PREFERRED PROVIDER AGREEMENTS
The purpose of this chapter is to assure that health benefit plans encourage covered persons to seek health care services from preferred providers and that contracts or agreements between preferred providers and health care insurers are fair and in the public interest. Further, this chapter establishes reasonable regulatory requirements for health care insurers in a manner to contain health care costs while preserving the quality of care.
Source. 1987, 112:1, eff. July 5, 1987.
In this chapter:
I. "Commissioner" means the insurance commissioner.
II. "Covered person" means an individual entitled to reimbursement for expenses of health care services under a policy issued or administered by a health care insurer.
II-a. "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.
III. "Health benefit plan" means the contract between the covered person or policyholder and the health care insurer which defines the services covered.
IV. "Health care insurer" means an insurance company, including nonprofit (tax exempt) health service corporations as defined in RSA 420-A, authorized in this state to issue policies that provide reimbursement for expenses of health care services.
V. "Health care services" means services or products rendered by a preferred provider which may include physician, hospitalization, laboratory, and x-ray services, and medical equipment and supplies, and which further may include, but are not limited to: medical, surgical, and dental care; psychological, obstetrical, osteopathic, optometric, optic, podiatric, chiropractic, nursing, physical therapy, and pharmaceutical services; health education; preventive medical, rehabilitative, and home health services; inpatient and outpatient hospital services, extended care, nursing home care, convalescent institutional care, laboratory and ambulance services, appliances, drugs, medicines, and supplies; and any other care, service, or treatment of disease, correction of defects, or the maintenance of the physical and mental well-being of the insured.
VI. "Preferred provider" means a licensed provider or group of providers who have contracted with or been designated by the health care insurer to provide health care services to covered persons under a health benefit plan.
VII. "Provider" means any physician, hospital or other institution, organization, or other person who furnishes health care services.
Source. 1987, 112:1. 2007, 289:17, eff. Jan. 1, 2008.
420-C:3 Reimbursement Agreements.
Notwithstanding any other law to the contrary, a health care insurer may:
I. Enter into contracts or other agreements with preferred providers for the delivery of health care services to covered persons. Such contracts or agreements may:
(a) Establish the amount and method of payment to the preferred provider;
(b) Establish a procedure for the review and control of utilization of health care services; and
(c) Establish a mechanism for determining whether the health care services rendered are medically necessary.
II. Issue or administer policies or contracts which provide incentives for the covered person to use the health care services of preferred providers.
III. Issue or administer policies or contracts which provide benefits for health care services only if the services have been rendered by a preferred provider.
Source. 1987, 112:1, eff. July 5, 1987.
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.
420-C:4-a Dependent Coverage.
I. A policy may, at the election of the carrier, insure, originally or by subsequent amendment, upon application of an adult member of a family who shall be deemed the policyholder, any 2 or more eligible members of that family, including husband, wife, dependent children, or any other person dependent upon the policyholder. In the event a carrier elects to provide coverage for dependent children, the term "dependent child" shall include a subscriber's child by blood or by law, who is under age 26.
I-a. The coverage of any family member insured by such policy, pursuant to paragraph I, who is mentally or physically incapable of earning his or her own living as of the date on which such dependent's status as a covered family member would otherwise expire because of age, shall continue under such policy while such policy remains in force or is replaced by another policy as long as such incapacity continues and as long as such dependent remains chiefly financially dependent on the policyholder or the employee or his or her estate is chargeable for the care of such dependent; provided, that due proof of such incapacity is received by the insurer within 31 days of such expiration date. If such coverage is continued in accordance with this paragraph, such dependent shall be entitled upon the termination of such incapacity to coverage offered by the New Hampshire high risk pool under RSA 404-G.
II. Nothing in this section shall be construed to require:
(a) Coverage for services provided to a dependent before the effective date of this section; or
(b) That an employer pay all or part of the cost of family coverage that includes a dependent as provided pursuant to this section.
III. A subscriber that elects family coverage during any applicable open enrollment period may enroll any dependent eligible pursuant to this section.
IV. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following:
(a) The dependent is disqualified for dependent status as set forth in paragraph I of this section; or
(b) The date upon which the employer under whose contract coverage is provided to a dependent ceases to provide coverage to the subscriber.
V. Nothing in this section shall be construed to permit a health insurance carrier to refuse an election for coverage by a dependent pursuant to paragraph III, based upon the dependent's prior disqualification pursuant to subparagraph IV(a).
VI. (a) Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to a subscriber:
(1) In the certificate of coverage prepared for subscribers on or about the date of commencement of coverage; and
(2) Within 30 days following the effective date of the passage of this law.
(b) Such notice shall also include information regarding the required special open enrollment period.
Source. 2007, 352:4. 2009, 235:13. 2010, 243:11, eff. Sept. 23, 2010.
420-C:4-b Coverage for Dependents.
If the coverage for dependent children includes coverage for dependent children who are full-time students, as defined by the appropriate educational institution, beyond the age of 18, such dependent coverage shall include coverage for a dependent's medically necessary leave of absence from school for a period not to exceed 12 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy, whichever comes first. Any breaks in the school semester shall not disqualify the dependent child from coverage under this section. Documentation and certification of the medical necessity of a leave of absence shall be submitted to the insurer by the student's attending physician and shall be considered prima facie evidence of entitlement to coverage under this section. The date of the documentation and certification of the medical necessity of a leave of absence shall be the date the insurance coverage under this section commences.
Source. 2007, 289:18, eff. Jan. 1, 2008.
420-C:4-c Pre-certification Requirement.
In the event that a person is covered by more than one plan that requires pre-certification, the member shall obtain pre-certification from the primary plan. Although the member shall not be required to obtain pre-certification from the secondary plan, the secondary plan shall not be required to treat such services as covered services if the services do not meet its certification criteria. The secondary plan shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan.
Source. 2007, 289:18, eff. Jan. 1, 2008.
420-C:5 Discrimination Prohibited.
No health care insurer shall discriminate against any provider on the basis of religion, race, color, national origin, age, sex, gender identity, sexual orientation, or marital status. Reasonable terms and conditions including, but not limited to, those based on economic or geographic considerations, certain affiliations, or professional privileges shall not be prohibited under this section.
Source. 1987, 112:1, eff. July 5, 1987. 2019, 332:18, eff. Oct. 15, 2019.
420-C:5-a Prohibiting Limitations on Liability; Disclosure of Information.
I. No contract between a health care insurer 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 care insurer for any actions of the physician for which the health care insurer might otherwise be liable.
II. No contract between a health care insurer 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 care insurer's products as they relate to the needs of such provider's patients except for trade secrets of significant competitive value.
III. 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.
IV. No contract between a health care insurer and a health care provider shall limit coverage for preexisting conditions beyond 9 consecutive months from the date of enrollment.
Source. 1995, 126:5. 1996, 149:5. 1998, 377:2. 2007, 289:19, eff. Jan. 1, 2008.
I. The commissioner may adopt rules under RSA 541-A necessary for the implementation and administration of this chapter, relative to:
(a) The length of time necessary for health care insurers to comply with this chapter; and
(b) The information he shall require health care insurers to provide to demonstrate compliance with this chapter.
II. The commissioner may adopt rules under RSA 541-A relative to the administration of this chapter.
Source. 1987, 112:1. 2002, 207:30, eff. July 15, 2002.
Any health care insurer commencing a preferred provider agreement shall notify the commissioner within 30 days.
Source. 1987, 112:1, eff. July 5, 1987.
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-G and RSA 420-J.
Source. 1997, 344:9, eff. July 1, 1997; 344:17, eff. Jan. 1, 1998.