N.H. Admin. Code § Ins 6204.03

Current through Register No. 49, December 5, 2024

Section Ins 6204.03 - Minimum Standards for Benefits

(a) A specified disease policy or certificate of insurance shall:

(1) Cover cancer-only or cancer in conjunction with other conditions or diseases and meet the standards of paragraph (b) and either (d), (e) or (f) below; and;

(2) Cover specified diseases other than cancer and meet the standards of paragraph (b) and either (c) or (f) below.

(b) Except for cancer coverage provided on an expense-incurred basis, either as cancer-only coverage or in combination with one or more other specified diseases, the following rules shall apply to specified disease coverages in addition to all other rules imposed by this regulation. In cases of conflict between the following and other rules, the following shall govern:

(1) Policies covering a single specified disease or combination of specified diseases may not be sold or offered for sale other than as specified disease coverage under this section;

(2) Any policy or certificate issued pursuant to this part that conditions payment upon pathological diagnosis of a covered disease shall also provide that, if the pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted instead;

(3) Specified disease policies or certificates that do not pay on a fixed, one-time lump sum basis, upon proof of diagnosis, shall provide benefits to any insured person not only for the specified diseases but also for any other conditions or diseases directly caused or aggravated by the specified diseases or the treatment of the specified diseases;

(4) Individual ancillary health policies or certificates containing specified disease coverage shall be at least guaranteed renewable;

(5) An application or enrollment form for specified disease coverage shall contain a statement above the signature of the applicant or enrollee that a person to be covered for a specified disease is not also covered by any program under 42 USC 7, Title XIX, 1396-1396w-5. The statement may be combined with any other statement for which the insurer may require the applicant's or enrollee's signature;

(6) Benefits for specified disease coverage shall be paid regardless of other coverage;

(7) After the effective date of the coverage, or any applicable waiting period, benefits shall begin with the first day of care or confinement, when the care or confinement is for a covered disease, even if the diagnosis is made at some later date. The retroactive application of the coverage may not be less than 90 days prior to the diagnosis;

(8) Payments may be conditioned upon medical necessity;

(9) Hospice care is an optional benefit. However, if a specified disease insurance product offers coverage for hospice care, it shall meet the following minimum standards:

a. Eligibility for payment of benefits when the attending physician of the insured provides a written statement that the insured person has a life expectancy of 6 months or less;

b. A fixed-sum payment of at least $50 per day;

c. A lifetime maximum benefit limit of at least $10,000; and

d. Does not provide coverage for non-terminally ill patients who may be confined in a:

1. Convalescent home;

2. Rest or nursing home;

3. Skilled nursing facility;

4. Rehabilitation unit; or

5. Facility providing treatment for persons suffering from mental diseases or disorders, substance use disorders, or custodial care; and

(10) Major organ failure coverage is an optional benefit. However, if offered, it shall meet the following minimum standards:

a. Surgical requirements must be waived if the insured is too ill to undergo surgery, but surgery or placement on the United Network of Organ Sharing (UNOS) would otherwise be recommended due to the organ failure; and

b. Coverage may be limited to a particular organ but must include coverage for the transplant of a partial or full organ.

(c) The following minimum benefits standards apply to non-cancer coverages:

(1) Coverage for each insured person for a specifically named disease or diseases with a deductible amount not in excess of $250, an overall aggregate benefit limit of no less than $10,000, and a benefit period of not less than 2 years for at least the following incurred expenses:

a. Hospital room and board and any other hospital furnished medical services or supplies;

b. Treatment by, or under the direction of, a physician;

c. Private duty services of a registered nurse (RN);

d. X-ray, radium, and other therapy procedures used in diagnosis and treatment;

e. Professional ambulance for local service to or from a local hospital;

f. Blood transfusions and their administration, including expense incurred for blood donors;

g. Drugs and medicines prescribed by a physician;

h. The rental of respirators or other breathing therapy apparatus;

i. Braces, crutches, or wheel chairs as prescribed by provider for the treatment of the disease;

j. Emergency transportation if, in the opinion of the attending physician, it is necessary to transport the insured to another locality for treatment of the disease; and

k. May include coverage of any other expenses necessarily incurred in the treatment of the disease; or

(2) Coverage for each insured person for a specifically named disease or diseases with no deductible amount, and an overall aggregate benefit limit of not less than $25,000 payable at the rate of not less than $50 a day while confined in a hospital and a benefit period of not less than 500 days.

(d) A policy that provides coverage for each insured person for cancer-only coverage, or cancer coverage in combination with one or more other specified diseases, on an expense-incurred basis for services, supplies, and care and treatment of cancer, in amounts not in excess of the usual and customary charges, with a deductible amount not in excess of $250, an overall aggregate benefit limit of not less than $10,000, and a benefit period of not less than 3 years shall provide at least the following minimum provisions:

(1) Treatment by, or under the direction of, a physician;

(2) X-ray, radium chemotherapy, and other therapy procedures used in diagnosis and treatment;

(3) Hospital room and board and any other hospital furnished medical services or supplies;

(4) Blood transfusions and their administration, including expense incurred for blood donors;

(5) Drugs and medicines prescribed by a physician;

(6) Professional ambulance for local service to or from a local hospital;

(7) Private duty services of a registered nurse provided in a hospital; and

(8) May include coverage of any other expenses necessarily incurred in the treatment of the disease; however, subparagraphs (1), (2), (4), (5), and (7) plus at least the following also shall be included, but may be subject to copayment by the insured person not to exceed 20 percent of covered charges when rendered on an out-patient basis:

a. Braces, crutches, and wheelchairs deemed necessary by the attending physician for the treatment of the disease;

b. Emergency transportation if, in the opinion of the attending physician, it is necessary to transport the insured to another locality for treatment of the disease; and

c. Home health care that is necessary care and treatment provided at the insured person's residence by a home health care agency or by others. The program of treatment shall be prescribed in writing by the insured person's attending physician, who shall approve the program prior to its start. The physician shall certify that hospital confinement would be otherwise required. Home health care shall include at least:

1. Part-time or intermittent skilled nursing services provided by a registered nurse or a licensed practical nurse;

2. Part-time or intermittent home health aide services that provide support services in the home under the supervision of a registered nurse or a physical, speech, or hearing occupational therapist;

3. Physical, occupational, or speech and hearing therapy; and

4. Medical supplies, drugs, and medicines prescribed by a physician and any related pharmaceutical services and laboratory services, to the extent the charges or costs would have been covered if the insured person had remained in the hospital;

d. Physical, speech, hearing, and occupational therapy;

e. Special equipment, including hospital bed, toilet, pulleys, wheelchairs, aspirator, chux bed pads, oxygen, surgical dressings, rubber shields, and colostomy and ileostomy appliances;

f. Prosthetic devices, including wigs and artificial breasts;

g. Nursing home care for noncustodial services; and

h. Reconstructive surgery when deemed necessary by the attending physician.

(e) The following minimum benefits standards apply to cancer coverages written on a per diem indemnity basis:

(1) A fixed-sum payment of at least $100 for each day of hospital confinement for at least 365 days;

(2) A fixed-sum payment equal to one half the hospital inpatient benefit for each day of hospital or nonhospital outpatient surgery, chemotherapy, and radiation therapy for at least 365 days of treatment;

(3) A fixed-sum payment of at least $50 per day for blood and plasma, which includes their administration, whether received as an inpatient or outpatient, for at least 365 days of treatment; and

(4) Benefits tied to confinement in a skilled nursing home or to receipt of home health care are optional. If a policy offers these benefits, they shall equal the following:

a. A fixed-sum payment equal to one-fourth the hospital inpatient benefit for each day of skilled nursing home confinement for at least 100 days; or

b. A fixed-sum payment equal to one-fourth the hospital inpatient benefit for each day of home health care for at least 100 days; and

c. Benefit payments shall begin with the first day of care or confinement after the effective date of coverage, if the care or confinement is for a covered disease. If the diagnosis of a covered disease is made at some later date, benefits must provide retroactive coverage of at least 30 days from the date of diagnosis, if the initial care or confinement was for diagnosis or treatment of the covered disease; and

d. Any restriction or limitation applied to the benefits in a. and b., whether by definition or otherwise, shall be no more restrictive than those under Medicare.

(f) The following minimum standards apply to lump-sum indemnity coverage of any specified disease:

(1) Coverages shall pay indemnity benefits on behalf of insured persons for a specifically named disease or diseases;

(2) Benefits are payable as a fixed, one-time payment for each diagnosis of a covered disease made within 30 days of submission to the insurer of proof of diagnosis of the specified disease; and

(3) Where coverage is advertised or otherwise represented to offer generic coverage of a disease or diseases, the same dollar amounts shall be payable regardless of the particular subtype of the disease with one exception. In the case of clearly identifiable subtypes with significantly lower treatments costs, lesser amounts may be payable so long as the policy clearly differentiates that subtype and its benefits.

N.H. Admin. Code § Ins 6204.03

Derived from Volume XLI Number 6, Filed February 11, 2021, Proposed by #13163, Effective 1/25/2021, Expires 1/25/2031.