CHAPTER Ins 7000  SHORT TERM LIMITED DURATION HEALTH INSURANCE

 

Statutory Authority RSA 400-A:15, I; RSA 415:6, VII; RSA 415-A:2, I; RSA 415-A:3, I

 

PART Ins 7001 MINIUMUM STANDARDS FOR SHORT TERM LIMITED DURATION HEALTH INSURANCE

 

        Ins 7001.01  Purpose.  The purpose of this part is to implement the provisions of RSA 415:5, III and RSA 415-A to standardize and simplify the terms and coverages of individual non-renewable short term limited duration health insurance policies that provide medical, hospital, and major medical expense benefits for a specified term.

 

Source.  #12798, eff 6-10-19

 

        Ins 7001.02  Applicability and Scope.  This part shall apply to all individual health insurance policies providing health insurance for a limited duration that are delivered or issued for delivery in this state on and after the effective date of this part, as provided in RSA 415-A, and that are not specifically exempted from this part.

 

Source.  #12798, eff 6-10-19

 

        Ins 7001.03  Definitions.

 

        (a)  “Commissioner” means the commissioner of the New Hampshire insurance department.

 

        (b) “Medicare” means “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended”; and

 

        (c)  “Managed care plan” means “managed care plan” as defined in RSA 420-J:3, XXV.

 

        (d)  “Short term limited duration health insurance” means an individual non-renewable policy issued in accordance with RSA 415-A:3, I(e) and RSA 415:5, III.  It shall not be offered on a group basis.

 

        (e)  “Substance use disorder benefits” means the benefits with respect to services for substance use disorders.

 

Source.  #12798, eff 6-10-19

 

        Ins 7001.04  Policy Definition Requirements.  Except as provided in this part, an individual short term limited duration health insurance policy delivered or issued for delivery to any person in this state and to which this part applies shall contain definitions that comply with the requirements of this section as follows:

 

        (a)  “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, and:

 

(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;

 

        (b)  “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 individuals diagnosed with substance use disorders; or

 

c.  A home or facility primarily used for the care and treatment of mental diseases or disorders or for custodial or educational care;

 

        (c)  “Hospital” may be defined in relation to its status, facilities, and available services or to reflect its accreditation by The Joint Commission, previously known as The Joint Commission on Accreditation of Healthcare Organizations, and:

 

(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 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 rehabilitative care;

 

c. Facilities for the aged or for the care of individuals diagnosed with substance use disorders; 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;

 

        (d)  “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;

 

        (e)  “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 New Hampshire board of nursing;

         

        (f)  “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, including advanced practice registered nurses and physician’s assistants;

 

        (g)  “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”; and

 

        (h)  “Sickness” shall not be defined to be more restrictive than the following: “Sickness means illness, disease, or medical condition, including pregnancy, 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 workers’ compensation, occupational disease, or employers’ liability or similar law.

 

Source.  #12798, eff 6-10-19

 

          Ins 7001.05  Prohibited Policy Provisions.

 

          (a)  Except as provided in Ins 7001.04(g), an individual non-renewable short term limited duration health insurance policy shall not contain provisions establishing a waiting period during which no coverage is provided under the policy.

 

          (b)  In all circumstances in which an insurer does not request information about an applicant’s

health history or medical treatment in the application process, the policy shall cover the loss consistent with RSA 415-A:5, I.  Otherwise, a policy or certificate shall not exclude coverage for a loss due to a preexisting condition for a period of greater than 6 months following the issuance of the policy.

 

          (c)  A policy shall not limit or exclude coverage by type of sickness, accident, treatment, or medical condition, except as follows:

 

(1)  Preexisting conditions or diseases, other than congenital anomalies of a covered

dependent child;

 

(2)  Mental or emotional disorders and substance use disorders;

 

(3)  Sickness, treatment, or medical condition arising out of:

 

a.  War or act of war, whether declared or undeclared, or service in the armed forces or units auxiliary to it;

 

b.  Professional sports;

 

c.  Cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;

 

d.  Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet; or

 

e.  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 of it, where the interference is the result of or related to distortion, misalignment of subluxation of, or in the vertebral column; 

 

(4)  Treatment provided in a government hospital, benefits provided under Medicare or other governmental program, other than Medicaid, state or federal workers’ compensation, or an employers’ liability or occupational disease law, 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;

 

(5)  Dental care or treatment;

 

(6)  Routine eye care, including eye glasses and examinations for the prescription or fitting of them;

 

(7)  Rest cures, custodial care, transportation, and routine physical examinations; and

 

(8)  Territorial limitations.

 

          (d)  A policy shall not contain arbitration provisions.

 

          (e)  Any rider or endorsement that reduces or eliminates coverage under the policy shall be prohibited.

 

          (f)  A policy shall not contain any provision that excludes coverage by use of the terms "chronic disease" or "organic disease".

 

          (g)  Policy provisions precluded in this section shall not be construed as a limitation on the authority of the commissioner to disapprove other policy provisions in accordance with RSA 415-A that in the opinion of the commissioner are unjust, unfair, or unfairly discriminatory to the policyholder, beneficiary, or a person insured under the policy.

 

          (h)  Short term limited duration health insurance shall not be group coverage.

 

          (i)  Services that are provided at facilities that are not licensed as hospital emergency facilities shall not be subject to member cost-sharing associated with emergency services.

 

          (j)  If a policy provides for a reduction in benefits due to the failure of the insured or the insured’s physician to follow required procedures or obtain any necessary authorization, the reduction in benefits or penalty may not be more than 50% of the benefit that would have otherwise been payable, or $1,000.00, whichever is less. With respect to a provision that requires authorization from the insurer prior to a hospital admission, the insurer may, in lieu of a percentage reduction, state that either the benefits payable or eligible charges will be reduced or denied up to a specified dollar amount. In no event shall a policy provision provide for a reduction in benefits or penalty that is greater than $1,000.00.

 

          (k)  In the case of an emergency admission, the policy shall not require pre-admission authorization unless the insured is allowed 48 hours following the admission within which to request authorization for the admission, or as soon as reasonably possible, whichever is later.

 

Source.  #12798, eff 6-10-19

 

          Ins 7001.06  Required Policy Provisions.

 

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

 

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

 

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

 

(3)  A policy may:

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

b.  Hospital services and supplies;

 

c.  Surgical services:

 

d.  Anesthesia services;

 

e.  In-hospital medical and diagnostic services;

 

f.  Emergency care services;

 

g.  All individual policy mandates under New Hampshire statute;

 

h.  In-hospital prescription drugs and medications;

 

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

 

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

 

1.  In-hospital private duty registered nurse services;

 

2.  Convalescent nursing home care;

 

3.  Diagnosis and treatment by a radiologist or physiotherapist;

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Source.  #12798, eff 6-10-19

 

          Ins 7001.07  Additional Policy Provisions.

 

          (a) Provisions requiring mandatory second surgical opinions shall comply with the following conditions:

 

(1)  The provision shall include a list of the surgical procedures to which the requirements apply;

 

(2)  The policy shall cover the second opinion obtained from a board-certified specialist;

 

(3)  In the event that an insured receives a non-confirming second opinion, the policy shall cover a third surgical opinion from a specialist jointly chosen by the insured and the insurer, and that opinion shall be final; and

 

(4)  The insurer shall waive the mandatory second surgical opinion requirement in the event a person is unable to obtain an appointment for a second opinion.

 

          (b)  A provision requiring an insured to have certain minor or elective surgical procedures performed at a physician’s office, free-standing surgical facility, or outpatient department of a hospital shall include a list of the surgical procedures subject to this requirement.  Procedures shall be available to obtain an exception to the requirement that a surgical procedure be done on an outpatient basis in those cases where the patient’s medical history or other conditions dictate the advisability of having the surgery performed on an inpatient basis.

 

Source.  #12798, eff 6-10-19

 

          Ins 7001.08  Disclosures.  Policies shall display prominently in the contract and on any application materials provided in connection with enrollment in such coverage, in at least 14 point type:

 

“This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.”

 

Source.  #12798, eff 6-10-19

 

          Ins 7001.09  Outline of Coverage.

 

          (a)  An outline of coverage, in the format prescribed below, shall be issued in connection with policies meeting the standards of this part.

 

          (b)  The items included in the outline of coverage must appear in the following sequence:

 

(1)  A brief specific description of the benefits provided;

 

(2)  A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefit described in paragraph (1) above shall be included; and

 

(3)  A description of policy provisions with respect to renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums shall be included.

 

         (c)  The notice required by paragraphs (a) – (b) above shall be in the same form as follows:

 


“[COMPANY NAME]

 

INDIVIDUAL SHORT TERM LIMITED DURATION HEALTH INSURANCE

 

OUTLINE OF COVERAGE

 

(1)  Read Your Policy Carefully.  This outline of coverage provides a brief description of the important features of your policy.  This is not the insurance contract and only the actual policy provisions will control.  The policy itself sets forth in detail the rights and obligations of both you and your insurance company.  It is, therefore, important that you READ YOUR POLICY CAREFULLY!

 

(2)  Individual short term limited duration health insurance coverage is designed to provide, to persons insured, comprehensive coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness.  Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care, subject to any deductibles, copayment provisions, or other limitations that may be set forth in the policy.”

 

          (d)  The notice shall include a brief specific description of the benefits, including dollar amounts, contained in this policy, in the following order:

 

(1)  Daily hospital room and board;

 

(2)  Miscellaneous hospital services;

 

(3)  Professional services including surgical and anesthesia services;

 

(4)  In-hospital medical services;

 

(5)  Out-of-hospital care;

 

(6)  Maximum dollar amount for covered charges;

 

(7)  Coverage mandated by statute; and

 

(8)  Other benefits, if any;

 

          (e)  The notice shall include a listing of exclusions and limitations; and

 

          (f)  The notice shall include a statement that short term limited duration health insurance is not renewable and is not a replacement for individual health insurance as defined in state and federal law.

 

Source.  #12798, eff 6-10-19

 

          Ins 7001.10  Grievance and Appeals.

 

          (a)  Each policy of short term limited duration insurance (STLDI) shall include a written procedure by which a claimant, or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and fair review of the claim denial.

 

          (b)  Managed care policies shall include the process for filing grievances and appealing adverse

determinations in accordance with RSA 420-J and Ins 2703.

 

          (c)  For non-managed care policies, the following shall apply:

 

(1)  Full and fair review shall require that:

 

a.  The persons reviewing the grievance shall not be the same person or persons making the initial determination, and shall not be subordinate to or the supervisor of the person making the initial determination;

 

b.  For medical necessity appeals, at least one person reviewing the appeal shall be a practitioner in the same or similar specialty who typically treats the medical condition, performs the procedure, or provides the treatment at issue in the appeal.  A practitioner shall be considered of the same specialty if he or she has similar credentials and licensure as those who typically treat the condition or health problem in question in the appeal.  A practitioner shall be considered of a similar specialty if he or she has experience treating the same problems as those in question in the appeal, in addition to expertise treating similar complications of those problems;

 

c.  The claimant shall have at least 180 days following receipt of a notification of a claim denial to appeal;

 

d.  The claimant shall have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those documents or materials were considered in making the initial determination;

 

e.  The claimant shall be provided, upon request and without charge, reasonable access to and copies of all documents, records, and other information relevant to or considered in making the initial adverse claim determination; and

 

f.  The review shall be a de novo proceeding and shall consider all information, documents, or other material submitted in connection with the appeal without regard to whether the information was considered in making the denial;

 

(2)  In the appeal of a claim denial that is based in whole or in part on a medical judgment:

 

a.  The review shall be conducted by or in consultation with a health care professional in the same or similar specialty who typically treats the medical condition, performs the procedure, or provides the treatment at issue in the appeal.  A practitioner shall be considered of the same specialty if he or she has similar credentials and licensure as those who typically treat the condition or health problem in question in the appeal.  A practitioner shall be considered of a similar specialty if he or she has experience treating the same problems as those in question in the appeal, in addition to expertise treating similar complications of those problems;

 

b.  The titles and qualifying credentials of the person conducting the review shall be included in the decision; and

 

c.  The identity and qualifications of any medical or vocational expert whose advice was considered, without regard to whether it was relied upon in making the initial claim denial, shall be made available to the claimant upon request;

 

(3)  In the appeal of a claim for urgent care, a claim involving a matter that would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function, or a claim concerning an admission, availability of care, continued stay or health care service for a person who has received emergency services but who has not been discharged from a facility, an expedited appeal process shall be made available which shall provide for:

 

a.  The submission of information by the claimant to the carrier by telephone, facsimile, or other expeditious method; and

 

b.  The determination of the appeal not more than 72 hours after the submission of the request for appeal;

 

(4)  For making appeals determinations, the timing and notification requirements shall be as follows:

 

a.  In the case of nonexpedited appeal of a pre-service claim or post-service claim, a carrier shall make the determination on appeal within a reasonable time appropriate to the medical circumstances, but in no event more than 30 days after receipt by the carrier or other licensed entity of the claimant's appeal;

 

b.  In the case of an expedited appeal related to an urgent care claim, a carrier shall make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the appeal is filed.  If the expedited review involves ongoing urgent care services, the service shall be continued without liability to the covered person until the covered person has been notified of the determination.  A carrier or other licensed entity shall provide written confirmation of its decision concerning an expedited review within 2 business days of providing notification of that decision, if the initial notification was not in writing; and

 

c.  The period of time within which a decision shall be rendered on appeal shall begin to run at the time the appeal is filed in accordance with the appeal procedures of the carrier or other licensed entity, without regard to whether all the information necessary to make a determination on appeal is contained in the filing.  In the event the claimant fails to submit information necessary to decide the appeal, the period for making the determination on appeal shall be tolled from the date the claimant is notified in writing of precisely what is required until the date the claimant responds to the request.  The carrier or other licensed entity shall provide notification of incompleteness as soon as possible, but in no event more than 24 hours after the filing of the appeal in appeals involving urgent care.  The carrier shall allow the claimant at least 45 days from the date of notification to provide sufficient information;

 

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

that includes:

 

a.  The specific reason or reasons for the determination, including reference to the specific provision, rule, protocol, or guideline on which the determination is based;

 

b.  A statement that the rule, protocol, or guideline governing the appeal will be provided without charge to the claimant upon request;

 

c.  A statement describing all other dispute resolution options available to the claimant, including, but not limited to other options for internal review, options for external review if available under the policy, and options for bringing a legal action;

 

d.  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;

 

e.  If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the claim denial, 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 claim denial and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the claimant upon request;

 

f.  If the claim denial is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the denial, 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;

 

g.  If the appeal involves an adverse determination and external review is available, a copy of the notice of the right to external review that includes the specific requirements for filing an external review; and

 

h.  A statement describing the claimant's right to contact the insurance commissioner's office for assistance which shall include the toll-free telephone number and address of the commissioner;

 

(6)  A carrier or other licensed entity that offers STLDI shall provide to consumers:

 

a.  A description of the internal grievance procedure required by this part for claim denials and other matters and a description of the process for obtaining external review if available under the policy.  These descriptions shall be set forth in or attached to the policy;

 

b.  A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner; and

 

c.  A statement that the carrier or other licensed entity will provide assistance in preparing an appeal of an adverse benefit determination, and a toll-free telephone number to contact the carrier or other licensed entity;

 

(7)  With respect to mandatory levels of appeal:

 

a.  If a carrier or other licensed entity provides 2 mandatory levels of appeal, the first level shall be completed within 15 days and the second level completed within the 30-day time period beginning from the initial date of filing the appeal or grievance;

 

b.  If a carrier or other licensed entity provides a single mandatory level of appeal, the single mandatory level shall be completed within the 30-day time period beginning from the initial date of filing the appeal;

 

c.  With respect to a mandatory second level of appeal involving a claim for continuation of services or urgent care, the carrier or other licensed entity shall make a decision and notify the claimant within 72 hours after the mandatory second level appeal is filed; and

 

d.  For appeals involving post-service claims, the carrier shall make a decision and notify the claimant within 60 days of the date the completed appeal was filed;

 

(8)  Subparagraph (7) shall not prohibit a carrier or other licensed entity from offering additional voluntary levels of appeal in addition to any mandatory levels of appeal offered, provided that:

 

a.  The claimant may elect to pursue any additional level of appeal under this subparagraph voluntarily;

 

b.  A carrier may not assert failure to exhaust administrative remedies where a claimant elects to pursue a claim through other venues rather than through the voluntary level of appeal;

 

c.  Any statute of limitations or time limits to pursue other remedies, as set forth in this part, shall be tolled during the voluntary appeals process;

 

d.  Voluntary levels of appeal are available only after a claimant has completed required mandatory levels of appeal required under the plan or by regulation;

 

e.  The carrier provides a claimant with sufficient information to make an informed decision whether to submit the claim through any voluntary appeals process;

 

f.  No fees or costs are imposed on the claimant as part of any voluntary appeals process; and

 

g.  Any voluntary level of appeal requested by a claimant under this subparagraph shall be completed within 30 days from the date of the request for the voluntary appeal;

 

(9)  In an appeal of a claim denial or other matter, the claimant may authorize a representative to pursue a claim or an appeal by submitting a written statement to the carrier or other licensed entity that acknowledges the representation; and

 

(10)  No fees or costs shall be assessed against a claimant related to a request for a grievance or appeal.

 

          (d)  A carrier or other licensed entity that offers short term limited duration insurance shall:

 

(1)  Maintain written records documenting all grievances and appeals received during a calendar year, a general description of the reason for the appeal or grievance, the name of the claimant, the dates of the appeal or grievance, and the date of resolution;

 

(2)  File annually with the commissioner a certificate of compliance stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this part. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective; and

 

(3) File annually with the commissioner a report regarding plan complaints, adverse determinations, claim denials, and prior authorization statistics.

 

Source.  #12798, eff 6-10-19

 

         Ins 7001.11  Continuation of Coverage for Hospital Confinement.  Every policy subject to this part issued on or after the effective date of this part, or under which the level of benefits is altered, modified, or amended on or after the effective date of this part, shall provide coverage for continued treatment for a period of up to 90 days in the event of  hospitalization as of the date of policy termination.

 

Source.  #12798, eff 6-10-19

 

         Ins 7001.12  Waiver of Rules.

 

          (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.

 

          (c)  Any person or entity seeking a waiver shall make a request in writing.

 

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

 

Source.  #12798, eff 6-10-19

 

APPENDIX

 

Rule

Specific State Statute the Rule Implements

Ins 7001.01

RSA 400-A:15, I; RSA 415-A:2; RSA 415-A:3, I(e)

Ins 7001.02

RSA 400-A:15, I; RSA 415-A

Ins 7001.03

RSA 400-A:15, I; RSA 415-A:2, I(n)

Ins 7001.04

RSA 400-A:15, I; RSA 415:6; RSA 415-A:2; RSA 415-A:3

Ins 7001.05

RSA 400-A:15, I; RSA 415:5; RSA 415:6; RSA 415-A:2; RSA 415-A:3

Ins 7001.06

RSA 329:31-b; RSA 400-A:15, I; RSA 415:5; RSA 415:6; RSA 415-A:2;

RSA 415-A:3; RSA 420-J:8-e

Ins 7001.07

RSA 400-A:15, I; RSA 415-A:2, I

Ins 7001.08

RSA 400-A:15, I; RSA 415-A:4; RSA 420-G:2, IX and XI

Ins 7001.09

RSA 400-A:15, I; RSA 415-A:2, I

Ins 7001.10

RSA 400-A:15, I; RSA 415-A:2, I

Ins 7001.11

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