N.H. Code Admin. R. Ins 1907.05 - Application of Ins 1907.03 to Plan Benefits; Preexisting Condition Exclusions; Similarly Situated Individuals

(a) Subject to (b) and (c) below, Ins 1907.03 does not require a carrier subject to this chapter to provide coverage for any particular benefit to any group of similarly situated individuals.
(1) A carrier subject to this chapter shall make the benefits provided under a plan available uniformly to all similarly situated individuals, as those groups are determined under (c) below.
a. For any restriction on a benefit or benefits provided under a plan, a carrier subject to this chapter:
1. Shall apply the restriction uniformly to all similarly situated individuals; and
2. Shall not direct the restriction, as determined based on all of the relevant facts and circumstances, at individual participants or beneficiaries based on any health factor of the participants or beneficiaries.
b. A carrier subject to this chapter may impose annual, lifetime or other limits on benefits and may require a deductible, copayment, coinsurance or other cost-sharing requirement in order to obtain a benefit under the plan if the limit or cost-sharing requirement:
1. Applies uniformly to all similarly situated individuals; and
2. Is not directed at individual participants or beneficiaries based on any health factor of the participants or beneficiaries.
c. For purposes of (a), a plan amendment applicable to all individuals in one or more groups of similarly situated individuals under the plan and made effective no earlier than the first day of the first plan year after the amendment is adopted is not considered to be directed at any individual participants or beneficiaries.
(2) If a carrier subject to this chapter generally provides benefits for a type of injury, the plan or carrier shall not deny an individual participant or beneficiary benefits otherwise provided under the plan for treatment of the injury if the injury results from an act of domestic violence or a medical condition.
(3) A carrier subject to this chapter with a cost-sharing mechanism, such as a deductible, copayment or coinsurance, that requires a higher payment from an individual, based on a health factor of that individual or dependent of that individual, than for a similarly situated individual under the plan, does not violate this section if the payment differential is based on whether the individual has complied with the requirements of a bona fide wellness program.
(b) Ins 1907.03 does not prohibit a carrier subject to this chapter from imposing a preexisting condition exclusion period if:
(1) The preexisting exclusion period:
a. Complies with the requirements for imposing a preexisting condition exclusion period established by federal regulation;
b. Is applied uniformly to all similarly situated individuals, as those groups are determine under (d) below; and
c. Is not directed at individual participants or beneficiaries based on any health factor of the participants or beneficiaries.
(2) For purposes of this subsection, a plan amendment relating to a preexisting condition exclusion that is applicable to all individuals in one or more groups of similarly situated individuals under the plan and made effective no earlier than the first day of the first plan year after the amendment is adopted is not considered to be directed at any individual participants or beneficiaries.
(c) This subsection applies only within a group of individuals who are treated as similarly situated individuals, so that:
(1) Subject to (4) below of this subsection, Ins 1907.03 does not prohibit a carrier subject to this chapter from treating participants as 2 or more distinct groups of similarly situated individuals if the distinction made between or among groups of participants is based on a bona fide employment-based classification that is consistent with the employer's usual business practice.
a. Whether an employment-based classification is bona fide shall be determined based on all of the relevant facts and circumstances.
b. For purposes of 1. a. above, relevant facts and circumstances include whether the employer uses the classification for purposes independent of qualification for health coverage, such classifications may include:
1. Full-time versus part-time status;
2. Geographic location;
3. Membership in a collective bargaining unit;
4. Date of hire;
5. Length of service;
6. Current employee versus former employee status; and
7. Occupation.
c. A classification based on a health factor shall not be determined to be a bona fide employment-based classification for purposes of this subjection unless the requirements of Ins 1907.03(c) and Ins 1907.04(e) are satisfied.
(2) Subject to subparagraph (4) of this subsection, Ins 1907.03 does not prohibit a carrier subject to this chapter from treating beneficiaries as 2 or more distinct groups of similarly situated individuals if the distinction is made between or among the groups of beneficiaries is based on any of the following factors:
a. A bona fide employment-based classification of the participant through whom the beneficiary is receiving coverage;
b. Relationship to the participant (e.g., as a spouse or as a dependent child);
c. Marital status;
d. With respect to a child of the participant, age or student status; or
e. Any other factor, if the factor is not a health factor.
(3)Subparagraph (1) above shall not be construed to prevent a carrier subject to this chapter from providing more favorable treatment of individuals under the plan with adverse health factors in accordance with Ins 1907.03(c) and Ins 1907.04(e).
(4) Notwithstanding subparagraphs (1) and (2) of this subsection, unless permitted under Ins 1907.03(c) and Ins 1907.04(e), if the creation or modification of an employment or coverage classification is directed at individual participants or beneficiaries based on a health factor of the participants or beneficiaries, the classification is not permitted under this subsection.

Notes

N.H. Code Admin. R. Ins 1907.05

#8607, eff 4-17-06

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