Plan types (indemnity, HMO, PPO, POS), cost sharing, HSAs and the ACA framework are covered in the national Medical Plans guide. This guide covers the New Hampshire statutes and rules on medical expense coverage that the Accident and Health exam tests. They come mainly from RSA 415 (accident and health policies), RSA 420-J (managed care and external review) and the Ins 1001 claims rule.

Children and dependents

• Dependent child means a subscriber's child by blood or by law who is under 26 (RSA 415:5).
• Disabled dependents. A child who can't support themselves because of a disability stays covered while the policy is in force and the incapacity and dependency continue, on proof of incapacity.
• Newborns (415:22):
  • Covered from the moment of birth, including congenital defects.
  • The birth mother's policy is always primary for the newborn, with no added cost sharing.
  • A policy may require notice and premium within 31 days, but no extra premium may be charged for those first 31 days.
• Adopted children are covered from the date the child is placed in the insured's custody for adoption. Coverage ends if the adoption petition is dismissed or withdrawn (415:22-a).
• Enrollment (RSA 161-H:2). An insurer can't deny a child's enrollment because the child was born out of wedlock, isn't claimed as a tax dependent, or doesn't live with the parent. A court-ordered child must be enrolled without regard to open enrollment limits.
• Maternity rider. If a policy doesn't cover maternity care, the insurer must offer an optional maternity rider. This doesn't apply to supplemental or disability policies (415:6-d).

Claims and prompt payment

• Decisions. Health insurers must make a complete coverage or denial decision within 30 days of receiving a claim, or explain the delay in writing (Ins 1001.02).
• Payment deadlines for clean claims (415:6-h):
  • 30 calendar days for paper claims
  • 15 calendar days for electronic claims
• Interest. Late claims carry interest of 1.5% per month from the date payment was due.

External review (RSA 420-J)

• A covered person may ask the Commissioner for external review within 180 days of the carrier's denial decision, generally after internal review is finished (420-J:5-a).
• An expedited external review is decided as quickly as the medical condition requires, and never more than 72 hours after the request (420-J:5-c).

Nondiscrimination

• Insurers may not discriminate within a class, including on the basis of gender identity, for covered services, medications, supplies or equipment (415:15).
• Refusing or limiting coverage solely because a person is a domestic abuse victim is an unfair practice (417:4, VIII).

Ancillary health coverage (Ins 6201)

• Free look. Supplemental health policies must carry a cover-page notice of the right to return the policy within 30 days of delivery. Single-premium nonrenewable policies are excepted.
• Convalescent care. A policy can't require admission within less than 14 days after a hospital discharge to qualify for convalescent or extended care benefits, and can't require a minimum hospital stay.
• Military suspension. A policy that suspends coverage during military service refunds premium pro rata within 30 days.
• Disability claims. Insurers can't demand extra physician reports to prove a disability that a prior report already established (Ins 1001.07).

Required individual policy provisions are in the New Hampshire Individual Accident and Health Provisions guide. Group rules and state continuation are in the New Hampshire Group Health Insurance guide.

Common exam traps

• Dependent children are covered to age 26.
• For a newborn, the birth mother's policy is always primary, and no premium is charged for the first 31 days.
• Clean claims are paid in 15 days if electronic, 30 days if paper, with 1.5% a month interest when late.
• External review must be requested within 180 days. Expedited reviews take no more than 72 hours.
• Ancillary health policies have a 30-day free look.