PREFERRED PROVIDER AGREEMENTS
420-C:4 Health Benefit Plans.
Health benefit plans issued under RSA 420-C:3 may include, but shall not be limited to, the following components which are designed to control the cost and improve the quality of health care for covered persons:
I. A per capita payment to preferred providers.
II. Differences between the benefit levels for the health care services of preferred providers and the benefit levels for the services of other providers.
III. Reasonable deductibles which may be different for preferred providers than for other providers.
IV. The standards to be met by a provider in order to become a preferred provider.
V. The preferred providers with whom the health insurer has contracted.
VI. Any other incentives allowed to covered persons if a preferred provider's services are used.
VI-a. A maternity benefits rider for covered persons who request it, if maternity benefits are not part of the health benefits plan. Nothing in this paragraph shall be construed to apply to supplemental health insurance and disability insurance policies.
VII. No preferred provider shall, when issuing or renewing a policy or contract of insurance or any certificate under such policy or contract covered by this chapter, deny coverage or limit coverage to any resident of this state on the basis of health risk or condition except that a waiting period consistent with insurance department rules may be imposed for pre-existing medical conditions. If a preferred provider accepts an application for group coverage, such acceptance shall be subject to the following:
(a) If the group has coverage in effect through another plan, the preferred provider shall accept all persons covered under the existing plan. If the group does not have coverage in effect through another plan, the preferred provider shall accept all persons for which the group seeks coverage.
(b) Once a group policy has been issued, any person becoming eligible for coverage shall become covered by enrolling within 31 days after first becoming eligible. Any person so enrolling shall not be required to submit evidence of insurability based on medical conditions. If a person does not enroll at this time, he is a late enrollee.
(c) Once a group policy has been issued, the preferred provider shall provide the group with an annual open enrollment period for late enrollees. During the open enrollment period, any late enrollee shall be permitted to enroll without submitting any evidence of insurability based on medical conditions. For late enrollees only, the pre-existing condition provisions shall apply for 18 months from the date of enrollment.
VIII. An insurer issuing policies of group insurance shall allocate the costs associated with maternity and childbirth over both males and females covered by its entire block of business in this state. In cases in which, because of the amount written in the state, allocation to an entire block of business needs to occur, the carrier may apply for a waiver from the insurance commissioner.
Source. 1987, 112:1. 1992, 222:4. 1993, 162:6, eff. July 1, 1993; 196:7, eff. Jan. 1, 1994.