N.H. Admin. Code § Ins 1907.02

Current through Register No. 45, November 7, 2024

Section Ins 1907.02 - Definitions

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:

1. In connection with a group health plan maintained by a partnership, the individual is a partner in relation to the partnership; or

2. 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:

1. Conditions arising out of acts of domestic violence; or

2. 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.

N.H. Admin. Code § Ins 1907.02

#8607, eff 4-17-06