CHAPTER
Ins 2200 HEALTH
MAINTENANCE ORGANIZATIONS
Statutory
Authority: RSA 400-A:15;
RSA 420-B:21
PART Ins 2201 LICENSING AND
REGULATION OF HEALTH MAINTENANCE ORGANIZATIONS
Ins 2201.01 Purpose. The purpose of this rule is to delineate a
system for regulation of health maintenance organizations that is fair and
efficient, and promotes their continued solvency.
Source. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16
Ins 2201.02 Applicability and Scope.
(a) No health maintenance organization shall,
without being licensed in accordance with this part:
(1) Provide or arrange for health care services to enrolled
participants in exchange primarily for a prepaid per capita or aggregate fixed
sum; or
(2) Commence operations, except as provided in Ins 2201.04(g),
with operations deemed to commence on the date on which any contracts for
health services are available to members or on which evidences of coverage are
issued.
(b) This part shall apply to any health
maintenance organization regardless of whether services are to be delivered
through physicians or other health professionals:
(1)
Who are employees of the health maintenance organization;
(2)
Who are organized on a group practice basis;
(3)
Who are organized on an individual practice basis; or
(4)
Under any other arrangements.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #5944, eff 1-1-95, EXPIRED: 1-1-03
New. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16
Ins 2201.03 Definitions.
(a) For the purposes of this part, the
definitions appearing in RSA 420-B:1 shall apply.
(b) With respect to the following words or
phrases used in this part, not defined in RSA 420-B:1,
the following definitions shall apply:
(1)
"Active recipient of mental health services" means an insured,
subscriber, or member of a replacing
carrier's health insurance benefit plan who received mental health services
from a mental health provider while covered by a prior carrier's benefit plan
provided such services were for a purpose other than monitoring medications and
were received at least as often as:
a. In the case of outpatient services:
1.
For 2 separate days during the 30 day period immediately prior to the
effective date of the replacing carrier's plan;
2.
For 3 separate days during the 90 day period immediately prior to the
effective date of the replacing carrier's plan; or
3.
For 5 separate days within the 12 month period immediately preceding the
effective date of the replacing carrier's plan; and
b. In the case of inpatient services, one inpatient confinement during
the 12 month period immediately prior to the effective date of the replacing
carrier's plan;
(2) "Complaints" means the grievances
of persons concerning the services of the health maintenance organization;
(3) "Controlling interest" means the
possession, either directly or indirectly, of the power of a person or persons
to direct or cause the direction of the management and policies of the health
maintenance organization, whether through the ownership of voting stock, or by
contract, other than commercial contract for goods or management services, or
through official position or positions of, or corporate office or offices held
by, the person or persons, or otherwise, and includes a presumed controlling
interest;
(4)
"Mental health
provider" means any professional or institution listed under RSA 415:18-a,
IV; and
(5)
"Presumed controlling interest" means the existence of a
controlling interest when any person, directly
or indirectly, owns, controls, holds, with the present power to vote more than
5 percent of the voting stock of the health maintenance organization, or holds
proxies representing more than 5 percent of the voting stock of any other
person or persons.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16
Ins 2201.04 Certificate of Authority.
(a) Any health maintenance organization seeking
to do insurance business in this state shall complete and submit an original copy
of the National Association of Insurance Commissioners (NAIC) Uniform
Certificate of Authority Application (UCAA) as a health maintenance
organization.
(b) The UCAA includes 3 applications, http://www.naic.org/industry_ucaa_corp_amend.html, available as noted in Appendix B:
(1)
The Primary Application - UCAA Form 2P, revised 08/18/14, for use by
newly formed companies seeking a Certificate of Authority in their domicile
state and by companies wishing to re-domesticate to a uniform state;
(2)
The Expansion Application - UCAA Form 2E, revised 08/18/14, for use by
companies in good standing in their state of domicile that wish to expand their
business
into a uniform state; and
(3)
The Corporate Amendments
Application - UCAA Form 2C, revised 12/19/14, for use by an existing
company for requesting amendments to its certificate of authority.
(c) The UCAA application shall be complete,
provided, however, that where a form mentions perjury, perjury shall mean any
applicable penalty found in RSA 641, falsification in official matters,
including RSA 641:3, unsworn falsification.
(d)
The UCAA application shall also include all required information
and attachments, and shall include the following state specific information and requirements:
(1)
If the applicant is not domiciled in this state, a power of attorney
duly executed and appointing the commissioner and his successors in office, and
duly authorized deputies, as true and lawful attorney for the applicant for
service of process in this state pursuant to RSA 420-B:4;
(2)
Payment by check or other draft of required application fees as set
forth in RSA 400-A:29;
(3)
Basic organizational documents, articles of incorporation, and all amendments thereto;
(4)
Copies of all by-laws, rules,
and regulations of the applicant;
(5)
Copies of the organizational chart of the applicant, including the
titles, names, and salaries, if any, of officers and key management personnel
dealing in marketing, administration, enrollment, grievance procedures, quality
assurance, contract negotiations, and financial matters;
(6)
A list of members of the board of directors, or similar policymaking
body of the applicant, with the name, principal occupation, and employer of
each;
(7)
A description of the applicant's proposed system for handling complaints
that shall include procedures for the registration of complaints and procedures
for the resolution of complaints;
(8)
Financial reports for the prior 3 fiscal years, with the qualification
that financial reports submitted
by insurance companies or hospital, medical, or health service corporations
applying for a certificate of authority to operate a health maintenance
organization as a subsidiary or affiliate pursuant to RSA 420-B:19 shall be restricted in subject matter to the finances of
such subsidiary or affiliate;
(9)
Financial statements projecting the results of the applicant's
operations for the next 3 years from the date of application, on a quarterly
basis for years one and 2 and annually for year 3, including the following:
a. Balance sheet;
b. Statement of income from all sources, and expenses;
c. Cash flow;
d. Present and anticipated capital expenditures;
e. Repayment schedules for existing or
anticipated loans or alternative financing arrangements;
f. Statement indicating when the applicant estimates
that income from enrollments and other operations will equal expenses; and
g. Detailed statements underlying assumptions used
and the basis thereof;
(10) A
detailed statement of the health maintenance organization's plan to establish
and maintain reserves or other funds necessary to cover any risks projected and
not otherwise assumed by another entity, carrier, or reinsurer;
(11) A detailed statement of current and projected
reserve-establishment calculations, as well as amounts, purpose and uses of the
reserves, and assumptions and bases therefor, including, but not limited to,
identification of reserves set aside to meet uncovered reinsurance items;
(12)
Copies of all reinsurance, conversion, or other arrangements with other
insurers, health providers, medical service corporations, hospital service
corporations, health service corporations, governmental agencies or
organizations, or other health maintenance organizations that provide payment
schedules for contracted-for
health care services, or made directly to provide services, in the event the health
maintenance organization is unable or ceases to provide contracted-for health
services for any reason;
(13) A
copy of the applicant's official notification of status as a federally
qualified health maintenance organization, if it is so designated;
(14) A
statement of insurance or funded self-insurance for:
a. Protection against loss of property and liability of
the applicant;
b. Workers' compensation to protect against claims
arising from work-related injuries of the applicant's employees; and
c. Medical malpractice liability insurance for the
applicant and its providers;
(15) A
listing of shareholders or other equity holders, or members with holdings of 5
percent or more of capital shares, partnership interest, or other evidence of
equity holdings, listed by name,
address, number and percentage of shares or other interest held, and any other
affiliations with the applicant;
(16) A listing of the applicant's legal,
accounting, and actuarial representatives by name and address;
(17) A
statement that fidelity bond coverage exists for all officers and employees
entrusted with the handling of funds for the applicant;
(18)
A statement of enrollment practices and procedures;
(19) An
enrollment projection of members per month for the next 3 years from the date
of application, on a quarterly basis for years one and 2, and annually for year
3, including:
a. The current total enrollment of the applicant;
b. The current categories of membership of the applicant:
1. Private;
2. Group;
3. Non-group;
4. Medicaid;
5. Medicare;
6. Federal employees;
7.
State employees; and
c. A detailed statement of assumptions used, and the
basis therefor;
(20) A
description of the geographical area to be served, including:
a. Present population
figures for each city or town within the current area; and
b. Projections of future population trends for each city and town within the current
area for the next 5 years from the date of application; and
(21)
A statement certifying to the commissioner that the health maintenance
organization is in compliance with all federal laws and regulations pertaining
to health maintenance organizations.
(e) The application documents
shall be compiled in the order in which they are required.
(f)
The applicant shall state the reasons for the absences of any items
required, but not
included in the application.
(g) In the event that the
commissioner finds the application incomplete, the commissioner shall provide
the applicant written notice specifying the additional documents or information
required under this part.
(h)
The
applicant shall have 30 days from receipt of the notice in which to file the
additional material required by (d) above or the application shall be deemed
rejected.
(i) Prior to the
issuance of a certificate of authority to operate a health maintenance
organization, an applicant may:
(1) Engage in such activities as are necessary to the gathering of
information for applications for certification as a federally qualified health
maintenance organization, and for certification pursuant to RSA 420-B and these
parts;
(2) Make contact with
potential enrolled participants, employers, or both for the purposes of
determining the feasibility of establishing a health maintenance organization
in a given area, and for the purpose of generally acquainting the potential
enrolled participants, employers, or both with the general benefits of the applicant's proposed
program; and
(3) Engage in the establishment of physical
facilities for the operation of the health maintenance organization.
(j)
In
no event, shall an applicant make a commitment to render services or initiate a
contract between the applicant and enrolled participants, employers, or both
until a certificate of authority has been issued by the department.
(k) The
applicant company may continue to operate pursuant to Ins 2201.04(i), above, until such time as its application shall be
denied.
(l) Before issuing a
certificate of authority to an applicant, the commissioner shall be satisfied,
by examination and evidence that the applicant has complied, and will continue
to comply with the requirements of RSA 420-B and this part.
(m) The commissioner shall act
upon an application for a certificate of authority within 90 days after the
filing of a completed application.
(n)
The
commissioner shall notify the applicant, in writing, of the approval of the
application or its denial, and if the application is denied, the reasons
therefor.
(o) If the applicant wishes a hearing before the commissioner
concerning the denial of the certificate of authority, it may make an
application for such hearing pursuant to RSA 400-A:17 and the hearing shall be
conducted in accordance with the provisions of RSA 400-A and Ins 200.
(p) Each
certificate of authority issued under this part shall be renewed pursuant to
RSA
420-B:5-a unless revoked or
suspended by the commissioner, provided that the health maintenance
organization commences operations within one year after the date on which the
certificate of authority was issued.
(q)
Failure to commence operations within the period in (p) above shall
invalidate the certificate of authority and a new application shall be submitted before another
certificate of authority will be issued.
(r) Grounds
for revocation or suspension of certificate of authority shall include:
(1)
An unsound financial condition;
(2) Business policies or methods are unsound or improper;
(3) Management conditions that render the further transaction of business
hazardous to the public or to its members;
(4) The committing of acts prohibited by RSA 420-B:12;
and
(5) Officers or agents that have refused to submit to an examination
as provided for in RSA 420-B:10.
(s)
Any denial or approval of the application
shall be public, however, all documents and workpapers
submitted or used in the course of analysis by the department of the financial
condition of the applicant shall be confidential in accordance with RSA
400-A:37 and not subject to disclosure under RSA 91-A. Any other information submitted as part of
the UCAA application by the health maintenance organization that is
confidential commercial information, proprietary information, information
protected as a trade secret, information that is confidential by law, or
information that, if disclosed, would constitute an invasion of privacy shall
be marked by the health maintenance organization as confidential and shall not
be subject to disclosure under RSA 91-A.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16
Ins
2201.05 Evidences
of Coverage and Advertising. All
evidences of coverage and advertising shall be made in accordance with Ins 400,
Ins 2600, and Ins 3100.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16
Ins 2201.06 Periodic and Special
Reporting.
(a)
The health maintenance organization shall provide concurrent notice to
the commissioner of any of the following events or occurrences:
(1) Plans to purchase, lease, construct,
renovate, operate, or maintain medical facilities;
(2) Any loans made with an annual aggregate from
one creditor exceeding one percent of the health maintenance organization's
liabilities, including:
a. The amount of the
loan(s);
b. The term(s) of
repayment;
c. Security given, if any;
and
d. Any guarantees or
sureties provided;
(3) Any contracts entered into with an insurance
company or health service corporation, excluding contracts for fringe benefits
for organization employees; and
(4) Any grants to be received from public or
private sources exceeding on an annual basis from any one source one percent of
the health maintenance organization's assets.
(b)
The health maintenance organization shall file a report of all changes
in controlling interest within 30 days of their occurrence.
(c)
Each health maintenance organization shall, within 5 business days after
the occurrence, inform the commissioner of any extraordinary loss or claim that
has the potential to render it incapable of meeting its obligations as they
become due.
(d)
The health maintenance organization shall maintain and provide to the
department upon request, the following information:
(1) Plans to purchase, lease, construct,
renovate, operate, or maintain medical facilities;
(2) Any loans made with an annual aggregate from
one creditor exceeding one percent of the health maintenance organization's
liabilities, including:
a. The amount of the
loan(s);
b. The term(s) of
repayment;
c. Security given, if any;
and
d. Any guarantees or
sureties provided;
(3) Any contracts entered into with an insurance
company or health service corporation, excluding contracts for fringe benefits
for organization employees;
(4) Any grants to be received from public or
private sources exceeding on an annual aggregate basis from any one source one
percent of the health maintenance organization's assets; and
(5) Membership changes in group and non-group
categories.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16
Ins 2201.07 Annual Reports.
(a) Every health maintenance organization shall
annually file with the commissioner and with the commissioner of the department
of health and human services, within 120 days after the close of its fiscal
year, 2 copies of a report, verified by an official of the organization,
showing the health maintenance organization's financial condition on the last
day of the preceding fiscal year.
(b) Each health maintenance organization shall
complete and submit the following materials to the commissioner as
documentation of its annual report:
(1) A financial statement, using the form
of the National Association of Insurance Commissioners (NAIC) Annual Statement
Blank available at http://www.naic.org/ industry_financial_filing.htm and as
noted in Appendix B, accompanied by a statement certified by an independent
public accountant;
(2)
Any changes, occurring during the preceding fiscal year, in information
that had been submitted with the health maintenance organization's application
for a certificate of authority;
(3)
Details of services provided by the health maintenance organization on a
fee-for-service or charitable basis;
(4)
A listing of all complaints received by the health maintenance
organization from members during the period of the preceding fiscal year, with
a description of the complaint, and how it was resolved;
(5)
A statement of all investments made by the health maintenance
organization, as provided in the NAIC Annual Statement Blank; and
(6)
A statement certifying to the commissioner that the health maintenance
organization is in compliance with federal laws and regulations pertaining to
health maintenance organizations.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16
Ins 2201.08 Licensing of Producers. All producers of health maintenance
organizations shall be licensed pursuant to RSA 402-J.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16
Ins 2201.09 Continuity of Benefits.
(a) The transition, under the employment-related
group health insurance plan, from a traditional indemnity or nonprofit health
service corporation mode of coverage to a health maintenance organization
shall:
(1) Be effected in every case without application of waiting periods or
exclusions or limitations based on health status as conditions of enrollment or
transfer; and
(2) Provide all basic health services, as defined in section 1302(1) of
the Health Maintenance Organization Act of 1973 (42USC§ 300e-1(1)) as amended,
that exist under the applicable traditional indemnity or nonprofit health
service corporation mode of coverage from which transfer is made.
(b) Whenever there is a replacement of a
carrier's benefit plan by the benefit plan of another carrier, the insureds, subscribers,
or members who were active recipients of mental health services under the prior
carrier's plan shall be entitled to continue to receive mental health services
from the same mental health provider who provided the services received while
the insured, subscriber, or member
was an active recipient of mental health services under the prior carrier's
plan.
(c) The entitlement to receive services pursuant
to (b) above shall:
(1)
Continue for one year following the effective date of the new carrier's
benefit plan;
(2)
Override any provisions in the replacing carrier's plan requiring the
insured, subscriber or member to receive mental health services from mental
health providers who have contracted with the replacing carrier to be part of
the replacing carrier's provider network;
(3)
Override any provisions in the replacing carrier's plan that reduce or
eliminate benefits for mental health services whenever such services are
received from a mental health provider who has not contracted to be part of the
replacing carrier's network;
(4)
Be provided to any insured, subscriber or member who, during an open
enrollment period, changed from a benefit plan sponsored by the employer to
another benefit plan sponsored by the same employer;
(5)
Be subject to any provisions of the replacing carrier's plan requiring
mental health services to be medically necessary, as defined in the replacing
carrier's plan;
(6)
Be subject to any provisions of the replacing carrier's plan requiring
mental health services to be preauthorized by the replacing carrier or its
utilization review agent;
(7)
Be subject to the provision of proof of receipt of prior services while
the prior carrier's plan was in effect as follows:
a. The insured, subscriber, or member shall be responsible for providing
such proof in the form of:
1.
An explanation of benefits form from the prior carrier;
2.
A letter from the provider who provided the services attesting to the
fact that services were provided together with the dates such services were
rendered; or
3.
Any other documentation which the replacing carrier determines to be
acceptable as proof; and
(8)
Be subject to verification that the provider of services under the prior
carrier is protected by a malpractice policy with coverage of at least
$1,000,000 per single incident and at least $3,000,000 in the aggregate.
(d) While the entitlement provided pursuant to
(b) above is in effect, benefits shall be paid by the replacing carrier as if
the insured, subscriber, or member
were receiving mental health services from a mental health provider who has
contracted with the replacing carrier.
(e) The replacing carrier shall not be required
to make direct benefit payments to a non-network provider nor shall the
liability of the replacing carrier exceed what its liability would have been if
the mental health services had been received from a contracting mental health
provider who is reimbursed on a fee-for-service basis.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08; ss
by #11194, eff 12-5-16 (from Ins 2201.10)
APPENDIX A: State
Statute Implemented
|
Rule |
Statute |
|
|
|
|
Ins 2201.01 |
RSA 400-A:15, I; 420-B:2 |
|
Ins 2201.02 |
RSA 400-A:15, I; 420-B:2 |
|
Ins 2201.03 |
RSA 400-A:15, I; 420-B:1; 420-B:2;
420-B:8-b |
|
Ins 2201.04 |
RSA 400-A:15, I; 420-B:2; 420-B:3,
420-B:4, 420-B:5; 420-B:5-a; 420-B:5-b; 420-B:6 |
|
Ins 2201.05 |
RSA 400-A:15, I; 420-B:12; 420-B:20; 406-A;
417 |
|
Ins 2201.06 |
RSA 400-A:15, I; 420-B:12, 420-B:20 |
|
Ins 2201.07 |
RSA 400-A:15, I; 420-B:9; 420-B:12;
420-B:20 |
|
Ins 2201.08 |
RSA 400-A:15, I; 402-J; 420-B:18 |
|
Ins 2201.09 |
RSA 400-A:15, I; 415:2, I(b); 417:4,
I; 420-B:7, X; 420-B:8-b; 420-B:8-c; 420-B:8-d; 420-B:8-i; 420-B:8-n;
420-B:12; 420-B:20 |
APPENDIX
B: Incorporation by Reference
Information
|
Rule |
Title |
Obtain: |
|
|
|
|
|
Ins
2201.04(a)(1) |
UCAA
Primary Application, Form 2P, Revised 08/18/14 |
Online:
http://www.naic.org/documents/industry_ucaa_form02P.doc No
cost to download this form |
|
Ins
2201.04(a)(2) |
UCAA
Expansion Application, Form 2E, Revised 08/18/14 |
Online:
http://www.naic.org/documents/industry_ucaa_form02E.doc No
cost to download this form |
|
Ins
2201.04(a)(3) |
UCAA
Corporate Amendments Application, Form 2C, Revised 12/19/14 |
Online:
http://www.naic.org/documents/industry_ucaa_form02C.doc No
cost to download this form |
|
Ins
2201.07(b)(1) |
NAIC
Annual Financial Statement Blank 2008
version, available for filing under current year |
Online: http://www.naic.org/industry_financial_filing.htm No
cost for this form |