New Hampshire Administrative Code

(a) Each carrier that collects CAHPS® data, a survey overseen by the United States Department of Health and Human Services, agency for healthcare research and quality (AHRQ) and used by NCQA as part of HEDIS® reporting, shall report those data that are collected and that pertain …

(a) Carriers and third-party administrators shall submit files that conform to the formats and standards in these rules, including the technical specifications in Ins 4009. (b) Carrier and third-party administrator files shall be evaluated upon receipt by the department or its de…

(a) Upon application of a carrier or third-party administrator, the department shall grant a waiver of the requirement to submit a particular data element required under these rules, upon a showing by the carrier or third-party administrator that: (1) The data element does not ex…

(a) The following table lists the subscriber and member identifiers that must be identical when reporting information about a subscriber or a member: Table 1: Matching Requirements for Subscriber/Member Identifiers Across Files Data Element Name* Subscriber and Member Identifiers…

(a) Carriers and third-party administrators shall use the values in the data tables contained in Ins 4010 or the corresponding externally maintained code tables referenced therein, and: (1) Carriers and third-party administrators shall submit tables and descriptions for all non-c…

(a) A validation process shall be employed to ensure that the format and content of the submitted files are valid and complete. The validation process is primarily composed of three groups of audits, field level audits, quality audits, and post data consolidation reasonableness, …

(a) Countries American National Standards Institute http://webstore.ansi.org/SdoInfo.aspx?sdoid=39& source;=iso_member_body (b) States, Zip Codes and Other Areas of the US U.S. Postal Service https://www.usps.com/ (c) National Provider Identifiers National Plan & Provider Enumera…

(a) Use Table 4010.7 (a) to determine member eligibility file mapping and formatting. (b) Member File Header Record Layout Table 4010.01(b) Member File Header Record Layout Data Element # Element Type Length (decimal places) Description/Codes/Sources HD001 Record Type Text 2 HD H…

(a) Medical Eligibility File Mapping and Format Information. Use Table 4010.7 (b) to determine medical eligibility file mapping and formatting. (b) Medical Claims File Header Record Layout Table 4010.02 (b) Medical Claims File Header Record Layout Data Element # Element Type Leng…

(a) Pharmacy Claims Mapping and Format Information. Use Table 4010.7 (c) to determine pharmacy claims file mapping and formatting. (b) Pharmacy Claims File Header Record Layout Table 4010.03(b) Pharmacy Claims File Header Record Layout Data Element # Element Type Length (decimal …

(a) Dental Claims Mapping and Format Information. Use Table 4010.7 (d) to determine dental claims file mapping and formatting. (b) Dental Claims File Header Record Layout Table 4010.05 (a) Provider File Header Record Layout Data Element # Element Type Length (decimal places) Desc…

(a) Provider File Header Record Layout Table 4010.05 (a) Provider File Header Record Layout Data Element # Element Type Length (decimal places) Description/Codes/Sources HD001 Record Type Text 2 HD HD002 Payer Text 8 Payer submitting payments. NHID Submitter Code HD003 National P…

(a) Insurance Type/Product Code - Eligibility File Table 4010.06 (a) Insurance Type/Product Code-Eligibility File Code Description 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in…

(a) Member Eligibility File Mapping and Format Information Table 4010.07 (a) Member Eligibility File Mapping and Format Information Data Element # Element HIPAA Reference Transaction Set/Loop/ Segment/Qualifier/Data Element ME001 Payer N/A ME002 National Plan ID 271/2100A/NM1/XV/…

The purpose of this part is to establish requirements for all filings of accident and health insurance rates covered by this chapter. Notes N.H. Admin. Code § Ins 4101.01 #9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12 The amended version of this section by…

This part shall apply to rate filings for all accident and health insurance policies covered by this chapter, except long term care insurance policies or certificates under RSA 415-D, Medicare supplement insurance policies or certificates under RSA 415-F, credit insurance policie…

The provisions of the US Department of Health and Human Services regulation, 45 CFR Subtitle A, Subchapter B Part 158 Issuer Use of Premium Revenue Reporting and Rebate, dated December 1, 2010,wherein referenced shall apply to all carriers subject to the provisions of Ins 4100. N…

For the purposes of this part: (a) "Carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of…

(a) All submissions shall be made by the carrier or by a licensed rating organization on behalf of the carrier. (b) When a submission is made on behalf of a carrier, a letter or other document authorizing the rating organization to file on behalf of the carrier shall be included …

(a) A rate filing shall be submitted whenever a new policy, rider, or endorsement form that affects benefits is submitted for approval or whenever there is a change in the rates applicable to a previously approved form. If the form does not require a change in the premium, the su…

The purpose of this part is to provide requirements for the submission and the filing of individual health insurance rates for all products that meet the definition of health coverage under RSA 420-G:2, IX. This part establishes standards for determining the reasonableness of the…

This part shall apply to all rate filings for individual health coverage plans subject to RSA 420-G. Notes N.H. Admin. Code § Ins 4102.02 #9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #10212, eff 11-1-12 The amended version of this section by New Hampshire Register Volume 39…

For the purposes of this part: (a) "Actuarial certification" means a written statement signed by a member of the American Academy of Actuaries; (b) "Actuarial memorandum" means the document describing the basis on which rates were determined and that includes other supporting doc…

(a) A carrier offering health coverage in the individual market: (1) Shall make all of its individual health plans available for purchase; (2) Shall not make available or offer any coverage that has been discontinued in accordance with RSA 420-G:5, VI. or VII.; and (3) May limit …

(a) A carrier offering health coverage in the individual market shall renew all of its individual health insurance plans provided such plans are currently available for purchase. (b) Rating factors based on health status shall not change at renewal due to changes in an individual…

(a) Carriers shall maintain records of earned premiums, incurred claims and reserves for each calendar year and for each policy form, including data for rider and endorsement forms that are used with the policy form for so long as the carrier maintains rates on the policy. (b) No…

(a) Carriers shall calculate the market rate in accordance with the following: (1) The calculation shall reflect the carrier's experience for all the products it sells and maintains in the individual health insurance market; (2) Plan relativity factors that are used to modify the…

(a) Carriers shall estimate the average monthly premium for each health plan coveragebased on an anticipated distribution of business by all significant criteria having a price difference, including: (1) Age; (2) Coverage amount; (3) Dependent status; and (4) Rider frequency. (b)…

The purpose of this part is to provide requirements for the submission and the filing of small employer group health insurance rates subject to RSA 420-G and to establish standards for determining the reasonableness of the relationship of benefits to premiums. Notes N.H. Admin. C…

This part shall apply to every small employer health insurance policy, rider or endorsement form affecting health coverage that constitutes health coverage as defined under RSA 420-G:2, IX. Franchise insurance as defined in RSA 415:19 which is not group supplement insurance shall…

For the purposes of this part: (a) "Actuarial certification" means a written statement signed by a member of the American Academy of Actuaries; (b) "Actuarial memorandum" means the document describing the basis on which rates were determined and that includes other supporting doc…

(a) A small employer carrier: (1) Shall make all of its small employer health insurance plans available for purchase; (2) Shall not make available for offer any coverage that has been discontinued in accordance with RSA 420-G:5; (3) May limit coverage offers and renewals to small…

(a) A small employer carrier shall renew all its small employer health insurance plans provided such plans are currently available for purchase. (b) Carriers shall use the same rating methodology, list bill or composite bill, as in the prior period unless the small employer conse…

(a) A health carrier shall provide the rate disclosure form with each premium rate quote. (b) The rate disclosure form shall include the health coverage plan rate for the coverage elected, and any adjustment thereto, for allowable case characteristics. (c) For composite billed gr…

(a) Carriers shall calculate a market rate in accordance with the following: (1) The calculation shall reflect the carrier's experience for all the products it sells and maintains in the small group health insurance market; (2) Plan relativity factors that are used to modify the …

(a) Carriers shall estimate the average annual premium per policy form based on an anticipated distribution of business by all significant criteria having a price difference, such as: (1) Age; (2) Coverage amount; (3) Dependent status; and (4) Rider frequency. (b) Carriers shall …

(a) Carriers shall notify insured members of their potential eligibility to obtain coverage in the New Hampshire Health Plan pursuant to RSA 415:18, or the federally qualified high risk pool pursuant to RSA 404-G:5-g. (b) Carriers shall use the notice language adopted by the New …

The purpose of this part is to provide requirements for filing large employer group health insurance rates and to establish standards for determining the reasonableness of the relationship of benefits to premiums. Notes N.H. Admin. Code § Ins 4104.01 #9690, eff 4-9-10; ss by #993…

This part shall apply to every large employer health insurance policy, rider or endorsement form affecting health coverage as that term is defined by RSA 420-G:2 IX. Notes N.H. Admin. Code § Ins 4104.02 #9690, eff 4-9-10; ss by #9938, eff 6-10-11 The amended version of this secti…

For the purposes of this part: (a) "Actuarial certification" means a written statement signed by a member of the American Academy of Actuaries, stating that to the best of the actuary's knowledge and judgment, the entire rate filing is in compliance with all of the applicable law…

(a) Large employer carriers shall file a report to the department on or before March 1st of each year detailing for the prior calendar year any instances where the carrier declined to offer coverage as applied for, and any instances where the carrier's quoted renewal rate represe…

A large employer carrier shall renew all its RSA 420-G:2, IX large employer health insurance plans provided such plans are currently available for purchase. Notes N.H. Admin. Code § Ins 4104.05 #9690, eff 4-9-10; ss by #9938, eff 6-10-11 The amended version of this section by New…

(a) Carriers shall calculate a market rate that is representative of all of the RSA 420-G:2, IX health coverage plans offered to large employers as follows: (1) Carriers shall provide the plan relativity factors that are used to modify experience under its existing coverages so t…

(a) Carriers shall estimate the average annual premium per policy form based on an anticipated distribution of business by all significant criteria having a price difference, such as:(1) Age; (2) Coverage amount; (3) Dependent status; and (4) Rider frequency. (b) Carriers shall a…

(a) Carriers shall notify insured members of their potential eligibility to obtain coverage in the New Hampshire Health Plan pursuant to RSA 415:18, or the federally qualified high risk pool pursuant to RSA 404-G:5-g. (b) Carriers shall use the notice language adopted by the New …

The purpose of this part is to provide requirements for the submission and the filing of group stop loss insurance rates and to establish standards for determining the reasonableness of the relationship of benefits to premiums. Notes N.H. Admin. Code § Ins 4105.01 #9690, eff 4-9-…

This part shall apply to every group stop loss health insurance policy, rider, certificate or endorsement form affecting stop loss health coverage. Notes N.H. Admin. Code § Ins 4105.02 #9690, eff 4-9-10; ss by #9938, eff 6-10-11 The amended version of this section by New Hampshir…