Health plans - New Hampshire

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply.

New Hampshire laws include the following provisions:

• Part time employees must be covered, but rate payment is left to the employer. §415:18 [paragraph (I)(q)]
• If maternity care is not covered, plans must offer optional maternity coverage. §415:18 [paragraph (I)(s)]
• Dependents who are mentally or physically incapable of earning his own living, must continue to be covered regardless of age. §415:18 (paragraph V), §415:5
• Effective September 14, 2009, dependents include a subscriber’s child by blood or by law, who is unmarried and one of the following:
  
  • • Under age 19.
    • Under age 25 if the child is a full-time enrolled student at an educational institution.
    • Under age 26, a resident of New Hampshire, and is not provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan, or health benefits plan, or entitled to Social Security benefits. §415:5, I(3)(a) (See HB 330)

• Effective June 22, 2006, if coverage includes dependent children who are full-time students beyond the age of 18, such coverage must include coverage for a dependent's medically necessary leave of absence from school for up to 12 months or the date on which coverage would otherwise end. §415:18 (paragraph V) (See HB 37)
• The plan must reimburse for services provided by those licensed to practice osteopathy, chiropractic, podiatry, optometry, or licensed as an advanced registered nurse practitioner. §415:18 (paragraph VI)
• Plans must cover mental illnesses on the same basis as other illnesses; emotional disorders, chemical dependency including alcoholism. §415:18-a
• Major medical expenses include the services of a psychiatrist, a licensed psychologist, a licensed pastoral psychotherapist, a psychiatric/mental health advanced registered nurse practitioner, a licensed clinical mental health counselor, a licensed alcohol and drug counselor, a licensed marriage and family therapist, a licensed clinical social worker, a licensed general hospital, a public or licensed mental hospital, or a community mental health center or psychiatric residential program. §415:18-a
• If the plan covers prostheses, it must cover scalp hair prostheses when medially necessary. §415:18-d
• Plans must cover nonprescription enteral formulas for the treatment of impaired absorption of nutrients when medically necessary. §415:18-e
• Plans must cover nonprescription enteral formulas and food products required for persons with inherited diseases of amino acids and organic acids when medically necessary. §415:18-e
• Plans must cover outpatient self-management training and educational services for diabetes per physician’s order. §415:18-f
• If the plan covers prescriptions, it must cover medically appropriate or necessary insulin, oral agents, and equipment used to treat diabetes. §415:18-f
• If the plan covers durable medical equipment, it must cover medically appropriate or necessary equipment used to treat diabetes. §415:18-f
• The plan must cover general anesthesia for dental procedures for children under 6 who require it, or those with exceptional medical circumstances or a developmental disability. §415:18-g
• If the plan covers outpatient services, it must cover outpatient contraceptive services under the same terms and conditions as for other outpatient services. §415:18-i
• If the plan covers prescriptions, it must cover off-label prescription drugs (not approved by the FDA). §415:18-j
• Plans must cover medically necessary routine patient care resulting from treatments provided in accordance with a clinical trial. §415:18-l
• Plans must cover prosthetic devices under the same terms and conditions that apply to other durable medical equipment. §415:18-n
• Effective April 14, 2006, if the plan provides maternity benefits, it must cover the services of certified midwives. §415:18-q
• Effective July 25, 2006, Plans must cover human leukocyte antigen testing for utilization in bone marrow transplantation. §415:18-r (see HB1452)
• Family provisions must cover newborns from the moment of birth, including newborns of dependents. Coverage must include the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. §415:22
• If the plan covers family members, cover adopted children from the date the children are placed in the custody of the insured. §415:22-a
• Plans must provide benefits for treatment and diagnosis of certain biologically-based mental illnesses under the same terms and conditions and which are no less extensive than coverage provided for any other type of health care for physical illness. §417E:1
• For managed care plans, if the plan covers chiropractic benefits, it must provide benefits to a covered person who utilizes services of a chiropractic provider (doctor of chiropractic) by self-referral for 12 visits. §420-J:6-b
• For managed care plans, if the plan covers prescription drugs, it must provide prospective enrollees, and covered persons, a description of the prescription drug benefit plan. §420-J:7-b
• Effective April 14, 2006, for managed care plans, if the plan provides maternity benefits, it must cover the services of certified midwives. §420-B:8-p
• Plans that give prior authorization cannot rescind or modify the authorization after the health care provider has rendered authorized emergency services care in good faith and the participant’s coverage was effective on the date of service. §417-F:3
• NH HealthFirst provides for affordable, wellness-based insurance plan for small employers. Carriers that offer coverage to small employers and had at least 1,000 covered participants at the end of the prior calendar year must offer the standard wellness plan to small employers. This standard wellness plan must create incentive to promote wellness, primary care, preventive care, medical home model, the use of cost effective care, quality of care by the use of evidence-based, best practice standards and patient-centered care; and manage and coordinate care for persons with chronic health conditions or acute illness. The Act is effective July 18, 2008, and the plan must be available on October 1, 2009.
• Effective September 14, 2008, group plans must provide coverage for the diseases and ailments caused by obesity and morbid obesity and treatment for such, including bariatric surgery, when medically necessary. Such treatment standards may include, but not be limited to, pre-operative psychological screening and counseling, behavior modification, weight loss, exercise regimens, nutritional counseling, and post-operative follow-up, overview, and counseling of dietary, exercise, and lifestyle changes. The covered insured shall be at least 18 years of age. SB 312-FN, §415:18-t
• Effective October 14, 2009, insurers offering a health may not deny coverage on the sole basis that the coverage is provided through telemedicine if the health care service would be covered if it were provided through in-person consultation between the covered person and a health care provider. §415-J (See SB 138)

State

  Contact

New Hampshire Insurance Department

Regulations

New Hampshire Revised Statutes

Title XXXVII Insurance, Chapter 415 Accident and Health Insurance

§415:5 Form of Policy.

§415:18 General Group or Blanket Policy Provisions.

§415:18-a Coverage for Mental or Nervous Conditions and Treatment for Chemical Dependency Required.

§415:18-d Coverage for Scalp Hair Prostheses.

§415:18-e Coverage for Nonprescription Enteral Formulas.

§415:18-f Coverage for Diabetes Services and Supplies.

§415:18-g Coverage for Dental Procedures; Medical or Hospital; Group.

§415:18-i Coverage for Prescription Contraceptive Drugs and Prescription Contraceptive Devices and for Contraceptive Services.

§415:18-j Off-Label Prescription Drugs.

§415:a8-l Coverage Required for Qualified Clinical Trials.

§415:18-n Coverage for Certain Prosthetic Devices.

§415:18-q Coverage for Certified Midwives.

§415:18-r Coverage for the Cost of Testing for Bone Marrow Donation.

§415:22 Newborn Children.

§415:22-a Coverage During Adoption Proceedings.

§417-E:1 Coverage for Certain Biologically-Based Mental Illnesses

§417-F Coverage for Emergency Services

§471-F:3 Prior Authorization.

§420-G Portability, Availability, and Renewability of Health Coverage

§420J Managed Care Law

§420-J:6-b Self-referrals for Chiropractic Care.

§420-J:7-b Prescription Drugs.

§420-B:8-p Coverage for Certified Midwives.

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)