RSA 420-B:12 · Prohibited Practices

420-B:12 Prohibited Practices. –

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I.

No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this chapter:

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(a)

A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrolled participant of, or person considering enrolling in, a health maintenance organization;

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(b)

A statement or item of information shall be deemed to be misleading, whether or not it may be literally true, if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information reasonably may be understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrolled participant of, or person considering enrollment in, a health care plan, if such benefit or advantage or absence of limitation, exclusion or disadvantage does not in fact exist;

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(c)

An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing special knowledge regarding health care plans or evidences of coverage therefor, to expect benefits, services, charges, or other advantages which the evidence of coverage does not provide or which the health care plan issuing such evidence of coverage does not regularly make available for enrolled participants covered under such evidence of coverage.

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(d)

In the event that a person is covered by more than one plan that requires pre-certification, the member shall obtain pre-certification from the primary plan. Although the member shall not be required to obtain pre-certification from the secondary plan, the secondary plan shall not be required to treat such services as covered services if the services do not meet its certification criteria. The secondary plan shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan.

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II.

RSA 406-A and RSA 417 shall be construed to apply to health maintenance organizations and evidences of coverage, except to the extent that the commissioner determines that the nature of the health maintenance organizations, and evidences of coverage render such statutes inappropriate.

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III.

No health maintenance organization, unless licensed as an insurer, may use in its name, evidences of coverage, contracts, or literature, any of the words "insurance," "casualty," "surety," "mutual," or any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in this state.

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IV.

No health maintenance organization shall exclude part-time employees or refuse to offer the same insurance benefits to part-time employees as it offers to the employee groups of which the part-time employees would be members if they were full-time employees. The insurer shall offer to include the part-time employees as part of the employer's employee group, at the full rate to be paid by the employer, at a rate prorated between the employer and the employee, or at the employee's expense. A part-time employee shall be any employee who regularly works at least half of the weekly hours of the full-time employee in the employee group of which the part-time employee would be a member if he were a full-time employee, but who works a minimum of at least 15 hours per week.

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V.

Every health maintenance organization which solicits bids from pharmacies for contracts to be preferred providers shall accept and list as preferred providers all pharmacies which meet the bid acceptable to the health maintenance organization.

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VI.

No health maintenance organization shall, when issuing or renewing a policy or contract of insurance or any certificate under such policy or contract covered by this chapter, deny coverage or limit coverage to any resident of this state on the basis of health risk or condition except that a waiting period consistent with insurance department rules may be imposed for pre-existing medical conditions. If a health maintenance organization accepts an application for group coverage, such acceptance shall be subject to the following:

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(a)

If the group has coverage in effect through another plan, the health maintenance organization shall accept all persons covered under the existing plan. If the group does not have coverage in effect through another plan, the health maintenance organization shall accept all persons for which the group seeks coverage.

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(b)

Once a group policy has been issued, any person becoming eligible for coverage shall become covered by enrolling within 31 days after first becoming eligible. Any person so enrolling shall not be required to submit evidence of insurability based on medical conditions. If a person does not enroll at this time, he is a late enrollee.

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(c)

Once a group policy has been issued, the health maintenance organization shall provide the group with an annual open enrollment period for late enrollees. During the open enrollment period, any late enrollee shall be permitted to enroll without submitting any evidence of insurability based on medical conditions. For late enrollees only, the pre-existing condition provisions shall apply for 18 months from the date of enrollment.

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VII.

An insurer issuing policies of group insurance shall allocate the costs associated with maternity and childbirth over both males and females covered by its entire block of business in this state. In cases in which, because of the amount written in the state, allocation to an entire block of business needs to occur, the carrier may apply for a waiver from the insurance commissioner.

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VIII.

[Repealed.]

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IX.

[Repealed.] Source. 1977, 282:1. 1986, 114:4. 1992, 113:1; 222:3. 1993, 162:5. 1995, 126:4. 1996, 149:4. 1997, 345:8, I. 2007, 289:16, eff. Jan. 1, 2008.

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