HEALTH MAINTENANCE ORGANIZATIONS
In this chapter:
I. "Advertising" means:
(a) Printed and published material and descriptive literature of an insurer used in newspapers, magazines, radio and television scripts, billboards, and similar displays;
(b) Descriptive literature and sales aids of all kinds issued by an insurer for presentation to members of the public, including, but not limited to, marketing, educational, or information letters; and
(c) Sales talks, presentations and material prepared by insurers for use by agents and brokers, and representations made by agents and brokers in accordance therewith.
II. "Commissioner" means the insurance commissioner.
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. "Enrolled participant" means a person who has entered into a contractual arrangement or on whose behalf a contractual arrangement has been entered into with a health maintenance organization to receive health care services.
IV. "Evidence of coverage" means any certificate, agreement, or contract issued to an enrolled participant setting out the coverage to which such participant is entitled including those issued pursuant to a contract under section 1876 or section 1833 of the federal Social Security Act (42 U.S.C. section 1395 et seq.) as amended.
V. "Health care services" means physician, hospitalization, laboratory, x-ray service and medical equipment and supplies, which may include but are not limited to: medical, surgical, and dental care; psychological, obstetrical, osteopathic, optometric, optic, podiatric, chiropractic, nursing, physical therapy services, 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 enrolled participants.
VI. "Health maintenance organization" means a public or private organization, organized under the laws of this state or the laws of another state which:
(a) Provides or otherwise makes available to enrolled participants health care services;
(b) Is compensated for the provision of one or more health care services to an enrolled participant on a primarily predetermined periodic rate basis;
(c) Provides physicians' services directly through physicians who are either employees or partners of such an organization, or under arrangements with one or more physicians or groups of physicians.
VII. "Provider" means any physician, hospital or other institution, organization, or other person who furnishes health care services.
Source. 1977, 282:1. 1997, 282:1. 2007, 289:14, eff. Jan. 1, 2008.
420-B:2 Certificate of Authority.
I. No person may operate a health maintenance organization without obtaining a certificate of authority from the commissioner. A foreign corporation may qualify under this chapter subject to its registration to do business in this state as a foreign corporation under RSA 293-A.
II. Every health maintenance organization, as of August 21, 1977, shall submit an application for a certificate of authority within 120 days of August 21, 1977. Each such applicant may continue to operate without certificate of authority until the commissioner acts upon the application.
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:3 Application for Certificate of Authority.
Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant and shall be in a form prescribed by the commissioner, containing such information as the commissioner may require.
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:4 Jurisdictional Power of Attorney.
Any applicant for a certificate of authority who is not domiciled in this state shall file with its application a power of attorney duly executed appointing the commissioner and his successors in office, and duly authorized deputies, as the true and lawful attorney of such applicant in and for the state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served.
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:5 Issuance of Certificate of Authority.
The commissioner shall issue a certificate of authority to any person filing an application within 90 days after filing of a completed application, payment of all required fees and receipt of endorsement or approval of the state health planning and development agency, as provided by law or regulation, if he is satisfied that the applicant is safe, reliable, entitled to confidence, in sound financial condition and that issuing the certificate of authority would be in the public interest.
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:5-a Renewal of Certificate of Authority.
The certificate shall be renewed annually on June 14 if the company complies with the requirements of this chapter, the commissioner regards it as safe, reliable, and entitled to confidence, and the company continues to conduct a meaningful business in New Hampshire, as determined by the commissioner.
Source. 1989, 186:2, eff. July 1, 1989.
420-B:5-b New License Required for Changed Conditions.
The commissioner shall require a health maintenance organization to apply for a new certificate in accordance with this chapter, if, after notice and hearing, the commissioner finds that the organization has undergone a substantial change in finances or managerial control since its last application for a certificate. The current certificate shall expire upon approval of the new application or 30 days after the decision of the commissioner that a substantial change has occurred, whichever is sooner.
Source. 1989, 186:2, eff. July 1, 1989.
420-B:6 Pre-Certificate Activities.
I. Upon request of any applicant, and subject to any regulations the commissioner may impose, the commissioner, in his discretion, may permit an applicant to contact potential enrolled participants prior to the issuance of a certificate of authority, to discuss the health care services the applicant proposes to offer and the proposed evidences of coverage.
II. The commissioner may, in his discretion in accordance with such regulations as he may impose, permit an organization to contact potential enrolled participants prior to the granting of a certificate of authority, to discuss the health care services such health maintenance organization proposes to offer if a certificate of authority is granted.
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:7 Powers of Health Maintenance Organizations.
The powers of a holder of a certificate of authority issued pursuant to RSA 420-B:5 shall include, in addition to any powers conferred by the law under which the health maintenance organization is organized, and subject to all restrictions imposed in this chapter, or by the commissioner, the following:
I. The power to purchase, lease, construct, renovate, operate, or maintain medical clinics and their ancillary equipment as may reasonably be required for its principal office or for such other purposes as may be necessary in the transaction of the business of the health maintenance organization;
II. The power to furnish health care services on a prepaid basis through providers which are under contract with, otherwise associated with, retained by or employed by the health maintenance organization;
III. The power to render health care services on a basis other than prepaid, including charitable and fee for service, through providers which are under contract with, otherwise associated with, retained by, or employed by the health maintenance organization;
IV. The power to make loans to a medical group under contract with the health maintenance organization in furtherance of its program, or make loans to a corporation or corporations under its control for the purpose of acquiring or constructing medical clinics, or in furtherance of a program providing health care services to enrolled participants;
V. The power to enter into evidences of coverage to provide an agreed upon set of health care services to enrolled participants or groups of enrolled participants in exchange for a prepaid per capita, or prepaid aggregate, fixed sum;
VI. The power to market evidences of coverage, enroll enrolled participants and administer its program of marketing, or contract with any person for the performance, on behalf of the health maintenance organization, of such functions;
VII. The power to contract with an insurance company licensed in this state, or with a hospital medical service or health service corporation authorized to do business in this state, for the provisions of insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization;
VIII. The power to offer, in addition to health care services, indemnity benefits covering out-of-area or emergency services; and
IX. The power to receive and accept from governmental or private agencies or any persons, payments or grants covering all or part of the cost of the services provided or arranged for by the health maintenance organization.
X. The power to offer out-of-plan covered services if those services are provided by a point-of-service product on an in-plan basis.
XI. The power to act as a health care insurer as defined in RSA 420-C:2, IV only when offering a Medicare Advantage plan in accordance with 42 U.S.C. sections 1395w-21 through1395w-29.
Source. 1977, 282:1. 2002, 207:7, eff. May 16, 2002. 2020, 39:13, eff. July 29, 2020.
420-B:8 Forms of Evidence of Coverage.
I. No evidence of coverage, or amendment thereto, shall be issued to any person in this state until a copy of the evidence of coverage, or amendment thereto including all rates to be charged, has been filed with and approved by the commissioner.
II. Every health maintenance organization shall provide evidence of coverage to each enrolled participant. If the enrolled participant obtains coverage through an insurance policy or a contract issued by a hospital, medical or health service corporation, whether by option or otherwise, the insurer or hospital or medical service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage. When a group of enrolled participants comprise a family unit a single evidence of coverage of said family unit shall be sufficient.
III. All forms of evidence of coverage issued by the health maintenance organization to enrolled participants, or other marketing documents purporting to describe the organization's health care services, shall contain clear and complete information indicating:
(a) The health care services and other benefits to which the enrolled participant is entitled;
(b) Any exclusions or any limitations on services or any other benefits to be provided, including any deductible or co-payment feature or any restrictions relating to pre-existing conditions;
(c) Where and in what manner information is available as to how services may be obtained;
(d) The predetermined periodic rate of payment for health care services and other benefits and other charges, if any, which the enrolled participant is obliged to pay; and
(e) All criteria relating to disenrollment or denials of re-enrollment.
(f) With respect to subscribers with Medicare supplement insurance benefits, the health maintenance organization shall allow each such subscriber a period of at least one year after the incurral of a covered expense within which the subscriber shall furnish any proof of loss required by the insurer. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and such proof was furnished as soon as was reasonably possible.
III-a. Every health maintenance organization shall state on its forms of evidence of coverage that a maternity benefits rider will be made available at the request of the enrolled participant, if maternity care is not covered in the insurance policy, contract or evidence of coverage. Nothing in this paragraph shall be construed to apply to supplemental health insurance and disability insurance policies.
III-b. The coverage of any family member insured by such policy, pursuant to RSA 420-B:8-aa, 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.
III-c. Non-group contracts issued by a health maintenance organization shall contain the following provision: Insurance with Other Insurers. If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or an expense incurred basis, payment shall not be prorated or reduced. In such a case, the insured shall be entitled to payment from both insurers. However, the provisions of this paragraph shall not prohibit the issuance of contracts including a "benefits deductible." The term "benefits deductible," as used in this paragraph means the term as defined in RSA 415:6, II(4).
IV. (a) The periodic rate of payment for health care services and other benefits and other charges, if any, included in any form of evidence of coverage shall be reasonable in relation to the benefits and health care services provided and not excessive, inadequate or discriminatory.
(b) A grace period shall be allowed the enrolled participant for making any payment due under the contract. Such period shall not be less than 10 days.
V. No health maintenance organization authorized under this chapter shall cancel the enrollment of an enrolled participant or refuse to transfer an enrolled participant from a group to an individual basis for reasons relating to health status.
VI. All advertising intended for use in this state whether through written, radio, or television medium shall be submitted to the commissioner of this state for review and approval by the commissioner prior to use, except that the commissioner may waive prior approval for any such materials which the department of health and human services has approved for use in the medicaid program.
VII. The commissioner may, at any time, after a hearing, if one is requested, withdraw his approval of any advertising, evidence of coverage or amendment thereto on any of the grounds stated as material to approval. It shall be unlawful for any health maintenance organization to issue any evidence of coverage or amendment thereto after the effective date of such withdrawal of approval.
Source. 1977, 282:1. 1993, 167:3; 196:6. 1995, 112:17. 1996, 188:8. 1997, 282:2. 2009, 235:10, eff. Sept. 14, 2009.
420-B:8-a Repealed by 1996, 188:14, IV, eff. Jan. 1, 1997.
420-B:8-aa 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.
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 child 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 this section.
(b) Such notice shall include information regarding the required special open enrollment period.
Source. 2007, 352:3. 2009, 235:11. 2010, 243:10, eff. Sept. 23, 2010.
420-B:8-b Health Maintenance Organization Benefits for Mental and Nervous Conditions and Treatment for Chemical Dependency.
I. (a) Benefits for mental or nervous conditions shall conform to the requirements of RSA 415:18-a or alternatively with the basic health services requirements of the Health Maintenance Organization Act of 1973 (P.L. 93-222), any amendments, and federal regulations issued under the authority of such federal law. However, where a health maintenance organization provides these alternative benefits, such benefits shall not be subject to any deductible. The coinsurance required by the enrolled participant shall not exceed 20 percent of the reasonable and customary charge for the services provided.
(b) In addition to the requirements of subparagraph (a), every health maintenance organization offering such benefits shall provide to its subscribers a list of psychiatrists and mental health care providers within the organization's network. The health maintenance organization shall allow its subscribers 2 visits for diagnosis followed by up to 3 treatment visits in each contract year. Subsequent visits within the contract year may be subject to utilization review. The policy shall also include a statement that a primary care physician may refer an enrolled participant to a psychiatrist or other mental health care provider within the organization's network. There shall be no economic penalty to the primary care physician for such a referral.
II. No evidence of coverage, or amendment thereto, issued, renewed or continued on or after January 1, 1993, shall contain any provision denying insurance benefits for psychiatric or psychological services, including psychological examinations, solely because they are rendered to an insured or a dependent in compliance with the lawful order of any court of this state. Benefits for such services shall be as favorable as for other psychiatric or psychological services, including psychological examinations, and shall be subject to the same dollar limits, deductibles, co-payments, and co-insurance factors and to terms and conditions of the policy or certificate, including any managed care provisions.
III. Coverage shall be provided for expenses arising from treatment for chemical dependency, including alcoholism, up to a specified limit which may be defined in terms of a dollar amount or a maximum number of days or visits. Coverage shall include both an inpatient and an outpatient benefit for detoxification and rehabilitation.
IV. "Mental and nervous conditions" shall be defined as mental disorders, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" (DSM), excluding those disorders designated by a "V Code" and those disorders designated as criteria sets and axes provided for further study in the DSM. This term shall not include chemical dependency including alcoholism.
V. The commissioner may adopt rules, under RSA 541-A, as may be necessary to effectuate any provisions of the Mental Health Parity Act of 2008 that relate to the business of insurance.
Source. 1989, 186:3. 1992, 177:5. 1995, 245:1. 1996, 188:9. 1998, 385:2. 2002, 204:2. 2009, 235:12, eff. Sept. 14, 2009.
420-B:8-c Cancellation or Nonrenewal of Group Health Maintenance Organization Contracts.
No group health maintenance organization contract, authorized under this chapter, may be cancelled or nonrenewed by the health maintenance organization, except for nonpayment of premium, unless the group contract holder receives either a notice of cancellation or nonrenewal or an offer of renewal in accordance with this section. The notice of cancellation or nonrenewal or offer of renewal shall be delivered to the group contract holder or mailed to the group contract holder's last address as shown in the records of the health maintenance organization at least 45 days prior to the renewal date of the contract. Notice of cancellation for lack of participation, if permitted by the terms of the contract, shall be delivered to the group contract holder or mailed to the group contract holder's last address as shown in the records of the health maintenance organization, at least 30 days prior to the effective date of the cancellation.
Source. 1990, 194:4. 1991, 23:4, eff. Jan. 1, 1992.
420-B:8-d Cancellation or Nonrenewal of Non-Group Health Maintenance Organization Contracts.
No non-group health maintenance organization contract, authorized under this chapter, may be cancelled or nonrenewed by the health maintenance organization except for nonpayment of premium, unless the enrolled participant receives either a notice of cancellation or nonrenewal or an offer of renewal in accordance with this section. The notice of cancellation or nonrenewal or offer of renewal shall be delivered to the enrolled participant or mailed to the enrolled participant's last address as shown in the records of the health maintenance organization at least 30 days prior to the renewal date of the contract.
Source. 1990, 194:4. 1991, 23:5, eff. Jan. 1, 1992.
420-B:8-e Repealed by 2010, 61:3, III, eff. May 18, 2010.
420-B:8-ee Coverage for Dental Procedures.
I. Every health maintenance organization and every other similar corporation licensed under the laws of another state that issues or renews any group policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to each covered individual or certificate holder who is a resident of New Hampshire coverage for the medically necessary hospital or surgical day care facility charges and administration of general anesthesia administered by a licensed anesthesiologist or anesthetist for dental procedures performed on a covered person who:
(a) Is a child under the age of 13 who is determined by a licensed dentist in conjunction with a licensed primary care physician to have a dental condition of significant dental complexity which requires certain dental procedures to be performed in a surgical day care facility or hospital setting; or
(b) Is a person who has exceptional medical circumstances or a developmental disability as determined by a licensed primary care physician which place the person at serious risk.
II. All of the terms and conditions of the covered person's policy shall apply to these services.
Source. 1998, 280:4. 2003, 278:4. 2010, 188:10, eff. Aug. 20, 2010. 2018, 188:8, eff. Aug. 7, 2018.
420-B:8-f Benefits for Scalp Hair Prostheses.
I. Benefits for scalp hair prostheses shall conform to the requirements of RSA 415:18-d. Such benefits shall not be subject to any greater deductible than any other prostheses benefits provided by the health maintenance organization. The coinsurance required by the enrolled participant shall not exceed the amount allowed under the contract for the reasonable and customary charge for the services provided. Such coverage, however, shall be subject to a written recommendation by the treating physician stating that the hair prosthesis is a medical necessity. Such coverage shall be subject to the same limitations and guidelines as other prostheses.
II. For the purposes of this section:
(a) "Prostheses" means artificial appliances used to replace lost natural structures. Prostheses include, but are not limited to, artificial arms, legs, breasts or glass eyes.
(b) "Scalp hair prostheses" means artificial substitutes for scalp hair that are made specifically for a specific individual.
Source. 1992, 246:5. 2001, 276:5, eff. Sept. 14, 2001.
420-B:8-ff Coverage for Nonprescription Enteral Formulas.
I. Every health maintenance organization and every other similar corporation licensed under the laws of another state that issues or renews any policy of individual or group health insurance providing benefits for medical or hospital expenses, shall provide to each individual or group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for the provision of nonprescription enteral formulas for the treatment of impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, or motility of the gastrointestinal tract. Such coverage shall be provided when the prescribing physician has issued a written order stating that the enteral formula is needed to sustain life, is medically necessary, and is the least restrictive and most cost effective means for meeting the needs of the patient.
II. Every health maintenance organization and every other similar corporation licensed under the laws of another state that issues or renews any policy of individual or group health insurance providing benefits for medical or hospital expenses, shall provide to each individual or group, or to the portion of each group comprised of certificate holders of such insurance who are resident of this state, coverage for the provision of nonprescription enteral formulas and food products required for persons with inherited diseases of amino acids and organic acids. Such coverage shall be provided when the prescribing physician has issued a written order stating that the enteral formula or food product is medically necessary and is the least restrictive and most cost effective means for meeting the needs of the patient. Coverage for inherited diseases of amino acids and organic acids shall, in addition to the enteral formula, include food products modified to be low protein in an amount not to exceed $1,800 annually for any insured individual.
III. The benefits included in this section shall not be subject to any greater deductible than any other benefits provided by the insurer. The coinsurance required by the enrolled participant shall not exceed the amount allowed under the contract for the reasonable and customary charge for the service provided.
Source. 1995, 235:5. 1996, 131:6. 2010, 188:11, eff. Aug. 20, 2010.
420-B:8-g Coverage During Adoption Proceedings.
All contracts issued by a health maintenance corporation which provide coverage for a family member of the subscriber shall, as to such family member's coverage, also provide that health insurance benefits applicable for children are payable with respect to any minor from the date such minor is placed in the custody of the subscriber pursuant to an adoption proceeding under the provisions of RSA 170-B. Such health insurance benefits shall terminate upon dismissal or withdrawal of the petition for adoption.
Source. 1992, 222:9, eff. Jan. 1, 1993.
420-B:8-gg Coverage for Prescription Contraceptive Drugs and Prescription Contraceptive Devices and for Contraceptive Services.
Every health maintenance organization and every other similar corporation licensed under the laws of another state that issues or renews any policy of group health insurance providing benefits for medical or hospital expenses, which provides coverage for outpatient services shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for outpatient contraceptive services under the same terms and conditions as for other outpatient services. "Outpatient contraceptive services" means consultations, examinations, and medical services, provided on an outpatient basis, including the initial screening provided through a pharmacy pursuant to RSA 318:47-l at a rate established by contract between the pharmacy and the insurer or its pharmacy benefits manager, and related to the use of contraceptive methods to prevent pregnancy which has been approved by the U.S. Food and Drug Administration. Each health maintenance organization and every other similar corporation licensed under the laws of another state that issues or renews any group health insurance providing benefits for medical or hospital expenses which provides a prescription rider shall cover all prescription contraceptive drugs and prescription contraceptive devices approved by the U.S. Food and Drug Administration under the same terms and conditions as other prescription drugs. Nothing in this section shall be construed as altering the terms and conditions of a contract relating to prescription drugs and outpatient services.
Source. 1999, 252:3. 2010, 188:13, eff. Aug. 20, 2010. 2018, 205:6, eff. Jan. 1, 2019.
420-B:8-h Notification of Allowable Benefit.
All health maintenance organizations shall provide to each subscriber, on request, a written statement of the dollar amount of allowable benefit for any procedure which is requested by the appropriate procedure code.
Source. 1993, 102:6, eff. Jan. 1, 1994.
420-B:8-i Incontestable Provision.
The validity of the contract shall not be contested except for nonpayment of premiums, after it has been in force for 2 years from its date of issue. No statement made by any person covered under the contract relating to insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of 2 years during such person's lifetime, and not unless it is contained in a written instrument signed by the person making such statement. No such provision, however, shall preclude the assertion, at any time, of defenses based upon the person's ineligibility for coverage under the plan or upon other provisions in the plan, except for any provisions establishing, as a requirement of eligibility, the furnishing of satisfactory evidence of insurability to the health maintenance organization.
Source. 1993, 167:4, eff. Jan. 1, 1994.
420-B:8-j Newborn Children.
I. All individual and group health maintenance organization contracts shall provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber or a dependent child of the insured or the subscriber from the moment of birth.
II. Coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.
III. If payment of a specific premium or subscription fee is required to provide coverage for a child, the contract may require that notification of birth of a newly born child and payment of the required premium or fee must be furnished to the health maintenance organization within 31 days after the date of birth in order to have the coverage continue beyond such 31-day period. Unless the contract specifically provides that grandchildren of the insured or subscriber are eligible for coverage, coverage for newly born children of a dependent child of the insured or subscriber shall not continue beyond the initial 31-day period following birth. Nor shall such newly born children be considered dependents of the insured for any purpose addressed in this title.
IV. This section applies to all health maintenance organization contracts delivered or issued for delivery or renewed in this state on or after January 1, 1997.
Source. 1996, 188:10, eff. Jan. 1, 1997.
420-B:8-k Coverage for Diabetes Services and Supplies.
Every health maintenance organization and every similar corporation licensed under the laws of another state that issues or renews any policy, plan, or contract of individual or group health insurance providing benefits for medical or hospital expenses, shall provide to each individual or group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for the medically appropriate and necessary outpatient self-management training and educational services, pursuant to a written order of a primary care physician or practitioner, including but not limited to medical nutrition therapy for the treatment of diabetes, provided by a certified, registered, or licensed health care professional with expertise in diabetes, subject to the terms and conditions of the policy. Each health maintenance organization that issues or renews any individual or group policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses which provides a prescription rider shall cover medically appropriate or necessary insulin, oral agents, and equipment used to treat diabetes subject to the terms and conditions of the policy. Each health maintenance organization that provides coverage for prescription insulin drugs shall cap the total amount that a covered person is required to pay for each covered insulin drug prescription at an amount not to exceed $30 for each 30-day supply of each insulin prescription. The maximum $30 copayment for each 30-day supply of each covered insulin drug prescription shall apply when an original prescription is dispensed as well as when refills of the prescription are dispensed, including early refills. Coverage for prescription insulin drugs shall not be subject to any deductible. Each health maintenance organization that issues or renews any individual or group policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses which provides for durable medical equipment coverage shall provide coverage for medically appropriate or necessary equipment used to treat diabetes subject to the terms and conditions of the policy.
Source. 1997, 258:6. 2010, 188:13, eff. Aug. 20, 2010. 2020, 13:4, eff. Sept. 14, 2020.
420-B:8-l Medicare Risk Contracts.
I. The requirements of RSA 417-E, RSA 420-B:8-b, RSA 420-B:8-e, RSA 420-B:8-f, and RSA 420-B:8-ff shall not apply to a Medicare risk policy issued pursuant to a contract under section 1876 or section 1833 of the federal Social Security Act (42 U.S.C. section 1395 et seq.) as amended.
II. In the event of termination of the contract between the Centers for Medicare and Medicaid Services (CMS) and the contractor, all current enrollees of the contractor who will lose their coverage as a result of this contract termination, shall be given an opportunity to enroll, without evidence of insurability, in any Medicare Supplement policy approved for sale in this state which is then being offered by the contractor.
Source. 1997, 282:3. 2003, 145:6, eff. Aug. 16, 2003.
420-B:8-m Patients' Bill of Rights.
All health maintenance organizations shall provide to each new subscriber who is a resident of this state a copy of the patients' bill of rights law under RSA 151:21.
Source. 1997, 331:17, eff. Aug. 22, 1997.
420-B:8-n Point of Service Plans.
I. A health maintenance organization may offer a point-of-service plan in accordance with the requirements of this section. A point-of-service plan is a health maintenance organization contract which includes coverage for both in-network services and coverage for services provided by non-contracted providers.
II. A point-of-service plan offered by a health maintenance organization shall:
(a) Provide incentives for enrollees to use in-network covered services.
(b) Offer out-of-network covered services only if those services are also covered on an in-network basis.
(c) Cover out-of-network emergency services as if they had been provided in-network.
III. A point-of-service plan offered by a health maintenance organization may:
(a) Limit or exclude specific types of services, other than emergency services, from coverage when obtained out-of-network.
(b) Include provisions for member cost sharing, annual out-of-pocket limits and annual and lifetime benefit allowances for out-of-network covered services which are separate from any limits and allowances applied to in-network covered services.
(c) Cover at the out-of-network benefit level, services provided by a participating provider for which proper authorization or referral was not obtained.
IV. Subject to the provisions of RSA 420-G, a health maintenance organization may limit the groups to which point-of-service plans are offered. If a point-of-service plan is offered to a group, it must be offered to all eligible members of the group.
V. A health maintenance organization may not expend more than 20 percent of its total annual health care expenditures on out-of-network covered services. If compliance with this requirement is not demonstrated on a quarterly basis on the health maintenance organization's quarterly financial report, the commissioner may prohibit the health maintenance organization from offering a point-of-service plan to new groups until compliance has been demonstrated.
VI. A health maintenance organization shall comply with all applicable form and rate filing requirements. In complying with said requirements, the health maintenance organization shall:
(a) Design the benefit levels for in-network covered services and out-of-network covered services to achieve the desired level of in-network utilization;
(b) Provide or arrange for adequate systems to:
(1) Process and pay claims for out-of-network covered services;
(2) Meet the requirements for point-of-service plans under this section; and
(3) Generate accurate financial and regulatory reports on a timely basis in order for the commissioner to evaluate experience with the point of service plan and monitor compliance with the requirements of this section.
VII. An explanation of benefits shall be provided to enrollees who obtain services at the out-of-network benefit level which is adequate to permit the enrollee to determine his or her financial liability under the plan.
VIII. All point-of-service contracts and certificates shall contain a provision permitting the enrollee to assign any benefits provided for medical or dental care on an expense-incurred basis to the provider of care. An assignment of benefits under this paragraph does not affect or limit the payment of benefits otherwise payable under the contract or certificate.
IX. Subscriber contracts and member handbooks shall contain a clear and concise explanation of the point of service plan. The explanation shall include:
(a) The method of reimbursement;
(b) The required co-payments, co-insurance and deductibles, as applicable;
(c) Other uncovered costs or charges;
(d) The services that an enrollee is permitted to obtain at the out-of-network benefit level; and
(e) Instructions for submitting claims for services obtained at the out-of-network benefit level.
Source. 2002, 207:8, eff. May 16, 2002.
420-B:8-o Third-Party Payment of Covered, Court-Ordered Services.
The existence of a court order under RSA 169-B, RSA 169-C, or RSA 169-D for a service, program, or placement that is covered under any insurance for the minor shall not be considered in determining qualification for third-party payment under such insurance. Benefits for such services shall be subject to the same dollar limits, deductibles, co-payments and co-insurance factors and to the terms and conditions of the policy or certificate, including any managed care provisions. However, the claimant or claimant's representative shall have 48 hours from the commencement of a court-ordered service, placement, or program to seek any pre-authorization, pre-certification, or referral required under the terms of the policy. The determination of these preservice claims for court-ordered services for a minor shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 48 hours after receipt of the request and sufficient information, 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 insurer shall notify the claimant or claimant's representative within 24 hours of receipt of the request and shall advise the claimant or claimant's representative of the specific information necessary to determine to what extent benefits are covered or payable. The claimant or 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 claim determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of:
I. The insurer's receipt of the specified additional information; or
II. The end of the period afforded the claimant or claimant's representative to provide the specified additional information.
Source. 2004, 117:3, eff. Aug. 15, 2004.
420-B:8-p Coverage for Certified Midwives.
Every health maintenance organization and every similar corporation licensed under the laws of another state that issues or renews any policy, plan, or contract of individual or group health insurance providing maternity benefits shall also provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage consistent with the terms and conditions of the policy for services rendered by a midwife certified under RSA 326-D. Such coverage shall be subject to each insurer's standards and mechanisms for credentialing and contracting pursuant to RSA 420-J:4 and RSA 420-J:8 respectively, where applicable, and contingent upon services being provided in a licensed health care facility or at home and within the scope of practice of a certified midwife. Benefits provided shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.
Source. 2006, 8:4. 2008, 298:4. 2010, 188:13, eff. Aug. 20, 2010.
420-B:8-q 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, 289:15, eff. Jan. 1, 2008.
420-B:8-r Coverage for Children's Early Intervention Services.
Every health maintenance organization and every similar corporation licensed under the laws of another state that issues or renews any policy, plan, or contract of individual or group health insurance providing benefits for medical, rehabilitation, or hospital expenses, shall provide to each individual or group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for expenses arising from the services of licensed and credentialed occupational therapists, physical therapists, speech-language pathologists, and clinical social workers working with children from birth to 36 months of age with an identified developmental disability and/or delay as specified in rules adopted pursuant to RSA 171-A:18, IV as long as the providing therapist receives a referral from the child's primary care provider if applicable. The benefits in this section shall not be subject to deductibles, copayments, or coinsurance; provided that the benefits included in this section may have a cap of $3,200 per child per year not to exceed $9,600 by the child's third birthday. For a health care contract that meets the definition of a "high deductible plan" set forth in 26 U.S.C. section 223(c)(2) or a catastrophic health plan, as defined under the Patient Protection and Affordable Care Act of 2009, a carrier shall be exempt from the deductible provisions of this section and may apply a deductible to children's early intervention therapy services until an enrollee's deductible has been satisfied for the year. Notwithstanding any provision of law or rule to the contrary, the coverage under this section shall apply to the medical assistance program, pursuant to RSA 161 and RSA 167.
Source. 2007, 338:4. 2010, 188:13, eff. Aug. 20, 2010. 2020, 26:42, eff. Sept. 18, 2020. 2021, 56:11, eff. July 24, 2021.
420-B:9 Reports to the Commissioner.
I. Every organization subject to this chapter annually, on March 1, shall file a report with the commissioner and with the commissioner of health and human services, said report verified by an appropriate official of the organization, showing its financial condition on the last day of the preceding fiscal year.
II. Such report shall be filed on forms prescribed by the commissioner and shall include:
(a) A financial statement of the organization, including its balance sheet and statement of income, and expenditures for the preceding year, certified by an independent public accountant;
(b) Any changes in the information submitted pursuant to RSA 420-B:4; and
(c) Such other information relating to the performance of the health maintenance organization as the commissioner or the commissioner of health and human services may require.
Source. 1977, 282:1. 2001, 224:8, eff. Jan. 1, 2002.
I. The commissioner shall make an examination of the affairs of any health maintenance organization and providers with whom such organization has contracts, agreements, or other arrangements as often as he or she deems it necessary, but not less frequently than once in every 5 years. All examinations shall be conducted at the expense of the health maintenance organizations.
II. Every health maintenance organization and provider shall submit its books and records relating its operation to such examinations and in every way facilitate them. For the purpose of examinations, the commissioner may issue subpoenas, administer oaths to, and examine the officers and agents of the health maintenance organization.
Source. 1977, 282:1, eff. Aug. 21, 1977. 2018, 36:2, eff. May 15, 2018.
420-B:11 Complaint System.
I. Every health maintenance organization shall establish and maintain a complaint system which has been approved by the commissioner to provide reasonable procedures for the resolution of written complaints initiated by enrolled participants concerning health care services.
II. Every health maintenance organization shall establish and maintain a full log of all written complaints initiated by enrolled participants which shall include a full description of all procedures taken under said complaints and their resolution.
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:12 Prohibited Practices.
I. No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this chapter:
(a) A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrolled participant of, or person considering enrolling in, a health maintenance organization;
(b) A statement or item of information shall be deemed to be misleading, whether or not it may be literally true, if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information reasonably may be understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrolled participant of, or person considering enrollment in, a health care plan, if such benefit or advantage or absence of limitation, exclusion or disadvantage does not in fact exist;
(c) An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing special knowledge regarding health care plans or evidences of coverage therefor, to expect benefits, services, charges, or other advantages which the evidence of coverage does not provide or which the health care plan issuing such evidence of coverage does not regularly make available for enrolled participants covered under such evidence of coverage.
(d) 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.
II. RSA 406-A and RSA 417 shall be construed to apply to health maintenance organizations and evidences of coverage, except to the extent that the commissioner determines that the nature of the health maintenance organizations, and evidences of coverage render such statutes inappropriate.
III. No health maintenance organization, unless licensed as an insurer, may use in its name, evidences of coverage, contracts, or literature, any of the words "insurance," "casualty," "surety," "mutual," or any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in this state.
IV. No health maintenance organization shall exclude part-time employees or refuse to offer the same insurance benefits to part-time employees as it offers to the employee groups of which the part-time employees would be members if they were full-time employees. The insurer shall offer to include the part-time employees as part of the employer's employee group, at the full rate to be paid by the employer, at a rate prorated between the employer and the employee, or at the employee's expense. A part-time employee shall be any employee who regularly works at least half of the weekly hours of the full-time employee in the employee group of which the part-time employee would be a member if he were a full-time employee, but who works a minimum of at least 15 hours per week.
V. Every health maintenance organization which solicits bids from pharmacies for contracts to be preferred providers shall accept and list as preferred providers all pharmacies which meet the bid acceptable to the health maintenance organization.
VI. No health maintenance organization 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 health maintenance organization 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 health maintenance organization shall accept all persons covered under the existing plan. If the group does not have coverage in effect through another plan, the health maintenance organization 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 health maintenance organization 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.
VII. 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. 1977, 282:1. 1986, 114:4. 1992, 113:1; 222:3. 1993, 162:5. 1995, 126:4. 1996, 149:4. 1997, 345:8, I. 2007, 289:16, eff. Jan. 1, 2008.
Upon satisfactory evidence that any health maintenance organization has violated any law or regulation or in any way has failed in meeting its obligations, the commissioner may, in his discretion, pursue any one or more of the following courses of action:
I. Suspend the certificate of authority to operate as a health maintenance organization under this chapter. When the certificate of authority is suspended, the organization shall not during the period of such suspension enroll any additional enrolled participants except newborn children or other newly acquired dependents of existing enrolled participants, and shall not engage in any advertising or solicitation whatever;
II. Revoke the certificate of authority to operate as a health maintenance organization under this chapter. When the certificate of authority is revoked, such organization shall proceed under the supervision of the commissioner, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of such organization. It shall engage in no further advertising or solicitation whatsoever. The commissioner may, by written order, permit such further operation of the organization as he may find to be in the best interest of enrolled participants, to the end that enrolled participants will be afforded the greatest practical opportunity to obtain continuing health care coverage;
III. Impose a penalty of not more than $2,500 for each and every unlawful act committed; each violation shall constitute a separate fineable offense;
IV. Issue an administrative order requiring the health maintenance organization: to cease or modify inappropriate conduct or practices by it or any of the personnel employed or associated with it; to fulfill its contractual obligations; to provide a service which has been improperly denied; or to take appropriate steps to restore the ability of the organization to provide a contracted-for service; and
V. Apply to any court for such legal or equitable relief as the commissioner deems appropriate.
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:14 Procedure and Appeals.
All procedures under this chapter shall be governed by the provisions of RSA 400-A and any person aggrieved by any order or decision of the commissioner pursuant to this chapter shall be entitled to an appeal in accordance with RSA 541.
Source. 1977, 282:1, eff. Aug. 21, 1977.
With the exception of investments made in accordance with RSA 420-B:7, the funds of a health maintenance organization shall be invested only in securities or other investments permitted by the laws of this state for the investment of assets constituting the legal reserves of life insurance companies, or such other securities or investments as the commissioner may permit.
Source. 1977, 282:1, eff. Aug. 21, 1977.
Every organization subject to this chapter shall pay to the commissioner those fees required for payment by hospital and medical service corporations under RSA 400-A:29.
Source. 1977, 282:1, eff. Aug. 21, 1977.
Every organization doing business pursuant to this chapter shall be subject to the premium tax requirements of RSA 400-A:31 and 32. Except for payments made by the state of New Hampshire, no tax shall be levied on any premiums, fees-for-service and other payments for health, dental, and employee benefit coverages from political subdivisions of the state of New Hampshire or from employees or retirees of such political subdivisions, either directly or indirectly. Nor shall any tax be levied on any revenues of such an organization that are derived from any business of the organization where the organization has assumed no insurance risk and is providing administrative services, only.
Source. 1977, 282:1. 1995, 256:3, eff. July 1, 1995.
420-B:18 Regulation of Agents.
All persons engaged in the solicitation or enrollment of enrolled participants shall be duly licensed agents for the sale of health insurance in the state pursuant to the provisions of RSA 402-J.
Source. 1977, 282:1. 2000, 315:23, eff. Jan. 1, 2001.
420-B:19 Powers of Insurers and Hospital and Medical Service Corporations.
I. An insurance company licensed in this state, or a hospital, medical or health service corporation authorized to do business in this state, either directly or through a subsidiary or affiliate, may organize and operate a health maintenance organization under the provisions of this chapter. An insurance company licensed in this state, or a hospital, medical or health services corporation shall obtain a certificate of authority pursuant to RSA 420-B:2 and shall comply with all of the provisions of this chapter with respect to its health maintenance organization activities. Notwithstanding any other law which may be inconsistent herewith, any 2 or more such insurance companies, hospitals or medical service corporations, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the providing of health care services by a health maintenance organization owned or operated by an insurer or a subsidiary thereof.
II. Notwithstanding any provisions of the laws of this state relating to insurance corporations engaged in the business of insurance, or any provisions of RSA 420-A relating to health service corporations, an insurer or health service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of failure of the health maintenance organization to meet its obligations. The enrolled participants of a health maintenance organization constitute a permissible group under such laws. Under the contracts set forth in this paragraph, the insurer or health service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers pursuant to the health care plan.
Source. 1977, 282:1. 1997, 190:15. 2011, 39:1, eff. July 8, 2011.
420-B:20 Statutory Construction and Relationship to Other Laws.
I. A health maintenance organization shall be considered an insurance company, however, except as provided in this chapter, title XXXVII shall not be applicable to any health maintenance organization granted a certificate of authority under this chapter; provided that this provision does not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance laws or the hospital or medical service corporation laws of this state, except with respect to its health maintenance organization activities authorized and regulated pursuant to this chapter.
II. The solicitation of enrolled participants or the provision of factually accurate information regarding coverage, rates, locations and hours of service, concepts and programs for the delivery of health care services, names of affiliated institutions, and credentials of participating providers, by a health maintenance organization or its agents to potential enrolled participants and to the general public shall not be construed to be violative of any provision of the laws of this state relating to solicitation or advertising by health professionals, nor be grounds for revocation or suspension of the license of a physician or surgeon under RSA 329:17.
III. The requirements of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415:6-g, RSA 415:6-m, RSA 415:6-o, RSA 415:6-r, RSA 415:6-t, RSA 415:6-u, RSA 415:6-v, RSA 415:6-w, RSA 415:6-x, RSA 415:6-y, RSA 415:6-z, RSA 415:6-a1, RSA 415:18, VII-a, RSA 415:18, XVI and XVII, RSA 415:18-i, RSA 415:18-j, RSA 415:18-r, RSA 415:18-t, RSA 415:18-u, RSA 415:18-v, RSA 415:18-w, RSA 415:18-y, RSA 415:18-z, RSA 415:18-aa, RSA 415:18-bb, RSA 415:18-cc, RSA 415:18-dd, RSA 415:18-ee, RSA 415-A, RSA 415-F, RSA 420-G, and RSA 420-J shall apply to health maintenance organizations.
Source. 1977, 282:1. 1989, 186:4. 1990, 114:2, 3. 1994, 166:10. 1995, 112:18. 1996, 188:11. 1997, 344:8, 16; 345:6. 1999, 323:8. 2000, 207:7. 2006, 187:4. 2007, 289:36. 2008, 389:4. 2010, 362:4. 2011, 133:4; 189:9, 11. 2012, 278:4. 2014, 299:4, eff. Sept. 30, 2014; 299:7, eff. Oct. 1, 2017. 2015, 263:10, eff. Jan. 1, 2017; 263:11, eff. Oct. 1, 2017 at 12:01 a.m.; 263:13, eff. Jan. 1, 2021. 2016, 326:6, eff. Aug. 23, 2016; 326:7, eff. Oct. 1, 2017 at 12:02 a.m.; 326:8, eff. Jan. 1, 2021 at 12:01 a.m.; 326:10, eff. Jan. 1, 2017 at 12:01 a.m. 2018, 4:15, eff. Feb. 8, 2018; 4:16, eff. Jan. 1, 2021 at 12:02 a.m.; 361:6, eff. Jan. 1, 2019; 361:7, eff. Jan. 1, 2021 at 12:02 a.m. 2019, 113:6, eff. Aug. 20, 2019; 113:7, eff. Jan. 1, 2021 at 12:03 a.m. 2020, 13:13, eff. Sept. 14, 2020; 13:14, eff. Jan. 1, 2021 at 12:04 a.m.; 30:13, eff. Sept. 21, 2020; 30:14, eff. Jan. 1, 2021 at 12:04 p.m.; 39:8, eff. Jan. 1, 2021 at 12:04 a.m.; 39:24, eff. June 30, 2021; 39:25, eff. Jan. 1, 2021 at 12:05 p.m.
The commissioner in accordance with RSA 541-A may promulgate reasonable rules for the implementation of the provisions of this chapter.
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:22 Federal Legislation.
Nothing in this chapter shall prohibit any health maintenance organization from meeting the requirements of any federal law which would authorize such health maintenance organization to receive federal financial assistance or enroll beneficiaries assisted by federal funds, or shall be interpreted or applied to prevent qualification of an organization holding a certificate of authority under this chapter from qualifying as a "health maintenance organization" under Public Law 93-222 as defined in 42 U.S.C. section 300e(a).
Source. 1977, 282:1, eff. Aug. 21, 1977.
420-B:23 Systems Failing to Meet Requirements of This Chapter; Operation, Licensing and Regulation.
Notwithstanding the provisions of this chapter, a person proposing to operate a system of health care delivery and financing which is to be offered to individuals, whether or not as members of groups, in exchange for a fixed payment and organized so that providers and the organization are in some part at risk for the cost of services in a manner similar to a health maintenance organization, but who fails to meet the requirements set forth in this chapter, may operate such a system if the commissioner finds that the proposed operation will benefit persons who will be served by it. The operation shall be licensed and regulated in the same manner as a health maintenance organization under this chapter, except to the extent that the commissioner determines that the regulation is inappropriate to the system of health care delivery and financing. A person operating a system of health care delivery and financing pursuant to this section shall not advertise or solicit or in any way identify itself in a manner implying to the public that it is a health maintenance organization licensed under this chapter.
Source. 1986, 56:1, eff. July 4, 1986.
420-B:24 Notification of Option to Enroll in Health Maintenance Organization.
I. Each employer, public or private, in this state which offers its employees a health benefit plan and employs at least 25 employees, and each employee benefit fund in this state which offers its members any form of health benefit, shall make available to and inform its employees or members of the option to enroll in at least one health maintenance organization holding a valid certificate of authority which provides health care services in the geographic areas in which a substantial number of such employees or members reside; provided, however, that such employer or employee benefit fund shall not be required to make available or inform its employees or members about such option if no health maintenance organization is available to such employer or employee benefit plan. Where there is a prevailing collective bargaining agreement, the selection of the available health maintenance organizations shall be made pursuant to the agreement.
II. No employer in this state shall be required to pay more for health benefits as a result of the application of this section than would otherwise be required by any prevailing collective bargaining agreement or other contract for the provision of health benefits to its employees, provided that the employer or benefits fund shall pay to the health maintenance organization chosen by each employee or member an amount equal to the lesser of:
(a) The amount paid on behalf of its other employees or members for health benefits; or
(b) The health maintenance organization's charge for coverage approved by the commissioner.
III. Should federal legislation requiring employers to offer to employees the option to enroll in a health maintenance organization be repealed or expire, the provisions of RSA 420-B:24, I and II shall no longer apply.
Source. 1989, 186:5, eff. July 1, 1989.
420-B:25 Capital Requirements.
I. Before issuing a certificate of authority under this chapter, the commissioner shall require that the health maintenance organization have an initial net worth of $6,000,000 and that the minimum net worth required under paragraph II is maintained.
II. Every health maintenance organization shall maintain a minimum net worth equal to the greater of:
(a) $6,000,000; or
(b) Seven and one-half percent of annual premium revenues as reported on the most recent annual financial statement filed with the commissioner. The minimum net worth shall be met by the health maintenance organization upon expiration of the certificate of authority.
III. In addition to paragraphs I and II, if at any time uncovered expenditures exceed 15 percent of the total health care expenditures, a health maintenance organization shall increase the required minimum net worth by 120 percent of the health maintenance organization's outstanding liability for uncovered expenditures for enrollees including incurred but not reported claims which shall be calculated as of the first date of the month and retained for the remainder of the month. The increase to minimum net worth required by this paragraph shall not exceed $5,000,000. Health maintenance organizations shall file a report within 45 days after the end of the calendar quarter with information sufficient to demonstrate compliance with this section.
IV. In addition to paragraphs I, II and III, the commissioner shall require additional capital if he finds that the health maintenance organization does not have reasonable and adequate specific stop-loss reinsurance for its individual members.
V. Every health maintenance organization shall, when determining liabilities, include an amount estimated in the aggregate to provide for any unearned premium and for the payment of all claims for health care expenditures which have been incurred, whether reported or unreported, which are unpaid and for which such organization is or may be liable, and to provide for the expense of adjustment of settlement of such claims.
VI. Such liabilities shall be computed in accordance with rules adopted by the commissioner upon reasonable consideration of the ascertained experience and character of the health maintenance organization.
Source. 1989, 186:5. 1990, 114:4, eff. July 1, 1990.
420-B:26 Repealed by 1997, 345:8, II, eff. Jan. 1, 1998.