CHAPTER 345

SB 178-FN - FINAL VERSION

4/3/97 0621s

20may97.....1425h

6/10/97 0050eba

1997 SESSION

97-1028

08/09

SENATE BILL 178-FN

AN ACT regulating managed care systems of health care delivery.

SPONSORS: Sen. Squires, Dist 12

COMMITTEE: Insurance

AMENDED ANALYSIS

This bill requires health carriers to:

1. Provide certain credentialing information about its health care professionals.

2. Establish written procedures for receiving and resolving grievances.

3. Establish written utilization review processes if they do not contract with a utilization review entity.

4. Provide an adequate network of providers.

5. Establish and maintain a written quality assessment and quality improvement program.

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Explanation: Matter added to current law appears in bold italics.

Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

4/3/97 0621s

20may97.....1425h

6/10/97 0050eba

97-1028

08/09

STATE OF NEW HAMPSHIRE

In the Year of Our Lord One Thousand Nine Hundred and Ninety-Seven

AN ACT regulating managed care systems of health care delivery.

Be it Enacted by the Senate and House of Representatives in General Court convened:

345:1 New Chapter; Managed Care Law. Amend RSA by inserting after chapter 420-I the following new chapter:

CHAPTER 420-J

MANAGED CARE LAW

420-J:1 Purpose and Intent. The purpose and intent of this chapter is to provide standards for certain fundamental operations of licensed entities providing health insurance through a managed care system of health care delivery and reimbursement. The establishment of these standards will ensure regulatory and quality consistency among the several and various licensees offering managed care type benefit plans and will enable consumers to make informed decisions in their relationships with managed care insurers. This chapter is intended to apply only to those insurers offering managed care plans. It is not intended to apply to traditional indemnity systems of reimbursement and fee-for-service forms of health care expense coverage. Health insurers which do not significantly limit covered persons' choices of providers shall not be subject to this chapter.

420-J:2 Applicability and Scope. This chapter shall apply to all health carriers offering a managed care plan in this state.

420-J:3 Definitions. In this chapter:

I. "Adverse determination" means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service is therefore denied, reduced, or terminated.

II. "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting.

III. "Appeals procedure" means a formal process whereby a covered person, a representative of a covered person, attending physician, facility or health care provider can contest an adverse determination rendered by the health carrier or its designee utilization review organization, which results in the denial, reduction or termination of a requested health care service.

IV. "Case management" means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.

V. "Certification" means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness.

VI. "Clinical peer" means a physician or other health care professional who holds a non-restricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. A "clinical peer" includes a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the health care professional who made the initial decision.

VII. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health carrier to determine the necessity and appropriateness of health care services.

VIII. "Commissioner" means the insurance commissioner.

IX. "Concurrent hospital review" means utilization review conducted during a patient's inpatient stay or course of treatment.

X. "Consumer" means someone in the general public who may or may not be a covered person or a purchaser of health care including employers.

XI. "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan.

XII. "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.

XIII. "Credentialing verification" is the process of obtaining and verifying information about a health care professional, and evaluating that health care professional, when that health care professional applies to become a participating provider in a managed care plan offered by a health carrier.

XIV. "Discharge planning" means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.

XV. "Emergency medical condition" means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy.

XVI. "Emergency services" means health care services that are provided to an enrollee, insured, or subscriber in a licensed hospital emergency facility by a provider after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity that the absence of immediate medical attention could be expected to result in any of the following:

(a) Serious jeopardy to the patient's health.

(b) Serious impairment to bodily functions.

(c) Serious dysfunction of any bodily organ or part.

XVII. "Facility" means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

XVIII. "Grievance" means a written complaint submitted by or on behalf of a covered person regarding the:

(a) Availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;

(b) Claims payment, handling, or reimbursement for health care services; or

(c) Matters pertaining to the contractual relationship between a covered person and a health carrier.

XIX. "Health benefit plan" means a policy, contract certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

XX. "Health care professional" means a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with state law.

XXI. "Health care provider" or "provider" means a health care professional or facility.

XXII. "Health care services" or "health services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.

XXIII. "Health 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 health care services, including an insurance company, a health maintenance organization, a hospital service corporation, a medical service corporation, a nonprofit health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services.

XXIV. "Intermediary" means a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network.

XXV. "Managed care plan" means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier.

XXVI. "Network" means the group of participating providers providing services to a managed care plan.

XXVII. "Participating provider" means a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier.

XXVIII. "Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing.

XXIX. "Prospective review" means utilization review conducted prior to an admission or a course of treatment.

XXX. "Quality assessment" means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups, or populations.

XXXI. "Quality improvement" means the effort to improve the processes and outcomes related to the provision of health care services within the health benefit plan.

XXXII. "Retrospective review" means a review of medical necessity conducted after services have been provided to a patient, but does not include a claims settlement process including an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, adjudication for payment, or whether a service is a covered benefit under the plan.

XXXIII. "Second opinion" means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health service to assess the clinical necessity and appropriateness of the initial proposed health service.

XXXIV. "Utilization review" means a set of formal techniques designed to monitor the use of or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services procedures, providers, or facilities. Techniques and methods may include ambulatory care review, case management, concurrent hospital review, discharge planning, prehospital admission certification, preinpatient service eligibility certification, prospective review, second opinion, or retrospective review.

XXXV. "Utilization review entity" means an entity, subject to licensure pursuant to RSA 420-E, that conducts utilization review, other than a health carrier performing review for its own health plans.

420-J:4 Credentialing Verification Procedures.

I. A health carrier shall:

(a) Establish written policies and procedures for credentialing verification of all health care professionals with whom the health carrier contracts and apply these standards consistently.

(b) Verify the credentials of a health care professional before the health care professional with whom the health carrier is contracting provides health services to covered persons. The medical director of the health carrier or other designated health care professional shall have responsibility for, and shall participate in, health care professional credentialing verification.

(c) Establish a credentialing verification committee consisting of licensed physicians and other health care professionals to review credentialing verification information and supporting documents and make decisions regarding credentialing verification.

(d) Make available for review by the applying health care professional upon written request all application and credentialing verification policies and procedures.

(e) Retain records and documents relating to a health care professional's credentialing verification process for 7 years.

(f) Keep confidential all information obtained in the credentialing verification process, except as otherwise provided by law.

II. A health carrier shall obtain verification of at least the following information about the applicant:

(a) Graduation from health care professional school.

(b) Completion of post graduate training (if applicable).

(c) The health care professional's license history in this and all other states.

(d) The health care professional's malpractice history.

(e) The health care professional's practice history.

(f) Current license, certificate of authority, or registration to practice a health care profession in New Hampshire.

(g) Current level of professional liability coverage (if applicable).

(h) Status of hospital privileges (if applicable).

(i) Specialty board certification status (if applicable).

(j) Current Drug Enforcement Agency (DEA) registration certificate (if applicable).

III. A health carrier shall thereafter obtain, at least every 2 years, verification of a participating provider's:

(a) Current license, certificate of authority or registration to practice a health care profession in New Hampshire.

(b) Current level of professional liability coverage (if applicable).

(c) Status of hospital privileges (if applicable).

(d) Current DEA registration certificate (if applicable).

(e) Specialty board certification status (if applicable).

IV. A health carrier shall require all participating providers to notify the health carrier of changes in the status of any items listed in this section at any time, and shall identify for participating providers the individual or department to whom they should report such changes.

V. Whenever a health carrier contracts to have another entity perform the credential verification functions required by this section or applicable rules, the commissioner shall hold the health carrier responsible for monitoring the activities of the entity with which it contracts and for ensuring that the requirements of this section and applicable rules are met.

VI. Nothing in this section shall be construed to require a health carrier to select a health care professional as a participating provider solely because the health care professional meets the health carrier's credentialing verification standards, or to prevent a health carrier from utilizing separate or additional criteria in selecting the health care professionals with whom it contracts.

420-J:5 Grievance Procedures.

I. A health carrier shall establish written procedures for receiving and resolving grievances from covered persons concerning adverse determinations and other matters and shall file and maintain the following:

(a) A copy of the grievance procedures, including all forms used to process a grievance shall be filed with the commissioner. Any subsequent material modifications to the documents also shall be filed. In addition, a health carrier shall file annually with the commissioner, as part of its annual report required by RSA 420-J:5, VII, a certificate of compliance stating that the health carrier has established and maintains, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter.

(b) A health carrier shall maintain written records documenting all grievances received during a calendar year, a general description of the reason for the grievance, the name of the covered person for whom the grievance was filed, the dates of the grievance and the date of resolution of each level of the grievance. These records shall be maintained in a manner that is reasonably clear and accessible to the commissioner.

` II. A health carrier shall provide to consumers:

(a) A description of the grievance procedure for adverse determinations and other matters which shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons.

(b) A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner.

(c) Upon written denial of a requested medical service or claim by the health carrier, a statement of the covered person's right to access the internal grievance process.

(d) Staff assistance in filing a grievance.

III. A health carrier shall provide first level grievance review procedures as follows:

(a) A grievance concerning any matter except an adverse determination may be submitted by a covered person or a covered person's representative. A health carrier shall issue a written decision to the covered person or the covered person's representative within 20 business days after receiving a grievance and all information necessary for the health carrier's review of the grievance. The person or persons reviewing the grievance shall not be the same person or persons who made the initial determination denying a claim or handling the matter that is the subject of the grievance. If a decision cannot be made within 20 business days due to circumstances beyond the carrier's control, the health carrier may take up to an additional 10 business days to issue a written decision.

(b) The written decision issued pursuant to the procedures described in subparagraph (a), shall contain:

(1) The titles and qualifying credentials of the persons participating in the first level grievance review process.

(2) A statement of the reviewers' understanding of the covered person's grievance.

(3) The reviewers' decision in clear terms and the contract basis or medical rationale in sufficient detail for the covered person to respond further to the health carrier's position.

(4) A reference to the evidence or documentation used as the basis for the decision.

(5) A description of the process to obtain a second level grievance review of a decision, and the written procedures governing a second level review, including any required time frame for review.

IV. A health carrier shall provide standard review of adverse determinations as follows:

(a) Written procedures for a standard review of an adverse determination shall be available to a covered person and to the provider acting on behalf of a covered person. For purposes of this section, covered person includes the representative of a covered person.

(b) Standard reviews shall be evaluated by an appropriate clinical peer or peers in the same or similar specialty as would typically manage the case being reviewed. The clinical peer shall not have been involved in the initial adverse determination.

(c) A health carrier shall issue a written decision on review of an adverse determination that complies with the requirements of RSA 420-J:5, III(a) and RSA 420-J:5, III(b) and which also includes instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination.

(d) In any case where the standard review process does not resolve a difference of opinion between the health carrier and the covered person or the provider's acting on behalf of the covered person, the covered person or the provider acting on behalf of the covered person may submit a written grievance, unless the provider is prohibited from filing a grievance by federal or other state law. A health carrier shall review it as a second level grievance.

V. A health carrier shall provide second level grievance review procedures as follows:

(a) A second level grievance review panel shall be established to give those covered persons who are dissatisfied with the first level grievance review decision the option to request a second level review.

(1) With respect to a second level review of a grievance concerning an adverse determination, a health carrier shall appoint a second level grievance review panel for each grievance.

(2) A majority of the panel shall be comprised of persons who were not previously involved in the grievance. A health carrier shall provide at least one clinical peer who has appropriate expertise to review a grievance involving an adverse determination.

(3) The review panel shall issue a written decision to the covered person within 5 business days of completing the review meeting. Upon concurrence of the covered person, a copy of the decision shall be forwarded to the insurance department. The decision shall include the titles of the members of the review panel; a statement of the review panel's understanding of the nature of the grievance, including issues raised by the covered person, and all pertinent facts; the rationale for the review panel's decision; reference to evidence or documentation considered by the review panel in making the decision; if an adverse decision is made, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination; and a statement of the covered person's right to file an external appeal as provided in RSA 420-J:5, VIII.

(b) Whenever a covered person requests the opportunity to appear in person before authorized representatives of the health carrier, a health carrier's procedures for conducting a second level grievance review shall include the following:

(1) The review panel shall schedule and hold a review meeting within 45 business days of receiving a request from a covered person for a second level review. The covered person shall be notified in writing at least 15 business days in advance of the review date.

(2) Upon request of a covered person, a health carrier shall provide to the covered person all relevant information that is not confidential or privileged.

(3) The review panel shall issue a written decision to the covered person within 5 business days of completing the review meeting. The decision shall include the titles of the members of the review panel; a statement of the review panel's understanding of the nature of the grievance and all pertinent facts; the rationale for the review panel's decision; reference to evidence or documentation considered by the review panel in making the decision; if an adverse decision is made, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination; and a statement of the covered person's right to file an external appeal as provided in RSA 420-J:5, VIII.

VI. A health carrier shall provide expedited grievance review procedures as follows:

(a) A health carrier shall establish written procedures for the expedited review of a grievance in a situation where the time frame of the standard grievance procedures set forth in this chapter would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function. Expedited reviews shall be evaluated by an appropriate clinical peer or peers in the same or similar specialty as would typically manage the case being reviewed. The clinical peer or peers shall not have been involved in the initial adverse determination.

(b) A health carrier shall provide expedited review to all requests concerning an admission, availability of care, continued stay or health care service for a covered person who has received emergency services but has not been discharged from a facility. Adverse determinations made on a retrospective basis may only be appealed through the standard grievance process. All necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or the provider acting on behalf of the covered person by telephone, facsimile or the most expeditious method available.

(c) In an expedited review, a health carrier shall make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the review is commenced. If the expedited review is a concurrent review determination, the service shall be continued without liability to the covered person until the covered person has been notified of the determination. A health carrier shall provide written confirmation of its decision concerning an expedited review within 2 business days of providing notification of that decision, if the initial notification was not in writing.

(d) A health carrier shall provide reasonable access, not to exceed one business day after receiving a request for an expedited review, to a clinical peer who can perform the expedited review.

(e) In any case where the expedited review process does not resolve a difference of opinion between the health carrier and the covered person or the provider acting on behalf of the covered person, the covered person or the provider acting on behalf of the covered person may submit a written grievance, unless the provider is prohibited from filing a grievance by federal or other state law. A health carrier shall review it as a second level grievance. In conducting the review, the health carrier shall adhere to time frames that are reasonable under the circumstances.

VII. Annual reports shall be made to the insurance commissioner regarding plan complaints, adverse determinations, and prior authorization statistics in such form and containing such information as the commissioner may by rule or otherwise prescribe.

VIII. An external process at the department shall be available to ensure that the health carrier has provided to the covered person grievance procedures consistent with this section and any additional procedures of the health carrier described pursuant to RSA 420-J:5, II. A written decision following the external review process shall be made available to the covered person.

IX. The insurance commissioner shall issue a report to the governor and the legislature on or before November 1, of each year, relative to external appeals under paragraph VIII. The report shall provide detailed information regarding the number and status of grievance appeals filed with the department.

420-J:6 Utilization Review.

I. Each health carrier which does not contract with a utilization review entity shall establish written procedures for carrying out its utilization review processes and shall file such procedures with the commissioner on or before April 1 of each year. Such carriers shall conform to the standards of either the utilization Review Accreditation Commission or the National Committee for Quality Assurances and are subject to all applicable rules issued pursuant to RSA 420-E:7.

II. The written procedures shall describe the categories of health care personnel that perform utilization review activities and whether or not such individuals are licensed in this state, and shall address at a minimum, second opinion programs; prehospital admission certification; preinpatient service eligibility certification; and concurrent hospital review to determine appropriate length of stay; as well as the process used by the health carrier to preserve confidentiality of medical information.

III. Notification of utilization review determinations shall be provided to the covered person or other party designated by the covered person within a time period that does not compromise the covered person's health.

IV. All contracts with utilization review entities shall be available to the commissioner upon request.

420-J:7 Network Adequacy.

I. A health carrier shall maintain a network that is sufficient in numbers, types, and geographic location of providers to ensure that all services to covered persons will be accessible without unreasonable delay.

II. The commissioner shall adopt rules under RSA 541-A for a health carrier's network adequacy. Such rules shall establish, but not be limited to:

(a) Waiting times for appointments for non-emergency care.

(b) Choice of and access to providers for specialty care, specifically addressing the needs of the chronically ill, mentally ill, developmentally disabled or those with a life threatening illness.

(c) Standards for geographic accessibility.

(d) Hours of operation for the carrier, including any entities performing prior approval or pre-authorization functions.

III. The health carrier shall keep, at its place of business, a detailed description of the health carrier's compliance with rules adopted pursuant to RSA 420-J:7, II as well as its procedures for monitoring network adequacy.

IV. Annually, the health carrier shall submit a report to the commissioner demonstrating compliance with the rules for network adequacy.

420-J:8 Provider Contract Standards.

I. Every contract between a health carrier and a participating provider shall set forth a hold harmless provision specifying protection for covered persons. This provision shall include language substantially as follows:

(a) Provider agrees that in no event, including but not limited to nonpayment by the health carrier or intermediary, insolvency of the health carrier or intermediary, or breach of this agreement, shall the provider bill, charge, collect a deposit from, seek payment or reimbursement from, or have recourse against a covered person or a person acting on behalf of the covered person (other than the health carrier or intermediary) for services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles, or copayments, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons. Nor does this agreement prohibit a provider and a covered person from agreeing to continue services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier may not cover or continue to cover a specific service or services. Except as provided in this chapter, this agreement does not prohibit the provider from pursuing any available legal remedy.

(b) Provider further agrees that:

(1) This provision shall survive the termination of this agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the covered person; and that

(2) This provision supersedes any oral or written contrary agreement now existing or hereafter entered into between provider and covered person or persons acting on their behalf.

(c) Any modifications, additions or deletions to the provisions of this section shall become effective on a date no earlier than 15 business days after the commissioner has received written notice of such proposed changes.

II. The execution of a contract by a health carrier shall not relieve the health carrier of its liability to any person with whom it has contracted for the provision of services, nor of its responsibility for the compliance with any law or rule.

III. The health carrier shall maintain provider and intermediary contracts at its principal place of business in this state, or the health carrier shall have access to all contracts and provide copies to facilitate regulatory review upon 15 business days prior written notice from the commissioner.

IV. No contract between a health carrier and a physician, for the purpose of delineating the rights and obligations of the parties within the provider network, shall limit the liability of the health carrier for any actions of the physician for which the health carrier might otherwise be liable.

V. No contract between a health carrier and a health care provider shall limit what information such health care provider may disclose to patients or to prospective patients regarding the provisions, terms, or requirements of the health carrier's products as they relate to the needs of such provider's patients except for trade secrets of significant competitive value.

420-J:9 Quality Assessment, Quality Improvement, and Reporting.

I. A health carrier shall:

(a) Establish and maintain a written quality assessment program designed to collect and evaluate information regarding the quality of the health care processes used by the health carrier and the health outcomes of its covered persons.

(b) Establish and maintain a written quality improvement program structured to identify opportunities to improve care, practices that result in improved health care outcomes, problematic utilization patterns, and those providers who may be responsible for either exemplary or problematic patterns of utilization.

II. The quality improvement program shall at a minimum include: a statement of the objectives of the program; a description of how the health carrier will conduct its quality improvement program; the lines of authority and accountability including data collection responsibilities; evaluation tools; performance improvement activities; and an annual effectiveness review.

III. The chief medical officer or clinical director of the health carrier shall have primary responsibility for the quality assessment and quality improvement activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter relative to quality assessment and quality improvement are met.

IV. A health carrier shall:

(a) Assure that participating providers have an opportunity to participate in developing, implementing, and evaluating the quality assessment and quality improvement programs.

(b) Maintain at its principal office a copy of the quality assessment program and the quality improvement program which shall be available for inspection by the commissioner or designee at any time during the health carrier's regular business hours.

(c) Certify to the commissioner on or before March 1 of each year that its quality assessment program and its quality improvement program meet the requirements of this chapter and any applicable rules.

(d) Notify the commissioner on or before March 1 of each year of its accreditation by any external accrediting agencies and shall provide a contact person and a phone number for consumer phone calls.

420-J:10 Confidentiality of Insurer Records.

I. Data or information pertaining to the diagnosis, treatment, or health of a covered person obtained from the person or from a provider by a health carrier is confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this chapter and as allowed by any applicable state or federal law; or upon the express consent of the covered person; or pursuant to statute or court order for the production of evidence or the discovery thereof; or in the event of a claim or litigation between the covered person and the health carrier where the data or information is pertinent, regardless of whether the information is in the form of paper, is preserved on microfilm, or is stored in a computer retrievable form.

II. If any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant is disclosed pursuant to paragraph I, the health carrier making this required disclosure shall not be liable for the disclosure or any subsequent use or misuse of the data.

III. A health carrier shall be entitled to claim any statutory privileges against disclosure that the provider who furnished the information to the health carrier is entitled to claim.

IV. The records of the quality assessment program, and the information considered by any quality committee and the records of its actions and proceedings shall be confidential and not subject to subpoena or order to produce except in proceedings before the department or other appropriate state licensing or certifying agency, or in an appeal, if permitted, from the quality committee's findings or recommendations. This section shall not be construed to affect the confidentiality of any other proprietary record of a health carrier.

420-J:11 Confidentiality of Insurance Department Records. All information, documents and copies thereof obtained by or disclosed to the commissioner or any other person in the course of an examination or investigation made pursuant to RSA 400-A:37, and, unless otherwise provided in this chapter, all information reported and maintained pursuant to this chapter shall be given confidential treatment and shall not be made public by the commissioner or any other person, except to insurance departments of other states, unless the commissioner after consultation with the affected parties, determines that the interest of policyholders, shareholders, or the public will be served by the publication thereof, in which event the commissioner may disclose all or any part thereof in such manner as the commissioner may deem appropriate.

420-J:12 Rulemaking Authority. The commissioner may adopt such rules, under RSA 541-A, and issue such orders as may be necessary to carry out the purposes and provisions of this chapter.

420-J:13 Severability. If any provision of this chapter or the application thereof to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the chapter which can be given effect without the invalid provisions or applications, and to this end the provisions of this chapter are severable.

420-J:14 Penalties. Any health carrier or other organization violating any of the provisions of this chapter may be subject to an administrative fine not to exceed $2,500 per violation. The commissioner may also suspend or revoke the certificate of authority or license of a health carrier or other organization for any violation of this chapter or the failure to comply with an order of the commissioner issued under this chapter.

345:2 Adding Reference. Amend RSA 415-E:13, II(a) to read as follows:

(a) Has violated any lawful order or rule of the commissioner, provision of this chapter, RSA 420-J, or relevant provision of RSA 161-H.

345:3 Adding Reference. Amend RSA 419:1 to read as follows:

419:1 Definition. A hospital service corporation is defined as a nonprofit sharing corporation without capital stock organized under the laws of the state for the purpose of establishing, maintaining, and operating a plan whereby hospital care may be provided, at the expense of the corporation, to subscribers to said plan. Every such corporation shall be governed by this chapter, RSA 420-J, and the relevant provisions of RSA 161-H and shall be exempt from the provisions of this title except as herein otherwise provided.

345:4 Adding Reference. Amend RSA 420:14 to read as follows:

420:14 Rules. The provisions of RSA 415-A and RSA 420-J shall apply to medical service corporations.

345:5 Adding Reference. Amend RSA 420-A:1, II to read as follows:

II. Every such corporation shall be governed by this chapter and shall be exempt from this title except for the provisions of RSA 400-A:39, RSA 415-A, RSA 415-F, RSA 415:18, VII(g), RSA 415:18, VII-a, RSA 415:22, RSA 419, [and] RSA 420, and RSA 420-J; provided, however, if any provisions of RSA 419 or RSA 420 are inconsistent with this chapter, the provisions of this chapter shall prevail. Every such corporation and its agents shall be subject to the fees prescribed for hospital and medical service corporations under RSA 400-A:29, VII.

345:6 Adding Reference. Amend RSA 420-B:20, III to read as follows:

III. The requirements of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 415:18, VII (g), RSA 415:18, VII-a, RSA 415-A, [and] RSA 415-F, and RSA 420-J shall apply to health maintenance organizations.

345:7 New Section; Other Applicable Statutes. Amend RSA 420-C by inserting after section 7 the following new section:

420-C:8 Other Applicable Statutes. Preferred provider agreements and health benefit plans subject to this chapter shall also be governed by the provisions of RSA 420-J.

345:8 Repeal. The following are repealed:

I. RSA 420-B:12, VIII and IX, relative to prohibiting contracts between health maintenance organizations and health care providers which limit the liability of the organization for the actions of the physician and which limit the information which a provider may disclose to patients about the contract.

II. RSA 420-B:26, relative to quality assurance programs.

III. RSA 420-E:2, II, relative to the registration of certain entities exempt from licensure as utilization review entities.

345:9 Applicable Statutes. Amend RSA 420-A:2 to read as follows:

420-A:2 Applicable Statutes. Every health service corporation shall be governed by this chapter and the relevant provisions of RSA 161-H, and shall be exempt from this title except for the provisions of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 415-A, RSA 415-F, RSA 415:6, II(4), RSA 415:18, V, RSA 415:18, VII(g), RSA 415:18, VII-a, RSA 415:18-a, RSA 415:22, RSA 417, RSA 417-E, 420-J, and all applicable provisions of title XXXVII wherein such corporations are specifically included. Every health service corporation and its agents shall be subject to the fees prescribed for health service corporations under RSA 400-A:29, VII.

345:10 Definition of Health Carrier. Amend RSA 420-J:3, XXIII to read as follows:

XXIII. "Health 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 health care services, including an insurance company, a health maintenance organization, [a hospital service corporation, a medical service corporation,] a [nonprofit] health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services.

345:11 Contingency. If HB 261 becomes law, sections 3-5 of this act shall not take effect and sections 9 and 10 of this act shall take effect January 1, 1998, at 12:01 a.m. If HB 261 does not become law, sections 3-5 shall take effect January 1, 1998, and sections 9 and 10 shall not take effect.

12 Effective Date. This act shall take effect January 1, 1998.

(Approved: June 23, 1997)

(Effective Date: January 1, 1998)

LBAO

97-1028

1/15/97

FISCAL NOTE

AN ACT regulating managed care systems of health care delivery.

FISCAL IMPACT:

The Insurance Department indicated that state restricted revenue and expenditures will increase by $31,042 in FY 1998, by $62,937 in FY 1999, by $65,708 in FY 2000 and by $68,220 in FY 2001. There will be no fiscal impact on county and local revenues or expenditures.

METHODOLOGY:

The Department states it will need to hire an Examiner II (LG 31) to manage the responsibilities associated with this bill. Additional costs will be for the purchase of a file cabinet at $250 and annual travel expense of $5,000. All costs will be charged against insurance companies as provided by RSA 400-A:39.