New Hampshire Code of Administrative Rules
Ins - Commissioner, Insurance Department
Chapter Ins 1900 - ACCIDENT AND HEALTH INSURANCE
Part Ins 1907 - NONDISCRIMINATION IN HEALTH INSURANCE COVERAGE IN THE GROUP MARKET
Section Ins 1907.05 - Application of Ins 1907.03 to Plan Benefits; Preexisting Condition Exclusions; Similarly Situated Individuals
Universal Citation: NH Admin Rules Ins 1907.05
Current through Register No. 12, March 21, 2024
(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:
1. Shall apply the restriction uniformly to
all similarly situated individuals; and
2. 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:
1. Applies
uniformly to all similarly situated individuals; and
2. 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:
1. Full-time versus part-time
status;
2. Geographic
location;
3. Membership in a
collective bargaining unit;
4. Date
of hire;
5. Length of
service;
6. Current employee versus
former employee status; and
7.
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.
#8607, eff 4-17-06
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