Each carrier shall submit to the department the following reports:

1. (a) Quarterly trend information on small group HealthFirst business and comparative small group trend information on other small group products no later than 30 days after the end of each calendar year quarter. Trend information shall include the total trend and detailed numerical information on utilization, cost, technology and other factors comprising total trend numbers.
2. (b) Quarterly total enrollment information on the HealthFirst product no later than 30 days after the end of the calendar year quarter. Enrollment information shall include the number of subscribers, the number of spouses or civil union partners, and the number of dependent children or other dependents by enrollment classification.

3. (c) Quarterly, no later than 30 days after the end of the calendar year quarter, the total premium earned and total paid claims for the preceding quarter.

   1. (1) $200 reward is granted to the subscriber, or to both the subscriber and the spouse or civil union partner, upon completion of all requirements and submission of the Wellness Verification Form. To receive the $200.00 reward for a family policy, both the subscriber and spouse or civil union partner shall establish compliance with all requirements.
   2. (2) Deductible Credits are awarded for the benefit year period following submission of the form.
   3. (3) For policies that cover 2 or more persons, the subscriber and spouse or civil union partner shall comply to obtain the deductible credit. If both satisfy the requirements, then the single deductible amount is reduced by 1 x the credit, and the family is reduced by 2 x the credit (i.e., one credit for each adult parent)
   4. (4) The deductible for children covered under a family plan shall match that of the parents.

   5. (5) The Form shall be submitted within 8 months of the benefit year start date to obtain the rewards.

      APPENDIX C - State Statutes and Federal Requirements Implemented

      Rule

      Specific State or Federal Statute the Rule Implements

      Ins 401.01

      RSA 400-A:15, I; 408; 408-A; 408-D:17; 409-A; 415:1; 420-A; 420-B:21

      Ins 401.02

      RSA 400-A:15, I

      Ins 401.03

      RSA 400-A:15, I ; 415-A:2; 415-F:3

      Ins 401.04

      RSA 400-A:15, I; 408:2-b; 408:2-c; 408:16; 408:16-d; 408:16-e; 408-A:7; 415:2 and 3; 415:18, I

      Ins 401.05

      RSA 400-A:15, I; 408:9 and10; 408-E:8; 409-A:3 and 409-A:9, II; 415:14

      Ins 401.06

      RSA 400-A:15, I; 415; 415-A; 415-F:3; 420-G:5, IV; 420-G:6, VI and VII

      Ins 401.07

      RSA 400-A:15, I; 408:15 and 16

      Ins 401.08

      RSA 400-A:15, I; 415:18; 415-F:3; 420-G

      Ins 401.09

      RSA 400-A:15, I

      Ins 401.10

      RSA 400-A:15, I; 408:27-34 and 52

      Ins 401.11

      RSA 400-A:15, I; 408:29

      Ins 401.12

      RSA 400-A:15, I; 408:9; 415:1 and 6; 415-A:2; 417:3

      Ins 401.13

      RSA 400-A:15, I; RSA 400-A:37, III(d); RSA 408-D:17

      Ins 401.14

      RSA 400-A:15, I; RSA 400-A:35; RSA 400-A:37, III(d);

      RSA 408; RSA 408-A; RSA 408-D; RSA 408-E; RSA 409;

      RSA 415; RSA 415-A; RSA 415-D; RSA 415-F; RSA 415-H; RSA 420-A; RSA 420-B; RSA 420-F; RSA 420-G; RSA 420-J

      Ins 401.15

      RSA 400-A:15, I and III; 408:8 and 12; 408-A:14; 415:20

      Ins 401.16

      RSA 400-A:15, I; RSA 541-A:22, IV

      Ins 403.01

      RSA 400-A:15, I; 420-G:4-a; 420-G:4-b

      Ins 403.02

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      Ins 403.03

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      Ins 403.04

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      Ins 403.05

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      Ins 403.06

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      Ins 403.07

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      Ins 403.08

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      Ins 403.09

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      Ins 403.10

      RSA 400-A:15, I.; 420-G:4-a; 420-G:4-b

      APPENDIX D – Rules Incorporated by Reference

      Rule

      Title

      Obtain:

      Ins 401.05(c)(2)a.

      Moody’s Corporate Bond Yield Average – Monthly Averages Corporates

      Online for no cost at:

      https://www.moodys.com/

      or by writing:

      Moody's Investors Service, Inc.
      One International Place
      100 Oliver Street, Suite 1400
      Boston, MA 02110

      Ins 401.10(d)(6)a.2.

      Annuity 2000 Mortality Table

      Online for no cost at: http://mort.soa.org/

      Ins 401.10(e)(7)a.2.

      Annuity 2000 Mortality Table

      Online for no cost at: http://mort.soa.org/

   Source. #9511, eff 7-10-09

   Appendix A

   NH HealthFirst Program Benefit Summary

   Benefits

   HealthFirst Plan

   Preventive Care Services:

   Immunizations, Lead Screenings, PSA, Routine Physical Exams (including family planning, pre-natal & well child care), annual ob-gyn visits (including mammography), Routine Hearing Laboratory and an Annual Care Plan for Chronic Illnesses

   Covered in Full

   Other Office Visits:

   Primary Care Copay

   Specialist Copay

   Colonoscopy

   $20 per visit

   $50 per visit

   Subject to $250 copay

   Deductible (single family traditional)

   Coinsurance

   Max out of pocket (single/family traditional)

   Tier 1 Facilities: $2,500/$5,000

   Tier 2 Facilities: $4,000/$8,000

   None

   $5,000/$10,000

   Lifetime Maximum

   No maximum

   In/Out Patient Hospital Care

   Subject to deductible, including diagnostic lab

   Skilled Nursing & Rehab Facilities:

   SNF limited to 100 days/CY, Rehabilitation Facility limited to 60 days/CY

   Subject to deductible

   Diagnostic Labs and X-Rays:

   Labs

   X-Rays

   MRI, CT and PET Scans

   Covered in full

   Subject to deductible

   Subject to deductible

   Outpatient Surgery:

   Doctor's Office

   Hospital/Surgical Day Care

   $20/$50 per visit

   Subject to deductible

   Urgent/Emergency Room Care:

   Urgent Care Facility Copay

   Emergency Room Facility Copay

   $100 per visit for the facility charge. All other services are subject to the Tier 1 or Tier 2 deductible.

   $200 per visit

   Ambulance (medically necessary)

   Subject to deductible

   Short Term Therapy (PT, OT, ST)

   $50 per visit

   Chiropractic

   Not covered

   Mental Health/Substance Abuse Services:

   Office Visits

   Facility

   $20 per visit

   Subject to deductible

   Durable Medical Equipment:

   Limited to $3,000/Mbr/CY

   Subject to deductible

   Prescription Drugs:

   Covered medication, diabetic supplies and contraception devices purchased at a network pharmacy

   Certain maintenance drugs are available for a supply greater than 30 days.

   Maximum out-of-pocket (single/family traditional)

   Important Notes:

   If, due to medical necessity, your physician prescribes a brand drug, you pay only the formulary or non-formulary brand copay shown on this summary.

   For formulary brand and non-formulary brand at least 2 brand drugs shall be available for each covered benefit therapeutic class.

   $10 copay/generic

   $35 copay/formulary brand

   $50 copay/non-formulary brand

   No Max

   Copayment applies to each 30 day supply.

   $5,000/$10,000

   Members are required to work with a care navigator for certain tests and procedures.

   Members shall establish a relationship with a primary care provider.

   The benefit plan shall additionally cover the following services:

   Screening and Brief Intervention for Alcohol and Drug Abuse

   Body Mass Index Screening

   After-hours care

   Appendix B

   NH HealthFirst Wellness Design

   Employees and Spouses Reward Per Adult

   Year One

   Establish and continue relationship with a Primary Care Provider

   Complete a Health Risk Questionnaire

   Remain Smoke-Free or Participate in a Smoking Cessation Program

   Get a BMI measurement and Blood Pressure reading, and maintain a BMI of <25 and BP of <140/90 or participate in a health management program

   Get your Blood Glucose and Cholesterol levels checked, and maintain acceptable levels or participate in a health management program

   $200 for Meeting All Requirements

   Year One -

   Within 8 Months of Employee's Effective Date

   Submit a Wellness Verification Form for Year 2 Deductible Credit

   Year Two

   Complete a Health Risk Questionnaire

   Remain Smoke-Free or Participate in a Smoking Cessation Program

   Maintain a BMI of <25 and a BP of <140/90 or participate in a health management program

   Maintain acceptable Blood Glucose and Cholesterol levels or participate in a health management program

   $1,000 Deductible Credit for Meeting All Requirements

   Year Two - Within 8 Months of Benefit Year Start Date

   Submit a Wellness Verification Form for Year 3 Deductible Credit

   Year Three

   Complete Health Risk Questionnaire

   Remain Smoke-Free or Participate in Smoking Cessation Program

   Maintain a BMI of <25 and BP of <140/90 or participate in a health management program

   Maintain acceptable Blood Glucose and Cholesterol levels or participate in a health management program

   $1,000 Deductible Credit for Meeting All Requirements