TITLE XXXVII
INSURANCE

Chapter 415-A
STANDARDS FOR ACCIDENT AND HEALTH INSURANCE

Section 415-A:1

    415-A:1 Definitions. –
In this chapter:
I. "Accident and health insurance" means insurance written under RSA 415 and coverages written under RSA 415-E, RSA 420-A, RSA 420-B, and RSA 420-C. For purposes of this chapter, multiple-employer welfare arrangements, nonprofit health service corporations, health maintenance organizations, and preferred provider agreements subject to RSA 420-C shall be deemed to be engaged in the business of insurance.
I-a. "Claim denial" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.
I-b. "Claim involving urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:
(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
(b) In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
I-c. "Claimant's representative" shall mean an individual authorized by a claimant in writing to pursue a claim or appeal on the claimant's behalf.
I-d. "Date of enrollment" means the first day of coverage under the plan, or, if there is a waiting period, the first day of the waiting period, which is typically the first day of work.
I-e. "Employee benefit plan" means employee welfare benefit plans described in section 3 of the Employee Retirement Income Security Act of 1974, 29 U.S.C., section 1002 and not exempted under section 4(b) of this Act, 29 U.S.C. section 1003, other than those plans, or portions of them, that provide disability benefits.
II. "Form" means policies, contracts, riders, endorsements, and applications as provided in RSA 415, RSA 415-E, RSA 420-A, RSA 420-B, and RSA 420-C.
III. "Policy" means the entire contract between the insurer and the insured, including the policy, riders, certificates, endorsements and the application, if attached, and also includes subscriber contracts issued by nonprofit hospital and medical service associations.
IV. "Post-service claim" means any claim for a health benefit to which the terms of the plan do not condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining the medical care. "Post-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.
V. "Pre-service claim" means any claim for a benefit under a health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care. "Pre-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.

Source. 1975, 494:1. 1995, 112:14. 1997, 190:9. 2001, 207:1, 2. 2003, 175:1, 2. 2007, 289:8, eff. Jan. 1, 2008. 2016, 111:4, eff. May 20, 2016.

Section 415-A:2

    415-A:2 Standards for Policy Provisions. –
I. The commissioner shall adopt rules to establish specific standards, including standards of full and fair disclosure, that set forth the manner, content and required disclosure for the sale of all policies of accident and health insurance which shall be in addition to, and in accordance with, applicable laws of this state, including RSA 415, which may cover but shall not be limited to:
(a) Terms of renewability.
(b) Initial and subsequent conditions of eligibility.
(c) Nonduplication of coverage provisions.
(d) Coverage of dependents.
(e) Preexisting conditions.
(f) Termination of insurance.
(g) Probationary periods.
(h) Limitations.
(i) Exceptions.
(j) Reductions.
(k) Elimination periods.
(l) Requirements for replacement.
(m) Recurrent conditions.
(n) The definition of terms including but not limited to the following: hospital, accident, sickness, injury, physician, accidental means, total disability, partial disability, nervous disorder, guaranteed renewable and noncancellable.
II. The commissioner may adopt rules prohibiting provisions which may be misleading or unreasonably confusing in connection with either the purchase of insurance or the settlement of claims; prohibiting provisions which may be contrary to the health care needs of the public or coverage which is so limited in scope as to be of no significant economic value to the holders thereof; and prohibiting provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair and unfairly discriminatory to the policyholder, certificate holder or subscriber, any other person insured under the policy, or the beneficiary.

Source. 1975, 494:1, eff. Aug. 28, 1975.

Section 415-A:2-a

    415-A:2-a Insurance Contracts; Welfare Recipients. – No accident or health insurance policy issued or renewed after August 28, 1981 shall contain any provision denying or limiting insurance benefits because services are rendered to an insured or a dependent who is eligible for or who receives medical assistance under RSA 167 or RSA 161.

Source. 1981, 502:3, eff. Aug. 28, 1981.

Section 415-A:2-b

    415-A:2-b Use of Term Physician in Provider Contracts. – No contract shall use the term physician for the purpose of allowing a health care insurer to avoid contracting with other health care professionals for health care services. A physician shall mean a person licensed to practice medicine under RSA 329. Nothing in this section shall be construed to require a health care insurer to contract with a health care provider.

Source. 1998, 377:1, eff. Aug. 25, 1998.

Section 415-A:3

    415-A:3 Minimum Standards for Benefits. –
I. The commissioner shall adopt rules to establish minimum standards for benefits under each of the following categories of coverage:
(a) Basic hospital expense coverage.
(b) Basic medical-surgical expense coverage.
(c) Basic hospital/medical-surgical expense coverage.
(d) Hospital confinement indemnity coverage.
(e) Major medical expense coverage.
(f) Basic medical expense coverage.
(g) Disability income protection coverage.
(h) Accident only coverage.
(i) Specified disease coverage.
(j) Specified accident coverage.
(k) Limited benefit health coverage.
(l) Student major medical expense coverage.
II. Nothing in this section shall preclude the issuance of any policy or contract which combines 2 or more of the categories of coverage enumerated in subparagraphs I(a) through (l).
III. No policy shall be delivered or issued for delivery in this state which does not meet the prescribed minimum standards for the categories of coverage listed in subparagraphs I(a) through (l) which are contained within the policy unless the commissioner finds such policy will be in the public interest and such policy meets the requirements set forth in RSA 415. The commissioner may disapprove specific policy forms pursuant to RSA 415:2 and 3.
IV. The commissioner shall prescribe the method of identification of policies and contracts based upon coverages provided and may issue rules prescribing reasonable standardization and simplification of coverage to facilitate understanding and comparisons.

Source. 1975, 494:1. 2002, 207:5, 6. 2010, 188:3, 4, eff. Aug. 20, 2010.

Section 415-A:4

    415-A:4 Outline of Coverage. –
I. In order to provide for full and fair disclosure in the sale of all policies of accident and health insurance, no such policy shall be delivered or issued for delivery in this state unless:
(a) In the case of a direct response insurance product, the outline of coverage described in paragraph III accompanies the policy; and
(b) In all other cases, the outline of coverage described in paragraph III is delivered to the applicant at the time application is made and an acknowledgment of receipt or certificate of delivery of such outline is provided the insurer with the application.
II. In the event the policy is issued on a basis other than that applied for, the outline of coverage properly describing the policy must accompany the policy when it is delivered and clearly state that it is not the policy for which application was made.
III. The commissioner shall prescribe the format and content of the outline of coverage required by paragraph I. "Format" means style, arrangement and overall appearance, including such items as the size, color and prominence of type and the arrangement of text and captions. Such outline of coverage shall include a:
(a) Statement identifying the applicable categories of coverage provided by the policy or contract as prescribed in RSA 415-A:3.
(b) Description of the principal benefits and coverage provided in the policy or contract.
(c) Statement of the exceptions, reductions and limitations contained in the policy or contract.
(d) Statement of the renewal provisions including any reservation by the insurer or nonprofit hospital or medical service association of a right to change premiums.
(e) Statement that the outline is a summary of the policy or contract issued or applied for and that the policy or contract should be consulted to determine governing contractual provisions.
(f) Statement that a maternity benefits rider will be made available at the insured's request, if maternity care is not covered under the policy. Nothing in this subparagraph shall be construed to apply to supplemental health insurance and disability insurance policies.

Source. 1975, 494:1. 1993, 196:2, eff. Jan. 1, 1994.

Section 415-A:4-a

    415-A:4-a Minimum Standards for Claim Review; Accident and Health Insurance. –
Any carrier that offers group health plans and employee benefit plans shall establish and maintain written procedures by which a claimant may obtain a determination of claims and by which a claimant may appeal a claim denial.
I. The procedures for determination of a claim shall meet the following minimum standards:
(a) The plan shall maintain a toll-free telephone number to ensure that a representative of the plan shall be accessible by telephone to insureds, patients, and claimant's representatives as required to meet the response times specified herein.
(b) Clinical review criteria considered or utilized in making claim benefit determinations shall be:
(1) Developed with input from appropriate practitioners with professional knowledge or clinical expertise in the area being reviewed;
(2) Updated at least biennially and as new treatments, applications, and technologies emerge;
(3) Developed in accordance with the standards of national accreditation entities;
(4) Based on current, nationally accepted standards of medical practice; and
(5) If practicable, evidence-based.
(c) The notification of a claim denial shall be communicated in writing or by electronic means and shall include:
(1) The specific reason or reasons for the determination and shall refer to the specific provision of the policy or plan on which the determination is based;
(2) A statement of the claimant's or the representative of the claimant's right to access the internal grievance process and the process for obtaining external review;
(3) If the claim denial is based upon a determination that the claim is experimental or investigational or not medically necessary or appropriate:
(A) The name and credentials of the carrier or other licensed entity, the medical director, including board status and the state or states where the person is currently licensed. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person; and
(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant's specific medical circumstances;
(4) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the benefit determination, a statement that such rule, guideline, protocol, or other similar provision was relied upon in making the claim denial;
(5) If clinical review criteria were relied upon in making the benefit determination, a statement that such clinical review criteria were relied upon in making the claim denial. The recitation of the terms of the clinical review criteria required under RSA 415-A:4-a(c)(3)(B) shall be accompanied by the following notice: "The clinical review criteria provided to you are used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract;"
(6) A description of the plan's grievance procedures and the time limits applicable to such procedures. In the case of a denial of a benefit concerning a claim involving urgent care or in the case of a denial of a claim related to continuation of an ongoing course of treatment for a person who has received emergency services, but who has not been discharged from a facility, a description of the expedited review applicable to such a claim shall be included in the determination. For all other claim benefit determinations, a description of the grievance process shall be specifically described in the determination.
II. Notification of a claim denial shall be made within the following time periods:
(a) The determination of a claim involving urgent care shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours after receipt of the claim, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable. In the case of such failure, the licensee shall notify the claimant or claimant's representative within 24 hours of receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. The claimant or the claimant's representative shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Thereafter, notification of the benefit determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.
(b) The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim, provided that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment.
(c) The determination of all other claims for preservice benefits shall be made within a reasonable time period appropriate to the medical circumstances, but in no event more than 15 days after receipt of the claim. This period may be extended one time by the licensee for up to 15 days; provided, that the licensee both determines that such an extension is necessary due to matters beyond the control of the licensee and notifies the claimant or claimant's representative, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the licensee expects to render a decision. If such an extension is necessary due to a failure of the claimant or claimant's representative to provide sufficient information to determine whether, or to what extent, benefits are covered as payable, the notice of extension shall specifically describe the required additional information needed, and the claimant or claimant's representative shall be given at least 45 days from receipt of the notice within which to provide the specified information. Notification of the benefit determination following a request for additional information shall be made as soon as possible, but in no case later than 15 days after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.
(d) The determination of a post-service claim shall be made within 30 days of the date of filing. In the event the claimant fails to provide sufficient information to determine the claim, the carrier shall notify the claimant within 15 days as to what additional information is required to process the claim and the claimant shall be given at least 45 days to provide the required information. The 30-day period for claim determination shall be tolled until such time as the claimant submits the required information.
III. Any carrier or other licensed entity that offers group health plans and employee benefit plans shall file with the department a copy of its claim determination procedure, including all forms used, and a copy of the materials designed to inform its members or insureds of the requirements of the claim determination and grievance procedure and the responsibilities and rights of the members or insureds under the plan each year. The carrier shall also file an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.
IV. In any request for a benefit determination, the claimant may authorize a representative to pursue the claim or benefit determination by submitting a written statement to the licensed entity that acknowledges the representation.
V. No fees or costs shall be assessed against a claimant related to a request for claim benefit determination.

Source. 2001, 207:3. 2003, 175:3, 4; 276:4-7. 2005, 248:7. 2006, 304:2, eff. Aug. 18, 2006.

Section 415-A:4-b

    415-A:4-b Appeal Procedure. –
Every carrier or other licensed entity which offers group health insurance or employee benefit plans shall file with the insurance department, by April 1 of each year, and shall maintain a written procedure by which a claimant, or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and fair review of the claim denial. The written procedure filed with the insurance department shall include all forms used to process an appeal.
I. Full and fair review shall require that:
(a) The person or persons reviewing the grievance shall not be the same person or persons making the initial determination, shall not be subordinate to or the supervisor of the person making the initial determination, and shall act as a fiduciary;
(b) The person reviewing the grievance on a first or second level appeal shall have appropriate medical and professional expertise and credentials to competently render a determination on appeal;
(c) The claimant or claimant's representative shall have at least 180 days following receipt of a notification of an adverse claim determination to appeal;
(d) The claimant or claimant's representative shall have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those documents or materials were considered in making the initial determination;
(e) The claimant or claimant's representative shall be provided upon request, and without charge, reasonable access to, and copies of all documents, records, and other information relevant to or considered in making the initial adverse claim determination; and
(f) The review shall be a de novo proceeding and shall consider all information, documents, or other material submitted in connection with the appeal without regard to whether the information was considered in making the claim denial.
II. In the appeal of a claim denial that is based in whole or in part on a medical judgment:
(a) The review shall be conducted by or in consultation with a health care professional who has appropriate training and experience in the field of medicine;
(b) The titles and qualifying credentials of the person conducting the review shall be included in the decision; and
(c) The identity and qualifications of any medical or vocational expert whose advice was considered, without regard to whether it was relied upon in making the initial claim denial, shall be made available to the claimant upon request.
III. In the appeal of a claim for urgent care, a claim involving a matter that would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function, or a claim concerning an admission, availability of care, or the continued stay or health care service for a person who has received emergency services, but who has not been discharged from a facility, an expedited appeal process shall be made available which shall provide for:
(a) The submission of information by the claimant to the carrier by telephone, facsimile, or other expeditious method; and
(b) The determination of the appeal shall be made not more than 72 hours after the submission of the completed request for appeal.
IV. Timing and Notification for Determination on Appeal.
(a) In the case of nonexpedited appeal of a pre-service claim or a post-service claim, the determination on appeal shall be made within a reasonable time appropriate to the medical circumstances, but in no event more than 30 days after receipt by the carrier or other licensed entity of the claimant's appeal.
(b) In the case of an expedited appeal related to an urgent care claim, a carrier or other licensed entity 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 appeal is filed. If the expedited review involves ongoing urgent care services, the service shall be continued without liability to the covered person until the covered person has been notified of the determination. A carrier or other licensed entity 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.
(c) The period of time within which a decision shall be rendered on appeal shall begin to run at the time the appeal is filed in accordance with the appeal procedures of the carrier or other licensed entity, without regard to whether all the information necessary to make a determination on appeal is contained in the filing. In the event the claimant fails to submit information necessary to decide the appeal, the period for making the determination on appeal shall be tolled from the date the claimant is notified in writing of what additional information is required until the date the claimant responds to the request. The carrier or other licensed entity shall provide notification of incompleteness as soon as possible; but in no event more than 24 hours after the filing of the appeal in appeals involving urgent care. In the event that the claimant fails, within a 45-day period from the date of notification, to provide sufficient information, the carrier may deny the appeal on the basis of incompleteness. The appeal may be reopened upon receipt of the required information.
V. Manner and Content of Notification of Determination on Appeal.
(a) The carrier or other licensed entity shall provide a claimant with a written determination of the appeal that shall include:
(1) The specific reason or reasons for the determination, including reference to the specific provision of the policy or plan on which the determination is based;
(2) If the determination is based upon a finding that the claim is experimental or investigational or not medically necessary or appropriate:
(A) The name and credentials of the person reviewing the grievance, including board status and the state or states where the person is currently licensed; and
(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant's specific medical circumstance;
(3) A statement describing all other dispute resolution options available to the claimant, including, but not limited to other options for internal review and options for external review, and options for bringing a legal action;
(4) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits;
(5) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the claim denial, a statement that such rule, guideline, protocol, or other similar provision was relied upon in making the claim denial; and
(6) A statement describing the claimant's right to contact the insurance commissioner's office for assistance which shall include a toll-free telephone number and address of the commissioner.
(b) A carrier or other licensed entity that offers group health plans or employee benefit plans shall file with the commissioner by April 1 of each year, a copy of its current grievance procedures, with all changes from the previous year annotated in the document, and a certificate of compliance , stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective.
(c) A carrier or other licensed entity that offers group health plans or employee benefit plans shall maintain written records documenting all grievances and appeals received during a calendar year, a general description of the reason for the appeal or grievance, the name of the claimant, the dates of the appeal or grievance and the date of resolution.
(d) A carrier or other licensed entity that offers group health plans or employee benefit plans shall provide to consumers:
(1) A description of the internal grievance procedure for claim determinations and other matters. The description shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons;
(2) 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; and
(3) A statement that the carrier or other licensed entity will provide assistance in preparing an appeal of an adverse benefit determination, and a toll-free telephone number to contact the carrier or other licensed entity.
(e) In any case where a carrier or other licensed entity that offers group health plans or employee benefit plans provides 2 levels of appeal for the pre-service claim determinations, the first level shall be completed within 15 days and the second level completed within the 30-day time period beginning from the initial date of filing the appeal or grievance. With respect to a second level appeal involving a claim for continuation of services or urgent care, the carrier or other licensed entity shall make a decision and notify the claimant within 72 hours after the second level appeal is filed. For second level appeals involving a post-service claim, the carrier shall make a decision and notify the claimant within 60 days of the date the appeal was filed.
(f) Annual reports shall be made to the insurance commissioner regarding plan complaints, claim denials, and prior authorization statistics in such form and containing such information as the commissioner may prescribe by rule or otherwise.
VI. In an appeal of a claim denial or other matter, the claimant may authorize a representative to pursue a claim or an appeal by submitting a written statement to the carrier or other licensed entity that acknowledges the representation.
VII. No fees or costs shall be assessed against a claimant related to a request for a grievance or appeal.

Source. 2001, 207:3. 2003, 175:5, 6. 2006, 304:3. 2007, 289:9. 2012, 99:2, eff. July 28, 2012.

Section 415-A:5

    415-A:5 Preexisting Conditions. –
I. If an insurer or a nonprofit hospital or medical service association elects to use a simplified application form for a policy other than a Medicare supplement policy, with or without a question as to the applicant's health at the time of application, but without any questions concerning the insured's health history or medical treatment history, the policy, 9 months after the date of enrollment, must cover any loss occurring from any preexisting condition not specifically excluded from coverage by terms of the policy and, except as so provided, the policy shall not include wording that would permit a defense based upon preexisting conditions.
II. [Repealed.]
III. Health carriers issuing policies subject to RSA 420-G shall not impose any preexisting condition exclusion that is inconsistent with that chapter.

Source. 1975, 494:1. 1981, 418:1. 1995, 112:23, II. 2004, 187:4. 2007, 289:10. 2011, 189:6, eff. Aug. 13, 2011. 2019, 220:12, eff. Sept. 10, 2019.

Section 415-A:5-a

    415-A:5-a Access to Enhanced 911 System. –
I. No accident or health insurance policy issued or renewed after July 7, 2000 shall contain any provision which establishes or promotes an emergency medical response or transportation system that encourages or directs access by an insured or enrollee in competition with or in substitution of the state enhanced 911 system or other state, county, or local government emergency medical services system.
II. Notwithstanding paragraph I, an insurer may use transportation outside the enhanced 911 or other government emergency medical services system for services that are not in response to an emergency medical condition, as defined in RSA 420-J:3, XV.
III. No accident or health insurance policy issued or renewed after July 7, 2000 shall contain any provision requiring an insured or enrollee to obtain prior authorization before accessing the enhanced 911 system or other state, county, or local government emergency medical services system for response and/or transportation for emergency services, as defined in RSA 420-J:3, XVI.
IV. No person who issues an accident or health insurance policy subject to this chapter shall use false or misleading language in its enrollment sales materials or in any other materials provided to insureds or enrollees to discourage or prohibit insureds or enrollees from accessing the enhanced 911 system for response and/or transportation for emergency services.

Source. 2000, 104:1, eff. July 7, 2000.

Section 415-A:6

    415-A:6 Adoption of Rules. –
I. Rules promulgated pursuant to this chapter shall be subject to notice and hearing pursuant to RSA 541-A. When a rule adopted pursuant to this chapter so provides, a policy of insurance issued subsequent to the rule's effective date and any optionally renewable policy of insurance renewed subsequent to the rule's effective date which does not comply with the rule shall, not less than 60 days after the rule's effective date, be construed, and the insurer or corporation shall be liable, as if the policy did comply with the rule.
II. The commissioner shall adopt rules to establish specific standards for processing benefit claims under group disability plans that shall be consistent with and not more restrictive than the United States Department of Labor Benefit Claims Procedure Regulation, 29 CFR 2560.503, as existing and thereafter amended, that sets standards for group disability plans under the Employee Retirement Income Security Act of 1974.

Source. 1975, 494:1. 2003, 175:7, eff. Jan. 1, 2004.

Section 415-A:7


[RSA 415-A:7 repealed by 2020, 15:2, effective July 1, 2024.]
    415-A:7 Establishing Excess Cost Sharing. –
I. In this section:
(a) "Insurer" 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 a policy of insurance, health service corporation, health maintenance organization, preferred provider agreement, or any other entity providing accident and health insurance.
(b) "Rebate" means:
(1) Negotiated price concessions including, but not limited to, base rebates and reasonable estimates of any price protection rebates and performance-based rebates that may accrue directly or indirectly to the insurer during the coverage year from a manufacturer, dispensing pharmacy, or other party to the transaction; and
(2) Reasonable estimates of any fees and other administrative costs that are passed through to the health carrier and serve to reduce the insurer's prescription drug liabilities for the coverage year.
II. All rebates remitted by or on behalf of a pharmaceutical manufacturer, developer or labeler, directly or indirectly, to an insurer, or to a pharmacy benefits manager under contract with an insurer, related to its prescription drug benefits shall be remitted in one or both of the following ways:
(a) Remitted directly to the covered person at the point of sale to reduce the out-of-pocket cost to the covered person associated with a particular prescription drug;
(b) Remitted to, and retained by, the insurer. Rebates remitted to the insurer shall be applied by the insurer in its plan design and in future plan years to offset the premium for covered persons.
III. Beginning November 1, 2020 and annually thereafter, an insurer shall file with the commissioner a report in the manner and form determined by the commissioner demonstrating the manner in which the insurer has complied with this section.
IV. Any insurer that violates any provision of this section may, at the discretion of the commissioner, be subject to subparagraph (a) or (b), or both:
(a) Its certificate of authority may be indefinitely suspended or revoked.
(b) A civil fine not to exceed $2,500 may be imposed for each violation. Repeated violations of the same provision shall constitute separate civil offenses.
V. In making the disclosures required under this section, an insurer shall not be required by the department to publish or otherwise reveal information regarding the amount of rebates it receives, including, but not limited to, information regarding the amount of rebates it receives on a product-, manufacturer-, or pharmacy-specific basis. Such information is protected as a trade secret, is not a public record subject to disclosure under RSA 91-A:1, and shall not be disclosed directly or indirectly. An insurer shall impose the confidentiality provision of this section on any vendor or third party that performs health care or administrative services on behalf of the insurer that may receive or have access to rebate information.

Source. 2020, 15:1, eff. Sept. 15, 2020.