EXPLANATION OF BENEFITS

RSA tit. XXXVII, ch. 420-H

in effect

RSA 420-H:1 Purpose.

420-H:1. Purpose. The legislature finds and declares that: I. Current and prospective beneficiaries, and enrollees and subscribers of group and individual health policies and hospital service plans, nonprofit health service plans, medical service plans, and health maintenance organizations do not always understand the medical services that will and will not be covered by such third-party payors, or the payment schedule contained in such policies or plans. II. Third-party payors should be required to provide such information regarding covered services in clear and simple terms with an easily understandable schedule of payment for services covered to current and potential beneficiaries, enrollees and subscribers. Source. 1994, 359:1, eff. Jan. 1, 1997.

RSA 420-H:2 Definitions.

420-H:2. Definitions. As used in this chapter: I. "Certificate" means a document received by an insured, enrollee, or subscriber from an insurer in lieu of a policy or contract which evidences the coverage to which the insured, enrollee or subscriber is entitled. II. "Commissioner" means the commissioner of the insurance department. III. "Company" or "insurer" means any life or health insurance company, fraternal benefit society, nonprofit health service corporation, nonprofit hospital service corporation, nonprofit medical service corporation, prepaid health plan, dental care plan, vision care plan, pharmaceutical plan, health maintenance organization, and all similar type organizations. IV. "Policy" or "policy form" means any policy, contract, certificate, plan or agreement of life or health insurance, including credit life insurance and credit health insurance, delivered or issued for delivery in this state by any company subject to this chapter; any certificate, contract or policy issued by a fraternal benefit society; and any certificate issued pursuant to a group insurance policy delivered or issued for delivery in this state. Source. 1994, 359:1, eff. Jan. 1, 1997.

RSA 420-H:3 Scope.

420-H:3. Scope. This chapter shall apply to all policies delivered or issued for delivery in this state by any company on or after the date such forms must be approved under this chapter, but nothing in this chapter, shall apply to: I. Any policy which is a security subject to federal jurisdiction; II. Any group policy covering a group of 1,000 or more lives at date of issue, other than a group credit life insurance policy or a group credit health insurance policy; however, this shall not exempt any certificate issued pursuant to a group policy delivered or issued for delivery in this state; III. Any group annuity contract which serves as a funding vehicle for pension, profit sharing or deferred compensation plans; IV. Any form used in connection with, as a conversion from, as an addition to, or in exchange pursuant to a contractual provision for, a policy delivered or issued for delivery on a form approved or permitted to be issued prior to the dates such forms must be approved under this chapter; V. The renewal of a policy delivered or issued for delivery prior to the dates such forms must be approved under this chapter. Source. 1994, 359:1, eff. Jan. 1, 1997.

RSA 420-H:4 Requirements.

420-H:4. Requirements. Enrollees, subscribers, certificate holders, and individual insureds shall receive in simple and concise written language at least the following information: I. An explanation of benefits provided. II. Any benefit limitations, reductions, exclusions or exceptions to covered services, including an explanation of any restrictions on a subscriber's access to network practitioners based upon the subscriber's choice of primary care physician. The explanation of restrictions shall include a section regarding "referrals to other providers or other medical specialists" that shall urge enrollees, subscribers, certificate holders, and individual insureds to inquire about their primary care provider's referral group within the insurer's network. Such explanation shall include a general statement regarding the existence of physician hospital organizations within the insurer's network, to which primary care providers may be associated. III. The nature of any payments required of the beneficiary, enrollee or subscriber such as copayments or deductibles. IV. The nature of any limitations on payment by the insurer, including limitations based on the use of network or out-of-network health care providers. V. The credentials of any health care provider the health care plan holds out as a specialist denoting board eligibility or board certification for such specialty. VI. For companies or insurers providing health insurance through a managed care system of health care delivery or reimbursement, a description of the grievance procedures as required pursuant to RSA 420-J:5. VII. For enrollees, subscribers, certificate holders, or individual insureds whose health insurance is provided through a managed care system of health care delivery and reimbursement, an explanation of a covered person's option to receive direct access to certain obstetrical-gynecological care, pursuant to RSA 420-J:6-a. Source. 1994, 359:1. 1998, 216:1; 319:2. 2001, 207:16. 2002, 59:1, eff. June 25, 2002.

RSA 420-H:5 Minimum Policy Language Simplification Standards.

420-H:5. Minimum Policy Language Simplification Standards. I. In addition to any other requirements of law, no policy forms, except as stated in RSA 420-H:3, shall be delivered or issued for delivery in this state on or after the dates such forms must be approved under this chapter unless: (a) The text achieves a minimum score of 40 on the Flesch reading ease test or an equivalent score on any other comparable test as provided in paragraph III; (b) It is printed, except for specification pages, schedules and tables, in not less than 10 point type, one point leaded; (c) The style, arrangement and overall appearance of the policy give no undue prominence to any portion of the text of the policy or to any endorsements or riders; and (d) It contains a table of contents or an index of the principal sections of the policy, if the policy has more than 3,000 words printed on 3 or fewer pages of text, or if the policy has more than 3 pages regardless of the number of words. II. For the purposes of this section, a Flesch reading ease test score shall be measured by the following method: (a) For policy forms containing 10,000 words or less of text, the entire form shall be analyzed. For policy forms containing more than 10,000 words, the readability of two 200 word samples per page may be analyzed instead of the entire form. The samples shall be separated by at least 20 printed lines. (b) The number of words and sentences in the text shall be counted and the total number of words divided by the total number of sentences. The figure obtained shall be multiplied by a factor of 1.015. (c) The total number of syllables shall be counted and divided by the total number of words. The figure obtained shall be multiplied by a factor of 84.6. (d) The sum of the figures computed under (b) and (c) subtracted from 206.835 equals the Flesch reading ease score for the policy form. (e) For purposes of RSA 420-H:5, II(b), (c) and (d), the following procedures shall be used: (1) A contraction, hyphenated word, or numbers and letters, when separated by spaces, shall be counted as one word; (2) A unit of words ending with a period, semicolon, or colon, but excluding headings and captions, shall be counted as a sentence; and (3) A syllable means a unit of spoken language consisting of one or more letters of a word as divided by an accepted dictionary. Where the dictionary shows 2 or more equally acceptable pronunciations of a word, the pronunciation containing fewer syllables may be used. (f) The term "text" as used in this section shall include all printed matter except the following: (1) The name and address of the insurer; the name, number or title of the policy; the table of contents or index; captions and subcaptions; specification pages, schedules or tables; and (2) Any policy language which is drafted to conform to the requirements of any federal law, regulation or agency interpretation, any policy language required by any collectively bargained agreement, any medical terminology, any words which are defined in the policy, and any policy language required by law or regulation, provided, however, the insurer identifies the language or terminology excepted by this subparagraph and certifies, in writing, that the language or terminology is entitled to be excepted by this subparagraph. III. Any other reading test may be approved by the commissioner for use as an alternative to the Flesch reading ease test if it is comparable in result to the Flesch reading ease test. IV. Filings subject to this section shall be accompanied by a certificate stating that the filing meets the minimum reading ease score on the test used or stating that the score is lower than the minimum required but should be approved in accordance with RSA 420-H:6. To confirm the accuracy of any certification, the commissioner may require the submission of further information to verify the certification in question. V. At the option of the insurer, riders, endorsements, applications and other forms made a part of the policy may be scored as separate forms or as part of the policy with which they may be used. Source. 1994, 359:1. 2007, 289:25, eff. Jan. 1, 2008.

RSA 420-H:6 Powers of the Commissioner.

420-H:6. Powers of the Commissioner. The commissioner may authorize a lower score than the Flesch reading ease score required in RSA 420-H:5, I(a) whenever he finds that a lower score: I. Will provide a more accurate reflection of the readability of a policy form; II. Is warranted by the nature of a particular policy form or type or class of policy forms; or III. Is caused by certain policy language which is drafted to conform to the requirements of any state law, rule or agency interpretation. Source. 1994, 359:1, eff. Jan. 1, 1997.

RSA 420-H:7 Approval of Forms.

420-H:7. Approval of Forms. A policy form meeting the requirements of RSA 420-H:5, I shall be approved notwithstanding the provisions of any other laws which specify the content of policies, if the policy form provides the policyholders and claimants protection not less favorable than they would be entitled to under such laws. Source. 1994, 359:1, eff. Jan. 1, 1997.

Source: New Hampshire General Court (gc.nh.gov)URL: https://gc.nh.gov/rsa/html/NHTOC/NHTOC-XXXVII-420-H.htmFetched: 10/20/2026