DC014

Member City Name of Residence

837/2010BA/N4/ /01, 837/2010CA/N4/ /01

DC015

Member State or Province

837/2010BA/N4/ /02, 837/2010CA/N4/ /02

DC016

Member ZIP Code of Residence

837/2010BA/N4/ /03, 837/2010CA/N4/ /03

DC017

Date Service Approved

N/A

835/Header Financial Information/BPR/ /16

DC018

Service Provider Number

835/21000/REF/1A/02, 835/2100/REF/1B/02,

835/2100/REF/1C/02, 835/2100/REF/1D/02, 835/2100/REF/G2/02, 835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09

DC019

Service Provider Tax ID Number

835/2100/NM1/FI/09

DC020

National Service Provider ID

N/A

837/2310B/NM1/XX/09

DC021

Service Provider Entity Type Qualifier

N/A

837/2310B/NM1/82/02

DC022

Service Provider First Name

N/A

837/2310B/NM1/82/04

DC023

Service Provider Middle Name

N/A

837/2310B/NM1/82/05

DC024

Service Provider Last Name or Organization Name

N/A

837/2310B/NM1/82/03

DC025

Service Provider Suffix

N/A

837/2310B/NM1/82/07

DC026

Service Provider Specialty

56a

837/2310B/PRV/PXC/03

DC027

Service Provider City name

837/2310C/N4/ /01

DC028

Service Provider State or Province

837/2310C /N4/ /02

DC029

Service Provider ZIP Code

837/2310C /N4/ /03

DC030

Facility Type - Professional

837/2300/CLM/05-1

DC031

Claim Status

N/A

835/2100/CLP/ /02

DC032

CDT Code

837/2400/SV3/AD/01-2

DC033

Procedure Modifier - 1

N/A

837/2400/SV3/AD/01-3

DC034

Procedure Modifier - 2

N/A

837/2400/SV3/AD/01-4

DC035

Date of Service - From

837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03

DC036

Date of Service - Thru

N/A

837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03

DC037

Charge Amount

837/2400/SV3/ /02

DC038

Paid Amount

N/A

835/2110/SVC/ /03

DC039

Copay Amount

N/A

835/2110/CAS/PR/3-03

DC040

Coinsurance Amount

N/A

835/2110/CAS/PR/2-03

DC041

Deductible Amount

N/A

835/2110/CAS/PR/1-03

DC042

Billing Provider Number

837/2010BB/REF/G2/02

DC043

National Billing Provider ID

N/A

837/2010AA/NM1/XX/09

DC044

Billing Provider Last Name

837/2010AA/NM1/ /03

DC101

Subscriber Last Name

837/2010BA/NM1/ /03

DC102

Subscriber First Name

837/2010BA/NM1/ /04

DC103

Subscriber Middle Initial

837/2010BA/NM1/ /05

DC104

Member Last Name

837/2010BA/NM1/ /03, 837/2010CA/NM1/ /03

DC105

Member First Name

837/2010BA/NM1/ /04, 837/2010CA/NM1/ /04

DC106

Member Middle Initial

837/2010BA/NM1/ /05, 837/2010CA/NM1/ /05

DC201

Carrier Associated with Claim

N/A

DC202

Carrier Plan Specific Contract Number

N/A

DC203

Practitioner Group Practice

N/A

DC204

Tooth Number/Letter

837/2400 TOO02

DC205

Dental Quadrant

N/A

DC206

Tooth Surface

837/2400 TOO03

DC207

Claim Version

N/A

DC208

Diagnosis Code

34, 34a-d

837/2300 H101-2

DC209

ICD Indicator

N/A

DC211

Cross Reference Claims ID

N/A

DC212

Allowed Amount

N/A

837/2300 HCP02

DC213

HIOS Plan ID

N/A

DC215

Service Line Type

N/A

DC218

Claim Processing Level Indicator

N/A

DC219

Denied Claim Indicator

N/A

DC220

Denial Reason

N/A

DC899

Record Type

N/A

DC900

In Network Indicator

N/A

DC901

Quantity

N/A

DC902

Claim Source

N/A

DC903

Claim Received Date

N/A

DC904

Insurance Group Name

N/A

DC905

Coordination of Benefits/Third Party Liability Amount

N/A

835/2320 AMT02

DC906

TPA Identifier

N/A

DC907

Prior Authorization

N/A

APPENDIX

RULE

STATUTE

Ins 4001.01

RSA 400-A:15, I; RSA 420-G:14

Ins 4002.01

RSA 400-A:15, I; RSA 420-G:14

Ins 4003.01

RSA 400-A:15, I; RSA 420-G:14

Ins 4003.02

RSA 400-A:15, I; RSA 420-G:14

Ins 4003.03

RSA 400-A:15, I; RSA 420-G:14

Ins 4004.01

RSA 400-A:15, I; RSA 420-G:14

Ins 4004.02

RSA 400-A:15, I; RSA 420-G:14

Ins 4004.03

RSA 400-A:15, I; RSA 420-G:14

Ins 4005.01

RSA 400-A:15, I; RSA 420-G:14

Ins 4005.02

RSA 400-A:15, I; RSA 420-G:14

Ins 4005.03

RSA 400-A:15, I; RSA 420-G:11; RSA 420-G:14

Ins 4006.01

RSA 400-A:15, I; RSA 420-G:14

Ins 4006.02

RSA 400-A:15, I; RSA 420-G:14

Ins 4006.03

RSA 400-A:15, I; RSA 420-G:14

Ins 4006.04

RSA 400-A:15, I; RSA 420-G:14

Ins 4006.05

RSA 400-A:15, I; RSA 420-G:14

Ins 4006.06

RSA 400-A:15, I; RSA 420-G:14

Ins 4007.01

RSA 400-A:15, I; RSA 420-G:14

Ins 4008.01

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4008.02

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4008.03

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4008.04

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4009.01

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4009.02

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4009.03

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4009.04

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4009.05

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4009.06

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

Ins 4009.07

RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2)

History

#10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.07)

Chapter Ins 4100 Requirements for Accident and Health Insurance Rate Submissions

Part Ins 4101 Requirements GOVERNING ALL Accident and Health Insurance Rate Submissions

N.H. Code Admin. R. Ann. Ins 4101.01 Purpose {#sec-ins-4101.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4101.01}

The purpose of this part is to establish requirements for all filings of accident and health insurance rates covered by this chapter.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4101.02 Applicability and Scope {#sec-ins-4101.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4101.02}

This part shall apply to rate filings for all accident and health insurance policies covered by this chapter, except long term care insurance policies or certificates under RSA 415-D, Medicare supplement insurance policies or certificates under RSA 415-F, credit insurance policies or certificates under RSA 408-A, or group disability income insurance.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4101.03 Federal Regulations Apply {#sec-ins-4101.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4101.03}

The provisions of the US Department of Health and Human Services regulation, 45 CFR Subtitle A, Subchapter B Part 158 Issuer Use of Premium Revenue Reporting and Rebate, dated December 1, 2010, wherein referenced shall apply to all carriers subject to the provisions of Ins 4100.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4101.04 Definitions {#sec-ins-4101.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 4101.04}

For the purposes of this part:

(a) “Carrier” means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an accident and health insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services;

(b) “Commissioner” means the insurance commissioner of this state;

(c) “Covered person” means a policyholder, certificate holder, subscriber, member, enrollee, dependent, or other individual entitled to benefits under a health benefit plan;

(d) “Department” means the New Hampshire insurance department;

(e) “National Association of Insurance Commissioners (NAIC)” means the organization of state insurance regulators of the 50 United States, Washington, DC, and the 5 US territories; and

(f) “NAIC System for Electronic Rate and Form Filing (SERFF)” means the automated system for handling insurance policy rate and form filings between regulators and insurance companies.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11 (from Ins 4101.03); ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4101.05 Rate Filing Review and Inventory Procedures {#sec-ins-4101.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 4101.05}

(a) All submissions shall be made by the carrier or by a licensed rating organization on behalf of the carrier.

(b) When a submission is made on behalf of a carrier, a letter or other document authorizing the rating organization to file on behalf of the carrier shall be included with the submission.

(d) All submissions shall include a fully completed NAIC uniform transmittal document, effective as of January 1, 2019, that is signed by a representative of the carrier authorized to certify compliance. This document shall be available as referenced in Appendix B and at http://www.naic.org/industry_rates_forms_trans_docs.htm.

(e) All submissions shall include a complete list identifying by number and title each form to which the rates apply.

(f) The department shall request additional information as necessary. Carriers shall have 30 days to respond to a request from the department for further information pursuant to this chapter.

(g) Carriers resubmitting a previously disapproved submission shall submit a complete, new submission that identifies and is responsive to all comments made by the department. The new submission shall include all correspondence from the previously disapproved submission.

(h) All submissions shall specify the date that the rates are intended to be effective. Unless specified otherwise in this chapter, rate submissions shall remain confidential until approved and effective. Effective dates shall not precede the approval date. All approved submissions shall be available for public review upon the effective date of the rates. Filings for individual and small group market plans, including stand-alone dental plans, shall be available for public review no later than the start of the annual open enrollment period set by the U.S. Department of Health and Human Services pursuant to 42 U.S.C. 1803 l (c)(6)(B).

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11 (from Ins 4101.04); ss by #10212, eff 11-1-12; amd by #10880, eff 7-10-15; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4101.06 Rate Filing Submission Requirements {#sec-ins-4101.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 4101.06}

(a) A rate filing shall be submitted whenever a new policy, rider, or endorsement form that affects benefits is submitted for approval or whenever there is a change in the rates applicable to a previously approved form. If the form does not require a change in the premium, the submission shall include a complete explanation of the effect of the rider or endorsement on the anticipated loss ratio.

(b) The rate filing shall include all rates and rating formulae.

(c) Rates, other than rate revisions, shall be filed with the policies, riders, or endorsements to which they apply and not separately.

(d) Every rate submission shall contain:

(1) Carrier information, including the name and address of the carrier and the name, signature, title, direct toll-free telephone number, and e-mail address of the person responsible for the filing;

(2) The scope and purpose of filing specifying whether this is a new form filing, a rate revision, or a justification of an existing rate;

(3) A description of benefits provided by each policy form and any riders or endorsements that may be used with the form;

(4) In-force business statistics, including policy count and annualized premium of New Hampshire policyholders or certificate holders, as well as the number of covered persons who will be affected by the proposed rate revision;

(5) A proposed effective date, including a description of how the proposed rate revision will be implemented, such as the next anniversary date or next premium due date; and

(6) The reasons for the revision, if the filing is for a rate revision.

History

#9938, eff 6-10-11 (from Ins 4101.05); ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

Part Ins 4102 Requirements for Individual Health Insurance Subject to Rsa 420-G

N.H. Code Admin. R. Ann. Ins 4102.01 Purpose {#sec-ins-4102.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4102.01}

The purpose of this part is to provide requirements for the submission and the filing of individual health insurance rates for all products that meet the definition of health coverage under RSA 420-G:2, IX. This part establishes standards for determining the reasonableness of the relationship of benefits to premiums.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4102.02 Applicability and Scope {#sec-ins-4102.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4102.02}

This part shall apply to all rate filings for individual health coverage plans subject to RSA 420-G.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4102.03 Definitions {#sec-ins-4102.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4102.03}

For the purposes of this part:

(a) “Actuarial certification” means a written statement signed by a member of the American Academy of Actuaries;

(b) “Actuarial memorandum” means the document describing the basis on which rates were determined and that includes other supporting documentation as required;

(c) “Anticipated loss ratio” means the calculation of the medical loss ratio over a period that is at least as great as the anticipated policy lifetime that does not exceed 20 years;

(d) “Case characteristics” means demographic or other relevant characteristics considered by the individual carrier in the determination of premium rates for an individual;

(e) “Durational medical loss ratio” means the medical loss ratio calculated for a specified duration not to exceed 12 months;

(f) “Earned premium” means premium revenue pursuant to 45 CFR Part 158.130;

(g) “Earned premium adjustments” means federal and state taxes and licensing and regulatory fees pursuant to 45 CFR Part 158.161 (a) and 158.162 (a)(1) and (b)(1);

(h) “Health coverage” means “health coverage” as defined in RSA 420-G:2, IX;

(i) “Incurred claims” means reimbursements for clinical services provided to enrollees, pursuant to 45 CFR Part 158.140;

(j) “Medical loss ratio” means “medical loss ratio” as defined in 45 CFR Part 158.221(a);

(k) “Member” means “covered person” as defined in Ins 4101.04(c);

(l) “Premium” means the total amount due from a policyholder to an individual carrier for the provision of health coverage;

(m) “Premium rate” means an amount per covered person used to calculate premium;

(n) “Quality improvement expenses” means amounts expended for activities that improve health care quality pursuant to 45 CFR 158.150 and 45 CFR 158.151; and

(o) “Tier” means a category of enrollment to which enrolled individuals can elect coverage, and includes, at a minimum, “single person”, “couple”, and “family” tiers;

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4102.04 Underwriting and Issue Requirements {#sec-ins-4102.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 4102.04}

(a) A carrier offering health coverage in the individual market:

(1) Shall make all of its individual health plans available for purchase;

(2) Shall not make available or offer any coverage that has been discontinued in accordance with RSA 420-G:6, VI or VII; and

(3) May limit health coverage offered to individuals based on health status only to the extent allowed under federal law.

(b) Carriers shall vary rates for health coverage in the individual market by using only the following allowable case characteristics:

(1) The attained ages of the covered individual and any covered dependents;

(2) The tier category or the number of covered individuals; and

(3) The smoking status of the covered individuals

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12 (from Ins 4103.04); ss by #12799,eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4102.05 Renewal Requirements {#sec-ins-4102.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 4102.05}

A carrier offering health coverage in the individual market shall renew all of its individual health insurance plans provided such plans are currently available for purchase.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #10212, eff 11-1-12 (from Ins 4103.05); ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4102.06 Data Considerations and Notice Requirements {#sec-ins-4102.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 4102.06}

(a) Carriers shall maintain records of earned premiums, incurred claims, and reserves for each calendar year and for each policy form, including data for rider and endorsement forms that are used with the policy form for so long as the carrier maintains rates on the policy.

(b) Notwithstanding (a) above, the carrier:

(1) May maintain separate data for each rider or endorsement form;

(2) May submit a request to the department to combine experience for the purposes of evaluating the data for rider and endorsement forms in relation to premium rates and rate revisions if the rider and endorsement forms provide similar coverage and provisions, are issued to similar risk classes, and are issued under similar underwriting standards, subject to the following:

a. Once a carrier combines experience pursuant to this paragraph, the carrier shall not again separate the experience; and

b. The carrier shall provide experience data for all issue years for all of the rider and endorsement policy forms that have been combined for this purpose; and

(3) Shall provide the ratios of actual claims to the claims expected according to the assumptions underlying the existing rates.

(c) In determining the credibility and appropriateness of experience data, the carrier shall consider the following relevant factors:

(1) Statistical credibility of premiums and benefits, including:

a. Low exposure; and

b. Low loss frequency;

(2) Experience and projected trends relative to the kind of coverage, including:

a. Inflation in medical expenses; and

b. Economic cycles affecting disability income experience;

(3) The concentration of experience at early policy durations where select morbidity and preliminary term reserves are applicable and where loss ratios are expected to be substantially lower than at later policy durations; and

(4) The mix of business by risk classification.

(d) The carrier shall consider the effect of making the following adjustments on the anticipated loss ratio:

(1) Substitution of actual claim run-offs for claim reserves and liabilities;

(2) Determination of loss ratios with the increase in policy reserves subtracted from premiums rather than added to benefits;

(3) Accumulation of experience fund balances;

(4) Substitution of net level policy reserves for preliminary term policy reserves;

(5) Adjustment of premiums to a monthly mode basis; and

(6) Other adjustments or schedules suited to the form and to the records of the company.

(e) The data used to make adjustments as required in (d) above shall be reconciled to the data required to calculate the anticipated loss ratio as prescribed.

(f) If a carrier provides a quote to a policyholder or prospective policyholder, where an alternative design exists with premium savings that are greater than the anticipated out of pocket expenses, the carrier shall disclose the availability of this policy alternative. Deductibles, co-insurance, and elimination periods shall be examples of benefit designs that shall be considered in calculating this difference. Variations in co-pays shall not be considered due to uncertainty with regard to utilization.

(g) Pursuant to (f) above, this policy alternative shall be made available on a guaranteed issue basis for renewal quotes.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12 (from Ins 4103.09); ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4102.07 Rate Filing Standards {#sec-ins-4102.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 4102.07}

(a) Carriers shall calculate the market rate in accordance with the following:

(1) The calculation shall reflect the carrier’s experience for all the products it sells and maintains in the individual health insurance market;

(2) Plan relativity factors that are used to modify the carrier’s experience to a common market rate shall be the same factors that were used to calculate the health coverage plan rates during the experience period;

(3) The market rate shall be normalized for the average plan relativity factor; and

(4) Other assumptions used by the carrier in the calculation of the market rate shall be specified.

(b) The carrier shall calculate from the market rate the health coverage plan rates for the coverages it will offer. The carrier shall provide plan relativity factors used to calculate the health coverage plan rates from the market rate. Any changes to the health coverage plan rates from the previously approved set of plan relativity factors shall be highlighted and the basis for the same shall be documented.

(c) Carriers shall calculate premium rates for individual policyholders from the health coverage plan rates through the application of factors for allowable case characteristics as follows:

(1) Carriers may use attained age, but the ratio of the largest factor attributable to age to the lowest factor attributable to age shall not exceed 3.0; and

(2) Carriers may use tobacco use, but the ratio of the largest factor attributable to tobacco use to the lowest factor attributable to tobacco use shall not exceed 1.5.

(d) All submissions shall:

(1) Include an actuarial certification and an actuarial memorandum consisting of various sections as prescribed herein;

(2) Be provided as electronic documents, in formats as prescribed in paragraphs (e) through (m) below; and

(3) Be attached to the SERFF filing under the supporting documents tab with the named components as prescribed herein.

(e) The actuarial memorandum shall include a component labeled “Public Information” that contains an electronic workbook that includes:

(1) A worksheet named “Cover Sheet” that includes the following information:

a. Contact information; and

b. A statement indicating that the filing includes all of the carriers individual health insurance rates, or an explanation as to why it does not;

(2) A worksheet named “Proposed Rate Change and Enrollment By Health Coverage Plan” that includes the following information for each health coverage plan:

a. Plan codes or suitable plan identifier;

b. The number of expected or enrolled policyholders and covered dependents;

c. The number of expected or enrolled policyholders and covered dependents that will be impacted by the proposed rate change; and

d. The proposed health coverage plan rate;

(3) A worksheet named “Plan Design and Plan Relativity Factors” that includes the following information:

a. Carrier plan code or name;

b. Primary Care Provider (PCP) office visit copay;

c. Specialist office visit copay;

d. Emergency department copay;

e. Outpatient surgery copay;

f. In-network single deductible;

g. In-network coinsurance;

h. In-network single out-of-pocket maximum;

i. Indication if the deductible applies to all medical services;

j. Services to which the deductible does not apply;

k. Indication if the deductible applies to pharmacy services;

l. Indication if preventive services are covered in full;

m. Indication if the health coverage plan type covers mental health and substance services;

n. Indication if the health coverage plan has a tiered network component;

o. Retail pharmacy single deductible generic;

p. Retail pharmacy single deductible brand formulary;

q. Retail pharmacy single deductible brand non-formulary;

r. Retail pharmacy copay generic;

s. Retail pharmacy copay brand formulary;

t. Retail pharmacy copay brand non-formulary;

u. Plan relativity factors for proposed rates;

v. Policy form number;

w. Indication if the health coverage plan is open or closed;

x. Indication if the health coverage plan is grandfathered or non-grandfathered by federal definition;

y. Renewability of the health coverage plan;

z. General marketing method;

aa. Issue age limits; and

ab. Indication if the health coverage plan is new;

(4) A worksheet named “Experience Used in the Rate Development” that includes a brief description of the source for the experience data and per member per month (PMPM) claims information for:

a. Inpatient facility;

b. Outpatient facility;

c. Professional services;

d. Prescription drugs;

e. Capitation arrangements;

f. Other provider payments; and

g. Other;

(5) A worksheet named “Administrative Charges” that includes administrative charges as PMPM amounts;

(6) A worksheet named “Retention Charges” that includes information for retention charges segmented by:

a. Administrative costs;

b. Investment income credits;

c. Contributions to surplus or profit; and

d. Other;

(7) A worksheet named “Illustrative Rates” that delineates the final rates for 2 hypothetical policyholders;

(8) A worksheet named “Summary of Rating Factors” that provides information regarding the carrier’s utilization of allowable rating factors;

(9) A worksheet named “Health Coverage Plan Rate PMPM Development for Standard Health Coverage Plan” that delineates how the health coverage plan rate is calculated for prescribed standard plans including the following information:

a. PMPM experience data;

b. Annual trend factor;

c. Months of trend;

d. Trend adjustments; and

e. PMPM retention; and

(10) A worksheet named “Medical Loss Ratio Exhibit for Individual Market” that includes documentation regarding calculation of the anticipated loss ratios with the following information:

a. Member months;

b. Incurred claims;

c. Earned premium;

d. Quality improvement expenses;

e. Earned premium adjustments; and

f. Interest rate assumption.

(f) The actuarial memorandum shall include a component on the supporting documentation tab in SERFF labeled “Supporting Public Information” with an attached portable document file (PDF) document that includes:

(1) An exhibit titled “Discussion of Credibility” that includes references to the sources for experience data, limitation on using plan specific experience, and any explanation for experience adjustments;

(2) An exhibit titled “Illustrative Rates” that delineates the rate development for 2 hypothetical policyholders;

(3) An exhibit titled “Rating Factors” that includes rate factor tables for each rating factor;

(4) An exhibit titled “Expected Distribution of Rating Factors” that includes information delineating the expected distribution of membership by allowable rating factors with tier and conversion factors; and

(5) An exhibit titled “Description of Methodology for the Projected Medical Loss Ratio” that includes a discussion of data sources and pricing assumptions used to calculate the anticipated loss ratio.

(g) The actuarial memorandum shall include a component on the supporting documentation tab in SERFF labeled “Confidential Information” that contains a Microsoft Excel or compatible workbook that includes a worksheet named “Detail on Final Trend Assumptions” with trend assumptions segmented by:

(1) Service categories, including:

a. Inpatient facility;

b. Outpatient facility;

c. Professional services;

d. Prescription drugs; and

e. Other; and

(2) Changes in:

a. Unit cost; and

b. Utilization.

(h) The actuarial memorandum shall include a component on the supporting documentation tab in SERFF labeled “Supporting Confidential Information” with an attached PDF document that includes:

(1) An exhibit titled “Description of Trend Development” that includes an explanation of the process used to develop trend assumptions; and

(2) An exhibit titled “Supporting Schedules for Trend Development” that includes documentation and other data to support the trend assumptions.

(i) Actuarial memoranda for rate revisions shall modify the worksheets required above as follows:

(1) The worksheet named “Cover Sheet” shall include the following additional information:

a. A statement certifying that there have been no changes to rating methodology since the most recently approved filing or a brief description of any such proposed changes; and

b. A statement certifying that there have been no benefit changes to any of the plans for which rates are being revised or a description of those benefit changes;

(2) The worksheet named “Proposed Rate Change and Enrollment by Health Coverage Plan” shall include the following additional information:

a. PMPM health coverage plan rate in effect 12 months prior to the proposed rate effective date; and

b. PMPM health coverage plan rate from the most recently approved filing;

(3) The worksheet named “Plan Design and Plan Relativity Factors” shall include:

a. Plan relativities for coverage in effect on the rate effective date one year prior to the rate filing effective date; and

b. Supporting documentation for plan relativity factor changes that exceed 5%;

(4) The worksheet named “Detail on Final Trend Assumptions” shall include the total annualized trend assumption from the most recently approved rate filing;

(5) The worksheet named “Administrative Charges” shall include:

a. The administrative charges used for coverages in effect on the rate effective date one year prior to the rating filing effective date; and

b. The administrative charges from the carrier’s most recently approved filing;

(6) The worksheet named “Retention Charges” shall include:

a. The retention charges used for coverages in effect on the rate effective date one year prior to the rate filing effective date; and

b. The retention charges from the carrier’s most recently approved filing;

(7) The worksheet named “Summary of Rating Factors” shall include an indication as to which of the rating factors have changed since the most recently approved rate filing; and

(8) The worksheet named “Health Coverage Plan Rate PMPM Development for Standard Health Coverage Plan” shall include:

a. The standard health coverage plan rates, PMPM, for coverages in effect on the rate effective date one year prior to the rate filing effective date; and

b. The standard health coverage plan rates, PMPM, which were approved in the carrier’s most recently approved filing.

(j) Actuarial memoranda for rate revisions shall include a component titled “Additional Required Public Information for Rate Revisions” that contains an electronic workbook with the following:

(1) A worksheet named “History of Rate Changes” that summarizes rate filings the carrier made over the prior 3 years including:

a. The rate effective date;

b. The average, annual proposed rate change; and

c. The average, annual approved rate change;

(2) A worksheet named “Distribution of Rate Changes” that includes the number of enrolled policyholders and covered dependents that will be impacted by the proposed change segmented by the anticipated rate change; and

(3) A worksheet named “Components of Average Proposed Rate Change” that includes the average rate change attributable to rate changes in:

a. Utilization;

b. Unit costs;

c. Retention;

d. Benefit changes required by law;

e. Other benefit changes;

f. Over or under statement of prior rates; and

g. Other.

(k) The actuarial memorandum for rate revisions shall include a component on the supporting documentation tab in SERFF titled “Supporting Documentation for the Additional Required Public Information for Rate Revisions” with a PDF document titled “Description of Rating Factors” that includes supporting documentation for any proposed changes to the rating factors.

(l) Carriers shall submit a complete filing, at least annually, that includes all of the documentation required for rate revisions even if no changes in rates are being proposed. The purpose of the rate filing shall be to demonstrate that the continued use of the previously approved rates is appropriate.

(m) All submissions shall include an actuarial certification provided as a PDF document attached to the supporting documentation tab in SERFF under the public information component with the following statements:

(1) A statement indicating that the filing conforms to generally accepted actuarial principals;

(2) A statement that the entire filing is in compliance with all applicable laws and rules;

(3) A statement that the premiums are not inadequate, excessive, unfairly discriminatory, or unreasonable in relation to the benefits;

(4) A statement that variations in health coverage plan rates:

a. Shall not exceed the maximum possible difference in benefits unless they are based on the following:

Expected utilization differences attributable to plan design;
Expected administrative cost differences attributable to plan design; and
Provider reimbursement variances attributable to plan design; and

b. Do not vary based on the health status, morbidity, or other demographics of the populations electing the varying plans;

(5) A statement indicating that premium rates are calculated from health coverage plan rates and that premium rates vary from health coverage plan rates using only allowable rating factors;

(6) A statement that benefits are neither excluded nor vary by any of the allowable rating factors; and

(7) A statement indicating that the health plan coverages for which rates are being filed are being actively marketed and are available to both new issues and renewing policyholders.

(n) Carriers shall use the calendar year as the rate effective period, such that:

(1) Rates quoted and established for new issues and renewals shall not vary within the rate effective period; and

(2) Rates shall be guaranteed to the policyholder, and shall not change, for 12 months from issue or renewal.

(o) Carriers shall file rates each year on or before the uniform filing date established by the department, consistent with annual guidance from the Center for Medicare and Medicaid Services (“CMS”), for the coming calendar year. For rates subject to 45 CFR Part 154, carriers shall, in addition to filing with the department, make all filings required with CMS under federal regulations.

(p) Final approved rates for all individual market filings shall be available for public review no later than the start of the annual open enrollment period set by the U.S. Department of Health and Human Services pursuant to 42 U.S.C. 1803 l(c)(6)(B).

(q) In accordance with RSA 91-A:5, IV, the department shall maintain the confidentiality of the commercial and proprietary trend assumptions and supporting documentation that is required to be submitted under Ins 4102.07 (g) and (h).

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12 (from Ins 4103.07); amd by #10880, eff 7-10-15; ss by #12799 eff 6-10-19; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4102.08 Loss Ratio Standards {#sec-ins-4102.08 omnilex-key=us-nh-regs-official--agency-ins--Ins 4102.08}

(a) Carriers shall estimate the average monthly premium for each health plan coverage based on an anticipated distribution of business by all significant criteria having a price difference, including:

(1) Age;

(2) Coverage amount;

(3) Dependent status; and

(4) Rider frequency.

(b) Carriers shall assume all policyholders elect the monthly mode, unless such mode is not available, and shall consider fractional premium loads in the average monthly premium calculation. If the monthly mode is not available, carriers shall assume the mode selected or anticipated to be selected by the greatest proportion of policyholders.

(c) For new health plan coverages, benefits shall be deemed reasonable in relation to the proposed premiums, provided that the anticipated loss ratio is at least as great as 70%.

(d) For rate revisions:

(1) If the policy forms constitute an open block, that is they are still being actively marketed, then benefits shall be deemed reasonable in relation to premiums, provided the revised rates meet the following standards derived from the previously approved rate filing for the form or forms:

a. The anticipated loss ratio over the entire future period for which the revised rates are computed to provide coverage shall be at least as great as the anticipated loss ratio calculated over the entire future period using the durational loss ratios from the previously approved rate filing; and

b. The anticipated loss ratio shall be at least as great as the anticipated loss ratio from the previously approved; and

(2) If the policy forms constitute a closed block, that is they are no longer being actively marketed, then the loss ratios in (d)(1) above shall be adjusted so that no additional revenue is generated to support the administration of these policy forms unless the demonstration includes supporting documentation demonstrating that the cost to administer this business has increased.

(e) Carriers may modify the loss ratio standards in (c) and (d) based on anticipated enrollment and the credibility adjustments allowed pursuant to 45 CFR Part 158.230.

(f) Carriers that fail to review their experience and file rate revisions at least annually shall not be permitted to increase rates beyond what would be needed to provide for just one year of experience deviations. Carriers shall not submit rate revisions in future years to recoup rate revisions disallowed by this section.

(g) Carriers shall not use rate revisions to recoup a prior year’s losses.

(h) Carriers under receivership or some other similar department oversight shall be exempt from the restrictions in (f) and (g) above.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

Part Ins 4103 Requirements for Small Employer Group Health Insurance Subject to Rsa 420-G

N.H. Code Admin. R. Ann. Ins 4103.01 Purpose {#sec-ins-4103.01 omnilex-key=us-nh-regs-official--agency-ins--Ins 4103.01}

The purpose of this part is to provide requirements for the submission and the filing of small employer group health insurance rates subject to RSA 420-G and to establish standards for determining the reasonableness of the relationship of benefits to premiums.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4103.02 Applicability and Scope {#sec-ins-4103.02 omnilex-key=us-nh-regs-official--agency-ins--Ins 4103.02}

This part shall apply to every small employer health insurance policy, rider or endorsement form affecting health coverage that constitutes health coverage as defined under RSA 420-G:2, IX. Franchise insurance as defined in RSA 415:19 which is not group supplement insurance shall be considered individual health insurance. Group supplemental insurance offered under RSA 415:19 shall not be subject to this part.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4103.03 Definitions {#sec-ins-4103.03 omnilex-key=us-nh-regs-official--agency-ins--Ins 4103.03}

For the purposes of this part:

(a) “Actuarial certification” means a written statement signed by a member of the American Academy of Actuaries;

(b) “Actuarial memorandum” means the document describing the basis on which rates were determined and that includes other supporting documentation as required;

(c) “Anticipated loss ratio” means the calculation of the medical loss ratio over the 12 month period that begins on the rate effective date;

(d) “Case characteristics” means demographic or other relevant characteristics of a small employer that are considered by the small employer carrier in the determination of premium rates for the small employer;

(e) “Earned premium” means premium revenue pursuant to 45 CFR Part 158.130;

(f) “Earned premium adjustments” means federal and state taxes and licensing and regulatory fees pursuant to 45 CFR Part 158.161 (a) and 158.162 (a)(1) and (b)(1);

(g) “Eligible employee” means any employee who is eligible for the employer’s sponsored health benefit plan and who regularly works at least 15 hours per week, or at least half the weekly hours full-time employees work, whichever is greater. The term includes a sole proprietor, a partner of a partnership, and an independent contractor, if these individuals are included as employees under the small employer’s health benefit plan;

(h) “Employee” means employee under Section 3(6) of Title I of the Employee Retirement Income Security Act of 1974 (ERISA);

(i) “Enrolled employee” means an eligible employee who has elected coverage in the employer’s sponsored health benefit plan;

(j) “Health coverage” means “health coverage” as defined in RSA 420-G:2, IX;

(k) “Incurred claims” means reimbursements for clinical services provided to enrollees, pursuant to 45 CFR Part 158.140;

(l) “List bill” means a method for computing premium rates that are based on each enrolled employee’s attained age;

(m) “Medical loss ratio” means “medical loss ratio” as defined in 45 CFR Part 158.221 (a);

(n) “Member” means “covered person” as defined in Ins 4101.04(c);

(o) “Premium” means the total amount due from a small employer policyholder to a small employer carrier for the provision of health coverage;

(p) “Premium rate” means an amount per covered person or an amount per enrolled employee used to calculate premium;

(q) “Quality improvement expenses” means amounts expended for activities that improve health care quality pursuant to 45 CFR 158.150 and 45 CFR 158.151;

(r) “Small employer” means any person, firm, corporation, partnership, or group of affiliated companies that are eligible to file a combined tax return and that is actively engaged in business that, on at least 50 percent of the working days during the preceding calendar year, employed at least one employee and no more than 50 eligible employees, the majority of whom are employed within this state;

(s) “Small employer carrier” means a carrier that offers health insurance to one or more small employers in this state;

(t) “Small employer health insurance plan” means all policies or plans sold or marketed by a carrier that meet the definition of health coverage under RSA 420-G:2, IX;

(u) “Subscriber” means an enrolled employee as defined in (i) above; and

(v) “Tier” means a category of enrollment to which enrolled employees can elect coverage, and includes, at a minimum, “single employee,” “couple,” and “family” tiers.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4103.04 Underwriting and Issue Requirements {#sec-ins-4103.04 omnilex-key=us-nh-regs-official--agency-ins--Ins 4103.04}

(a) A small employer carrier:

(1) Shall make all of its small employer health insurance plans available for purchase; and

(2) Shall not make available for offer any coverage that has been discontinued in accordance with RSA 420-G:6.

(b) The minimum participation percentage shall be:

(1) Seventy-five percent when the plan is the sole plan being sponsored by the employer group; and

(2) Thirty-seven point five percent when the plan is one of 2 or more plans being sponsored by the employer group.

(c) For the purposes of (a)(4) above, the total number of eligible employees shall not include eligible employees who decline coverage and are covered as a dependent on another person’s health coverage.

(d) Carriers shall only vary rates for health coverage provided to small employers by using allowable case characteristics that shall include:

(1) The attained ages of the covered population;

(2) The tier categories;

(3) The number of enrolled employees; and

(4) The type of industry in which the small employer is engaged.

(e) For purposes of (d) above, small employer carriers may use approximations to calculate allowable case characteristics provided such approximation methods:

(1) Are used uniformly for all small employer groups;

(2) Use the attained ages of enrolled employees with tier-based membership factors to approximate the attained ages of the covered population; and

(3) Use a prior census to estimate the actual enrollment.

(f) Rates calculated at issue, or at renewal, shall not change throughout the policy year if the allowable case characteristics of a small employer group change.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4103.05 Renewal Requirements {#sec-ins-4103.05 omnilex-key=us-nh-regs-official--agency-ins--Ins 4103.05}

(a) A small employer carrier shall renew all its small employer health insurance plans provided such plans are currently available for purchase.

(b) Carriers shall use the same rating methodology, list bill or composite bill, as in the prior period unless the small employer consents in writing to a change in the calculation methodology.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4103.06 Disclosure {#sec-ins-4103.06 omnilex-key=us-nh-regs-official--agency-ins--Ins 4103.06}

(a) A health carrier shall provide the rate disclosure form with each premium rate quote.

(b) The rate disclosure form shall include the health coverage plan rate for the coverage elected, and any adjustment thereto, for allowable case characteristics.

(c) For composite billed groups, the disclosure form shall be provided for the single employee rate. For list billed groups, the disclosure form shall be provided for each enrolled employee’s rate.

(d) Carriers may submit forms for department review, in accordance with Ins 401. The department shall approve forms that meet the requirements in this section.

History

#9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19

N.H. Code Admin. R. Ann. Ins 4103.07 Rate Filing Standards {#sec-ins-4103.07 omnilex-key=us-nh-regs-official--agency-ins--Ins 4103.07}

(a) Carriers shall calculate a market rate in accordance with the following:

(1) The calculation shall reflect the carrier’s experience for all the products it sells and maintains in the small group health insurance market;

(3) The market rate shall be normalized for the average plan relativity factor; and

(4) Other assumptions used by the carrier in the calculation of the market rate shall be specified.

(b) The carrier shall calculate health coverage plan rates for the coverages it will offer from the market rate. The carrier shall provide plan relativity factors used to calculate the health coverage plan rates from the market rate. Any changes to the health coverage plan rates from the previously approved set of plan relativity factors shall be highlighted, and the basis for the same shall be documented.

(c) Carriers shall calculate premium rates for each small employer from the health coverage plan rate through the application of factors for allowable case characteristics as follows:

(1) Carriers may use attained age, however, the ratio of the largest factor attributable to age to the lowest factor attributable to age shall not exceed 3.0; and

(2) Carriers may use tobacco use, however, the ratio of the largest factor attributable to tobacco use to the lowest factor attributable to tobacco use shall not exceed 1.5.

(d) All submissions shall:

(1) Include an actuarial certification and an actuarial memorandum, consisting of the sections prescribed herein;

(2) Be provided as electronic documents, in formats as prescribed in paragraphs (e) through (m) below; and

(3) Be attached to the SERFF filing under the supporting documentation tab with the components prescribed herein.

(e) The actuarial memorandum shall include a component labeled “Public Information” that contains an electronic workbook that includes:

(1) A worksheet named “Cover Sheet” that includes the following information:

a. Contact information;

b. A statement indicating that the filing includes all of the carriers small group health insurance rates, or an explanation as to why it does not; and

c. A statement indicating whether the carrier utilizes list billing, and if so, a description of the groups being list billed;

(2) A worksheet named “Proposed Rate Change and Enrollment by Health Coverage Plan” that includes the following information for each health coverage plan:

a. Plan codes or suitable plan identifier;

b. The number of expected or enrolled members, subscribers, and groups;

c. The number of expected or enrolled members, subscribers, and groups that will be impacted by the proposed rate change; and

d. The proposed health coverage plan rate;

(3) A worksheet named “Plan Design and Plan Relativities” that includes the following information:

a. Carrier plan code or name;

b. PCP office visit copay;

c. Specialist office visit copay;

d. Emergency department copay;

e. Outpatient surgery copay;

f. In-network single deductible;

g. In-network coinsurance;

h. In-network single out-of-pocket maximum;

i. Indication if the deductible applies to all medical services;

j. Services that deductible does not apply to;

k. Indication if the deductible applies to pharmacy services;

l. Indication if preventive services are covered in full;

m. Indication if the health coverage plan covers mental health and substance services;

n. Indication if the health coverage plan has a tiered network component;

o. Retail pharmacy single deductible generic;

p. Retail pharmacy single deductible brand formulary;

q. Retail pharmacy single deductible brand non-formulary;

r. Retail pharmacy copay generic;

s. Retail pharmacy copay brand formulary;

t. Retail pharmacy copay brand non-formulary;

u. Plan relativity factors for proposed rates;

v. Policy form number;

w. Indication if the health coverage plan is open or closed;

x. Indication if the health coverage plan is grandfathered or non-grandfathered by federal definition;

y. Renewability of the health coverage plan;

z. General marketing method;

aa. Issue age limits; and

ab. Indication if the health coverage plan is new;

(4) A worksheet named “Experience Used in the Rate Development” that includes a brief description of the source for the experience data and PMPM claims information for:

a. Inpatient facility;

b. Outpatient facility;

c. Professional services;

d. Prescription drugs;

e. Capitation arrangements;

f. Other provider payments; and

g. Other;

(5) A worksheet named “Administrative Charges” that includes administrative charges as PMPM amounts;

(6) A worksheet named “Retention Charges” that includes information for retention charges segmented by:

a. Administrative costs;

b. Investment income credits;

c. Contributions to surplus or profit; and

d. Other;

(7) A worksheet named “Illustrative Rates” that delineates the final rate for 2 hypothetical groups;

(8) A worksheet named “Summary of Rating Factors” that provides information regarding the carrier’s utilization of allowable rating factors;

a. PMPM experience data;

b. Annual trend factor;

c. Months of trend;

d. Trend adjustments; and

e. PMPM retention; and

(10) A worksheet named “Medical Loss Ratio Exhibit Small Group Market” that includes documentation regarding the calculation of the anticipated loss ratio with the following information:

a. Member months;

b. Incurred claims;

c. Earned premium;

d. Quality improvement expenses; and

e. Earned premium adjustments.

(f) The actuarial memorandum shall include a component on the supporting documentation tab labeled “Supporting Public Information” with an attached PDF document that includes:

(1) An exhibit titled “Discussion of Credibility” that includes references to the sources for experience data, limitation on using plan specific experience and any explanation for experience adjustments;

(2) An exhibit titled “Illustrative Rates” that delineates the rate development for 2 hypothetical groups;

(3) An exhibit titled “Rating Factors” that includes rate factor tables for each rating factor;

(g) The actuarial memorandum shall include a component on the supporting documentation tab in SERFF labeled “Confidential Information” that contains an electronic workbook that includes a worksheet named “Detail on Final Trend Assumptions” with trend assumptions segmented by:

(1) Service categories, including:

a. Inpatient facility;

b. Outpatient facility;

c. Professional services;

d. Prescription drugs;

e. Other; and

(2) Changes in:

a. Unit cost; and

b. Utilization.

(h) The actuarial memorandum shall include a component on the supporting documentation tab labeled “Supporting Confidential Information” with an attached PDF document that includes: