RSA 420-G:2 · Definitions

420-G:2 Definitions. – In this chapter:

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I.

"Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a small employer health carrier is in compliance with the provisions of and the rules adopted by the commissioner, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the small employer health carrier in establishing premium rates for applicable health benefit plans. I-a. "Case characteristics" means demographic or other relevant characteristics of a small employer group that may be considered by the health carrier in the determination of premium rates for that group.

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II.

"Commissioner" means the commissioner of insurance. II-a. "Composite billing" means a method of calculating premium rates for small employer groups in which each enrolled employee's rate varies only by the enrolled employee's family composition.

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III.

"Creditable coverage" means any public or private health insurance or health benefit plan, whether insured or self-insured, unless that coverage consists solely of benefits excluded from the definitions of "health coverage" in paragraph IX or "individual health coverage" in paragraph XI. Notwithstanding the exclusion in paragraph IX, short-term, nonrenewable individual policies for medical, hospital, or major medical coverage issued pursuant to RSA 415:5, III or other law shall be considered "creditable coverage." III-a. "Date of enrollment" means the first day of coverage under the plan, or, if there is a waiting period, the first day of the waiting period, which is typically the first day of work.

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IV.

"Department" means the department of insurance.

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V.

"Eligible dependents" means those persons who may be included under a covered person's health coverage by the terms of the policy or plan and in accordance with this chapter.

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VI.

"Eligible employee" means an employee who meets the requirements for eligibility set forth by the employer, the health coverage plan and state law. VI-a. "Employee" means "employee" as defined in the Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(6). VI-b. "Essential health benefits" means the categories of coverage identified in 42 U.S.C. section 18022(b)(1) and as further defined and implemented by the Secretary of the Department of Health and Human Services from time to time.

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VII.

"Exclusion period" means the length of time that must expire before a health carrier will cover medical treatment expense relating to a preexisting condition. VII-a. "Family composition" means health plan membership type, including: enrollee only; enrollee and spouse; enrollee and children; enrollee, spouse, and children; and other similar membership types.

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VIII.

"Health carrier" means any 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 services; including an insurance company, a health maintenance organization, a nonprofit health services corporation, or any other entity providing health coverage.

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IX.

"Health coverage" means any hospital or medical expense incurred policy or certificate, nonprofit health services corporation subscriber contract, or health maintenance organization subscriber contract and any other health insurance plan or health benefit plan. For the purposes of this chapter, health coverage does not include:

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(a)

Accident-only or disability income insurance.

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(b)

Coverage issued as a supplement to liability insurance.

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(c)

Liability insurance, including general liability insurance and automobile liability insurance.

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(d)

Workers' compensation or similar insurance.

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(e)

Automobile medical-payment insurance.

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(f)

Credit only insurance.

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(g)

Coverage for on-site medical clinics.

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(h)

Short-term, individual, nonrenewable medical, hospital, or major medical policies.

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(i)

Other similar insurance coverage, specified in rules, under which benefits for medical care are secondary or incidental to other insurance benefits.

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(j)

If offered separately:

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(1)

Limited scope dental or vision benefits.

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(2)

Long-term care, nursing home care, home health care, community-based care, or any combination thereof.

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(3)

Prescription drug benefits.

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(4)

Other similar, limited benefits as are specified in rules.

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(k)

If offered as independent, noncoordinated benefits:

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(1)

Specified disease or illness benefits.

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(2)

Hospital or surgical indemnity benefits.

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(l)

If offered as a separate insurance policy, Medicare supplemental health insurance, coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code, and similar supplemental coverage as specified in regulations. IX-a. "Health coverage plan rate" means a rate that is uniquely determined for each of the coverages or health benefit plans a health carrier writes and that is derived from the market rate through the application of plan factors that reflect actuarially demonstrated differences in expected utilization and health care costs attributable to differences in the coverage design and/or the provider contracts that support the coverage and by including provisions for administrative costs and loads. The health coverage plan rate is periodically adjusted to reflect expected changes in the market rate, utilization, health care costs, administrative costs, and loads.

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X.

"Individual" means a person who is not eligible for health coverage through employment and that person's dependents.

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XI.

"Individual health coverage" means health coverage issued by a health carrier directly to an individual and not on a group or group remittance basis. For the purposes of this chapter, franchise insurance, as defined in RSA 415:19, shall be considered individual health coverage.

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XII.

(a) "Large employer" means an employer that employed on average at least 51 persons, on business days, during the previous calendar year.

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(b)

In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year. XII-a. "List billing" means a method of calculating premium rates for small employer groups in which each enrolled employee's rate varies only by the enrolled employee's attained age and the enrolled employee's family composition. XII-aa. "Loss information" means the aggregate claims experience and shall include, but not be limited to, the number of covered lives, the amount of premium received, the amount of total claims paid, and the claims loss ratio. "Loss information" shall not include any information or data pertaining to the medical diagnosis, treatment, or health status that identifies an individual covered under the group contract or policy. Catastrophic claim information shall be provided as long as the provision of this information would not compromise any covered individual's privacy. XII-b. "Loss ratio" means the ratio between the amount of premium received and the amount of claims paid by the health carrier under the group insurance contract or policy. XII-c. "Market rate" means a single rate reflecting the carrier's average cost of actual or anticipated claims for all health coverages or health benefit plans the carrier writes and maintains in a market, including the nongroup individual health insurance market and, separately, the small employer group health insurance market, and which is periodically adjusted by the carrier to reflect changes in actual or anticipated claims.

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XIII.

"Medical underwriting" means the use of health status related information to establish or modify health coverage premium rates. XIII-a. "Modified experience rating" means a rating methodology to apply only to individual policies sold in the nongroup market, which modifies community rating to allow for limited consideration of health status, as detailed in RSA 420-G:4, I(a).

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XIV.

"Preexisting condition" means a condition, whether physical or mental, for which medical advice, diagnosis, care or treatment was recommended or received during the 3 months immediately preceding the enrollment date of health coverage. XIV-a. [Repealed.] XIV-b. "Premium rate" means the rates used by a carrier to calculate the premium. For group coverage, premium rates shall be expressed as a rate per enrolled employee.

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XV.

"Qualified association trust or other entity" means an association established trust or other entity in existence on January 1, 1995, and providing health coverage within the state of New Hampshire to at least 1,000 employees and/or the dependents of association members, which association:

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(a)

Was established and maintained for a primary purpose other than the provision of health coverage;

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(b)

Was in existence for at least 10 years prior to January 1, 1995; and

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(c)

Conducts regular meetings within the state of New Hampshire designed to further the interests of its members, and all members shall be given notice of such meetings at least 30 days prior to the date of any meeting. XV-a. "Rating period" means the time period for which the premium rate charged by a health carrier to an individual or a small employer for a health benefit plan is in effect.

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XVI.

(a) "Small employer" means a business or organization which employed on average, one and up to 50 employees on business days during the previous calendar year. A small employer is subject to this chapter whether or not it becomes part of an association, multi-employer plan, trust, or any other entity cited in RSA 420-G:3 provided it meets this definition.

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(b)

In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.

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XVII.

"Waiting period" means a period of time, determined by the employer, which must expire before an employee is eligible for health coverage as a condition of employment. Source. 1997, 344:1. 1998, 340:8; 375:1. 2000, 2:1. 2001, 120:1. 2003, 188:1-4. 2005, 225:1-8; 248:14. 2007, 289:21, 22. 2010, 346:3, I, eff. July 20, 2010. 2019, 220:1, 2, eff. Sept. 10, 2019.

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