He-C 5000 Payments Medic

CHAPTER He-C 5000 DEPARTMENTAL MEDICAID PROGRAM ADMINISTRATION

PART He-C 5001 PAYMENTS TO NON-PUBLIC DISPROPORTIONATE SHARE HOSPITALS

He-C 5001.01 Definitions.

(a) “Audit” means the independent disproportionate share hospital audit required by federal Medicaid regulations at 42 C.F.R. Part 455, Subpart D.

(b) “Department” means the New Hampshire department of health and human services.

(c) “Disproportionate share non-public hospitals” means, for purposes of this part, in-state hospitals, licensed under RSA 151, which participate in the provider network of the State Medicaid managed care program, and which meet the minimum criteria for disproportionate share hospital payments pursuant to 42 U.S.C. section 1396r-4(d), and in-state hospitals as identified by RSA 167:63, IV, which meet the requirements for a deemed disproportionate share hospital under 42 U.S.C. section 1396r-4(b), but do not include government facilities.

(d) “Disproportionate share payment,” in conformity with relevant provisions of RSA 167:64, the New Hampshire Title XIX Medicaid State Plan, federal law at 42 U.S.C. section 1396r-4, and federal regulations promulgated thereunder, means the amount determined by the department and paid to eligible hospitals to compensate the hospitals for services provided to Medicaid recipients and uninsured individuals.

(e) “Uncompensated care” means losses arising from the difference between the cost of providing inpatient or outpatient hospital services to Medicaid recipients and to uninsured patients during the year, and the reimbursement received for those recipients and patients consistent with 42 U.S.C. section 1396r-4(g) and related federal regulations promulgated by the Centers for Medicare and Medicaid Services.

(f) “Uncompensated care and Medicaid fund” means the fund established by RSA 167:63 through RSA 167:65, from which payments are made to eligible hospitals to support their services to Medicaid recipients and uninsured individuals.

(g) “Uninsured patient care” means inpatient and outpatient hospital services provided to any individual with no health insurance or source of third party coverage for services provided to the individual patient during the year. Uninsured patient care does not include care provided to patients with health insurance for the services provided in their third party coverage benefit package but who have unpaid co-pays or deductibles or any other unreimbursed costs associated with a patient’s out of pocket payment responsibilities for covered inpatient or outpatient hospital services provided to them.

Source. #5167, EMERGENCY, eff 6-21-91, exp. 10-19-91; ss by #5249, eff 10-18-91; ss by #6599, eff 10-8-97, EXPIRED: 10-8-05

New. #9814, INTERIM, eff 11-19-10, EXPIRES: 5-18-11; ss by #9916-A, eff 4-23-11; amd by #10029, INTERIM, eff 11-19-11, EXPIRES: 5-17-12; ss by #10109, eff 5-17-12; ss by #10789, eff 2-21-15; ss by #12468, eff 1-26-18; amd by #12719, eff 1-29-19

He-C 5001.02 Uncompensated Care Reimbursement System.

(a) The commissioner of the department shall determine, for each disproportionate share non-public hospital, its annual disproportionate share payment to the extent that such funds are available in the uncompensated care and Medicaid fund.

(b) The disproportionate share payments shall be made in accordance with RSA 167:64.

(c) Disproportionate share payments to the disproportionate share non-public hospitals shall be made at least annually in the fiscal year within which the uncompensated care funds became available, pursuant to He-C 5001.02, based upon the availability of funds in the uncompensated care fund.

(d) Disproportionate share non-public hospitals shall reconcile and submit repayment in the event of an overpayment or to ensure compliance with state and federal law and the Medicaid State Plan as approved by the Centers for Medicare and Medicaid Services.

Source. #5167, EMERGENCY, eff 6-21-91, exp. 10-19-91; ss by #5249, eff 10-18-91; ss by #6599, eff 10-8-97, EXPIRED: 10-8-05

New. #9814, INTERIM, eff 11-19-10, EXPIRES: 5-18-11; ss by #9916-A, eff 4-23-11; ss by #10029, INTERIM, eff 11-19-11, EXPIRES: 5-17-12; ss by #10109, eff 5-17-12; ss by #10789, eff 2-21-15

PART He-C 5002 UNCOMPENSATED CARE FUND REPORTING

REVISION NOTE:

Document #13165, effective 1-26-21, readopted with amendments the “Annual Medicaid Uncompensated Care Cost Data Request Form” pursuant to the expedited revisions to agency forms process in RSA 541-A:19-c. The “Annual Medicaid Uncompensated Care Cost Data Request Form” is incorporated by reference in He-C 5002.01(a) and also referenced in He-C 5002.01(b). Document #13165 contained only the amended form, giving it a new effective date. Since Document #13165 updated the revision date on the form from “(January 2019 Edition)” to “(January 2021 Edition)”, the revision date was subsequently updated editorially in He-C 5002.01(a) and (b) to “(January 2021 edition)”. The prior filing affecting rule He-C 5002.01 was Document #12719, effective 1-29-19, and the effective date of the rule remained unchanged by Document #13165.

He-C 5002.01 Reporting Requirements.

(a) All disproportionate share non-public hospitals, as defined in He-C 5001.01(c), shall complete and submit the “Annual Medicaid Uncompensated Care Cost Data Request Form” (January 2023 edition) as follows:

(1) To the office of the commissioner, NH department of health and human services;

(2) Annually, no later than the second to last Friday in February of each year; and

(3) Signed by the chief financial officer (CFO) of each hospital.

(b) Copies of the “Annual Medicaid Uncompensated Care Cost Data Request Form” (January 2023 edition) may be obtained from the office of the commissioner, department of health and human services, Concord, NH 03301-6505.

(c) Hospitals shall maintain all data on claims related to Medicaid and uninsured patients, including Medicare and third-party liability revenue until such time as directed otherwise by the Department.

Source. #6888, eff 11-21-98, EXPIRED: 11-21-06

New. #9814, INTERIM, eff 11-19-10, EXPIRES: 5-18-11; amd by #9916-A, eff 4-23-11, (para (b)); amd by 9916-B, eff 4-23-11, (para (a)); ss by #10029, INTERIM, eff 11-19-11, EXPIRES: 5-17-12; ss by #10109, eff 5-17-12; ss by #10789, eff 2-21-15; ss by #12468, eff 1-26-18; ss by #12719, eff 1-29-19; (see also Revision Note at part heading for He-C 5002); ss by #13545, eff 1-28-23

He-C 5002.02 Reconsideration of an Audited Hospital-Specific DSH Limit.

(a) A hospital may submit a written request to the department for reconsideration of its audited hospital-specific DSH limit pursuant to 42 U.S.C. section 1396r-4(j)(2) if the following criteria are met:

(1) The hospital has and submits additional data that has not been previously considered; and

(2) There has been no redistribution or recoupment of funds for the fiscal year in question for that hospital or any other hospital.

(b) For the fiscal year 2013 audit, which was issued December 31, 2016, hospitals shall have 13 months from the date of issuance to request reconsideration.

(c) For audit reports for fiscal year 2014 and later, hospitals may request reconsideration within 3 months of issuance of the audit report.

(d) If, in the auditor’s opinion, the additional data would have a material impact on the amount paid to the hospital for that year, the auditor shall conduct a reassessment and issue an addendum, which the auditor shall send to the department.

Source. #12468, eff 1-26-18

PART He-C 5003 PREMIUM SCHEDULE

Statutory Authority: RSA 167:3-c, XII

He-C 5003.01 Premium Schedule for Medicaid for Employed Adults with Disabilities (MEAD).

(a) Monthly premium calculation shall be determined by combining monthly net income for initial eligibility, based on current treatment, disregards and exclusions from income for aid to the permanently and totally disabled (APTD) and aid to the needy blind (ANB) recipients pursuant to He-W 654, with monthly Supplemental Security Income (SSI) and shall include deduction of private health insurance premiums pursuant to He-C 5003.02(b).

(b) As a condition of eligibility for MEAD, recipients shall pay a monthly premium.

(c) The amount of a premium charged to a recipient shall not exceed 7.5% of the recipient’s net income, and spouse’s net income if residing together, with combined net income of less than or equal to 450% of the federal poverty level (FPL).

(d) Premium payment shall be based on the recipient’s net income, and spouse’s net income if residing together, relative to the percent of FPL, rounded up to the next dollar amount, as follows:

(1) Recipients with net income of less than 150% FPL shall not pay a premium;

(2) Recipients with net income of 150% up to and including 200% FPL shall pay not more than 7.5% of 150% FPL;

(3) Recipients with net income of more than 200% up to and including 250% FPL shall pay not more than 7.5% of 200% FPL;

(4) Recipients with net income of more than 250% up to and including 300% FPL shall pay not more than 7.5% of 250% FPL;

(5) Recipients with net income of more than 300% up to and including 350% FPL shall pay not more than 7.5% of 300% FPL;

(6) Recipients with net income of more than 350% up to and including 400% FPL shall pay not more than 7.5% of 350% FPL; and

(7) Recipients with net income of more than 400% up to and including 450% FPL shall pay not more than 7.5% of 400% FPL.

(e) Notwithstanding (c) and (d) above, when a recipient’s annual adjusted gross income as defined by the IRS exceeds $75,000, that recipient shall pay the full premium identified in (f) below.

(f) The full premium shall be calculated annually as 7.5% of the recipient’s adjusted gross income.

(g) A choice to accept retroactive medicaid coverage for the month(s) prior to the date of application shall result in a premium payment due for all retroactive months covered.

(h) The retroactive premium payment shall be included in the first premium payment as specified in (i) below.

(i) The first premium payment shall be billed on the first day of the month following the month eligibility was determined and applied to the month(s) following the month non-retroactive eligibility was determined effective.

(j) Subsequent payments for all months, which shall follow retroactive and first premium payment month(s), shall be due on the first day of the month and applied to the current month.

(k) Premium payments are due by the recipient for every month except for the first month of non-retroactive coverage.

(l) A recipient shall be terminated from MEAD for non-payment of premiums for 2 consecutive months without good cause.

(m) A recipient who has been terminated from MEAD for non-payment of premium in accordance with (l) above shall be reinstated if the recipient meets all other MEAD eligibility criteria in accordance with He-W 641.03 and:

(1) The recipient has paid the past due premiums in full; or

(2) It has been determined by the premium collection agency that the recipient has exhausted all available liquid resources and income with which to pay past due premiums, in accordance with (n)(3) below.

(n) Non-payment of premiums for good cause shall:

(1) Not exceed 3 months;

(2) Be available once every 2 years from the date the last month’s premium was paid; and

(3) Exist only after the recipient has exhausted all available resources and income with which to pay his or her premium, due to one of the following:

a. A temporary or unexpected loss of income lasting for a minimum of 3 months;

b. An uncovered medical expense that prevents payment of the premium; or

c. A hardship due to:

1. Loss of home;

2. Costs associated with fire/flood;

3. Unexpected high heating bills resulting in a 25% increase over annual cost;

4. Significant car repairs totaling 25% of current gross monthly income; or

5. Replacement of a refrigerator or stove.

(o) A good cause determination for non-payment of premium shall be verified and made by the premium collection agency.

(p) A 3-month payment plan option shall be available once every 2 years, from the date of the last month a premium was paid, to ease a financial burden due to good cause.

(q) Termination from MEAD shall result from failure to pay in full the balance owed at the end of the 3-month plan in accordance with (p) above.

Source. #7637, eff 2-1-02; ss by #8237, eff 12-31-04; ss by #10261, eff 1-25-13

He- C 5003.02 Private Health Insurance.

(a) Recipients who are eligible for private health insurance through employment or membership in an organization, at no cost to them, shall be enrolled in those insurance plans in order to remain eligible for MEAD.

(b) The amount of any health insurance premium payments paid by a recipient for the recipient and for the recipient’s spouse or children shall be deducted from the recipient’s MEAD premium.

Source. #7637, eff 2-1-02; ss by #8237, eff 12-31-04; ss by #10261, eff 1-25-13

PART He-C 5004 TELEHEALTH SERVICES

He-C 5004.01 Definitions.

(a) “Current procedural terminology (CPT) code” and “current dental terminology (CDT) code” means a unique identifying code in the field of medical or dental nomenclature and designated by the United States Department of Health and Human Services as the national coding standard utilized in government and private health insurance programs for reporting medical and dental services and procedures.

(b) “Department” means the New Hampshire department of health and human services.

(c) “Distant site” means the location of the health care provider delivering services through telemedicine at the time the services are provided.

(d) “Healthcare common procedure coding system (HCPCS)” means a standardized coding system used by Medicare that describes services and procedures. HCPCS includes CPT codes that are used primarily to identify products, supplies, and services not included in the normal CPT code list, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), when used outside a physician’s office.

(e) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(f) “National correct coding initiative (NCCI) edits” means standardized coding edits developed by the Centers for Medicare and Medicaid Services (CMS) to reduce improper coding and prevent inappropriate payments when incorrect code combinations are reported.

(g) "Originating site" means the location of the patient, whether or not accompanied by a health care provider, at the time services are provided by a health care provider through telehealth, including, but not limited to, a health care provider's office, a hospital, or a health care facility, or the patient's home or another nonmedical environment such as a school-based health center, a university-based health center, or the patient's workplace.

(h) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(i) “Remote patient monitoring (RPM)” means “remote patient monitoring” as defined in RSA 167:4-d, II(e) namely “the use of electronic technology to remotely monitor a patient's health status through the collection and interpretation of clinical data while the patient remains at an originating site. Remote patient monitoring may or may not take place in real time. Remote patient monitoring shall include assessment, observation, education and virtual visits provided by all covered providers including licensed home health care providers”.

(j) "Store and forward," means “store and forward” as defined in RSA 167:4-d, II(f) namely, “as it pertains to telemedicine and as an exception to 42 C.F.R. section 410.78, means the use of asynchronous electronic communications between a patient at an originating site and a health care service provider at a distant site for the purpose of diagnostic and therapeutic assistance in the care of patients. This includes the forwarding and/or transfer of stored medical data from the originating site to the distant site through the use of any electronic device that records data in its own storage and forwards its data to the distant site via telecommunication for the purpose of diagnostic and therapeutic assistance”.

(k) “Teledentistry” means the acquisition and transmission of all necessary subjective and objective diagnostic data through interactive audio, video, or data communications by a dental provider subject to RSA 317-A:21-e to a NH Medicaid enrolled dentist at a distant site for triage, dental treatment planning, and referral.

(l) “Telehealth” means a two-way, real-time interactive communication between a patient and a physician or medical provider at a distant site through telecommunications equipment including video, audio, and audio-only equipment.

(m) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(n) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. #13651, eff 5-26-23

He-C 5004.02 Recipient Eligibility. All recipients shall be eligible for telehealth services when:

(a) Telehealth, including teledentistry, is determined medically necessary pursuant to He-W 530.01(e); and

(b) The recipient has consented to using telehealth, including teledentistry, as a method of receiving services.

Source. #13651, eff 5-26-23

He-C 5004.03 Medical Provider Participation.

(a) Pursuant to RSA 167:4-d(f), medical providers shall include, but are not limited to the following:

(1) Physicians and physician assistants, governed by RSA 329 and RSA 328-D;

(2) Advanced practice nurses, governed by RSA 326-B and registered nurses under RSA 326-B employed by home health care providers under RSA 151:2-b;

(3) Midwives, governed by RSA 326-D;

(4) Psychologists, governed by RSA 329-B;

(5) Allied health professionals, governed by RSA 328-F;

(6) Dentists, governed by RSA 317-A;

(7) Mental health practitioners governed by RSA 330-A;

(8) Community mental health providers employed by community mental health programs pursuant to RSA 135-C:7;

(9) Alcohol and other drug use professionals, governed by RSA 330-C;

(10) Dietitians, governed by RSA 326-H; and

(11) Professionals certified by the national behavior analyst certification board or persons performing services under the supervision of a person certified by the national behavior analyst certification board.

(b) Medical providers described in He-C 5004.03(a) above, shall be permitted to perform health care services through the use of all modes of telehealth, including video and audio, audio-only, or other electronic media.

(1) Be licensed to practice by the state of New Hampshire;

(2) Be a NH enrolled Title XIX provider;

(3) Request and obtain prior authorization in accordance with He-W 531.07 and dental request per He-W 566.07;

(4) Assure the same rights to confidentiality and security as provided in face-to-face services; and

(5) Ensure the patient’s informed consent to the use of telehealth and advise members of any relevant privacy considerations.

(d) Medical providers shall adhere to the same standards of clinical practice and record keeping that apply to other covered services.

Source. #13651, eff 5-26-23

He-C 5004.04 Service Limits.

(a) Telehealth services shall be subject to the same service limits set forth in He-W 530.03.

(b) Teledentistry services shall be subject to the same service limits set forth in He-W 566.04.

Source. #13651, eff 5-26-23

He-C 5004.05 Covered Services.

(a) Telehealth services, provided through a medicaid managed care organization (MCO), as defined in He-W 506.03(h) shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under fee-for-service as defined in He-W 506.03(f).

(b) The following considerations shall apply to RPM, as defined in He-C 5004.01(i) above, medical conditions that may be treated or monitored by means of RPM include but are not limited to:

(1) Congestive heart failure;

(2) Diabetes;

(3) Chronic obstructive pulmonary disease;

(4) Wound care;

(5) Polypharmacy, mental or behavioral conditions, and technology dependent care such as the use of continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding;

(6) Hypertension;

(7) Pneumonia; or

(8) Patients at high risk of hospitalization.

(c) Medical devices supplied to patients as part of RPM services shall comply with section 201 of the Federal Food, Drug and Cosmetic Act (FDA) which requires the wirelessly synced device to be reliable and to transmit data electronically for interpretation and recommendations automatically rather than the patient having to self-report to providers.

(d) Telehealth for developmental disabilities and acquired brain disorder home and community based care waiver services shall be provided in accordance with the Centers for Medicare and Medicaid’s “Appendix K: Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers” (effective March 2020 through 6 months after the end of the federal public health emergency), as available in Appendix A.

(e) Telehealth for choices for independence home and community based waiver services shall be provided in accordance with the Centers for Medicare and Medicaid’s “Appendix K: Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers” (effective March 2020 through 6 months after the end of the federal public health emergency), as available in Appendix A.

(f) Telehealth for in home supports home and community based waiver services shall be provided in accordance with the Centers for Medicare and Medicaid’s “Appendix K: Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers” (effective March 2020 through 6 months after the end of the federal public health emergency), as available in Appendix A.

Source. #13651, eff 5-26-23

He-C 5004.06 Confidentiality.

(a) All services delivered via telehealth shall comply with all applicable state and federal laws or regulations as allowed by the Medicaid program.

(b) Privacy shall be maintained during all patient-provider interactions.

(c) All existing confidentiality requirements that apply to medical records shall apply to services delivered by telehealth.

Source. #13651, eff 5-26-23

He-C 5004.07 Patient Rights and Consents.

(a) The provider shall present the patient with basic information about the services that the patient will be receiving via telehealth.

(b) The patient shall provide his or her consent to participate in services utilizing this technology.

(d) Culturally competent translation or interpretation services shall be provided when the patient and the distant provider do not speak the same language.

(e) Documentation in the patient’s medical record shall reflect that the patient was informed of the patient’s rights policies which include the following:

(1) The right to refuse to participate in services delivered via telehealth;

(2) The role of the provider at the distant site and the professional staff at the originating site who shall be responsible for follow up or ongoing care;

(3) The city and state of the distant site provider and all questions regarding the equipment and the technologies are addressed;

(4) The right to be referred to in-person emergency care when clinically appropriate;

(5) The right to be informed of all the parties who shall be present at each end of the telehealth transmission; and

(6) The right to know how an emergency would be handled by the provider during a telehealth visit.

Source. #13651, eff 5-26-23

He-C 5004.08 Failure of Transmission.

(a) All telehealth providers shall have written procedures detailing a contingency plan in the case of a failure of transmission or other technical difficulty that renders the service undeliverable.

(b) A claim for payment shall not be submitted to Medicaid when the transmission fails.

Source. #13651, eff 5-26-23

He-C 5004.09 Non-Covered Services. Installation to provide telehealth services or maintenance of telehealth hardware, software, or other equipment shall not be covered by Medicaid.

Source. #13651, eff 5-26-23

He-C 5004.10 Prior Authorization. Telehealth services, including teledentistry, shall be subject to the same prior authorization requirements as services delivered via face to face.

Source. #13651, eff 5-26-23

He-C 5004.11 Utilization Review and Control. The department’s program integrity unit shall monitor utilization of telehealth, including teledentistry services, to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, CFR 456, and He-W 520.

Source. #13651, eff 5-26-23

He-C 5004.12 Third Party Liability. All third party obligations shall be exhausted before Title XIX shall be billed, in accordance with 42 CFR 433.139.

Source. #13651, eff 5-26-23

He-C 5004.13 Payment for Services.

(a) Payment to medical providers, described in He-C 5004.03 above, shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) Services delivered via telehealth shall be reimbursed pursuant to RSA 167:4-d III(b) and (c).

(d) Dental providers shall use CDT procedure codes when billing.

(e) All claims for payment shall be submitted to the department’s fiscal agent.

(f) All providers shall maintain supporting records in accordance with He-W 520.

(g) All providers shall be responsible for determining that the recipient is Title XIX eligible on the date of service.

(h) Payment for store and forward and remote patient monitoring shall only be available as funding and resources within the current state fiscal year are available.

Source. #13651, eff 5-26-23

PART He-C 5005 through He-C 5009 - RESERVED

PART He-C 5010 DRUG USE REVIEW BOARD

He-C 5010.01 Purpose. The purpose of these rules is to describe the establishment and operation of the New Hampshire drug use review board (DUR board), created to comply with federal requirements of Section 4401 of the Omnibus Budget Reconciliation Act of 1990 relative to pharmaceutical services furnished under the medicaid fee for service (FFS) program and to comply with Chapter 19 Laws of New Hampshire (2009).

Source. #5529, eff 12-16-92; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09; ss by #12460, eff 1-13-18

He-C 5010.02 Definitions.

(a) “Commissioner” means the commissioner of the New Hampshire department of health and human services, or his or her designee.

(b) “Department” means the New Hampshire department of health and human services (DHHS).

(c) “Drug use review (DUR)” means a program designed to ensure that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical results.

(d) “DUR board” means an advisory board to the state’s medicaid pharmacy program as required by the Omnibus Budget Reconciliation Act of 1990.

(e) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(f) “Pharmacy benefit manager (PBM)” means the vendor representative designated by the department to administer the medicaid pharmacy benefit for medicaid recipients.

(g) “Prescriber” means any professional whose licensure and scope of practice permits prescribing medications.

(h) “Provider” means an entity or individual who furnishes health care services or supplies to medicaid recipients under a provider enrollment agreement with the department, and is licensed or certified pursuant to applicable state law and rules to provide such services and supplies.

(i) “Recipient” means any individual who is eligible for and receiving medical assistance under medicaid.

(j) “Surveillance and utilization review subsystem (SURS)” means the function within the department to assess the quality of care, services, or supplies received by medicaid recipients and to ensure that accurate billing and proper reimbursement has been made for the care, services, or supplies.

(k) “Title XIX program” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department, under the medicaid program.

(l) “Title XXI program” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. #5529, eff 12-16-92; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09; ss by #12460, eff 1-13-18

He-C 5010.03 DUR Board Composition.

(a) Membership of the DUR board shall comply with 42 USC 1396r-8(g)(3)(B) and be composed as follows:

(1) A total of 3 members shall be physicians, currently licensed and actively practicing medicine in New Hampshire pursuant to RSA 329; and

(2) A total of 3 members shall be pharmacists, currently licensed and actively practicing in New Hampshire pursuant to RSA 318.

(b) Each member shall possess one of the skills identified in 42 USC 1396r-8(3)(B)(i) and (ii), as well as one of the skills identified in 42 USC 1396r-8(3)(B)(iii) and (iv).

Source. #5529, eff 12-16-92; ss by #5608, eff 4-6-93; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09; ss by #12460, eff 1-13-18

He-C 5010.04 Staff Support. The department shall name one staff person to consult with the DUR board and participate in the DUR board’s deliberations. This individual shall not be a voting member of the DUR board and shall not be assigned to any drug-related SURS function within the department.

Source. #5529, eff 12-16-92; ss by #5608, eff 4-6-93; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09 (from He-C 5010.05); ss by #12460, eff 1-13-18

He-C 5010.05 Terms of Appointment.

(a) Each member of the DUR board shall be appointed by the commissioner to serve a 4 year term.

(b) Any vacancy on the DUR board shall be filled by the commissioner’s appointment of a person to serve the remainder of the current term. Such person shall be from the same category described in He-C 5010.03(a) as the person being replaced. All subsequent appointments shall be for 4-year terms.

Source. #5529, eff 12-16-92; ss by #5608, eff 4-6-93; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09 (from He-C 5010.06); ss by #12460, eff 1-13-18

He-C 5010.06 Operation of the DUR Board. The DUR board shall establish and comply with bylaws outlining procedures for accomplishing the following:

(a) Selecting a chairperson;

(b) Scheduling regular meetings;

(d) Preparing notices of meetings consistent with RSA 91-A:2;

(e) Affirming that all DUR board activities are consistent with applicable confidentiality requirements, and in accordance with 42 CFR 431, Part F;

(f) Preparing and disseminating minutes of each meeting;

(g) Preparing an annual report;

(h) Reviewing and updating the bylaws; and

(i) Other matters of internal governance, as necessary.

Source. #5529, eff 12-16-92; ss by #5608, eff 4-6-93; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09 (from He-C 5010.07); ss by #12460, eff 1-13-18

He-C 5010.07 Functions and Responsibilities of the DUR Board.

(a) The DUR board shall hold meetings no less than semi-annually.

(b) Based on 42 USC 1396r-8(g)(1)(A) and (B), the DUR board shall make recommendations to the commissioner regarding policy, procedures, and standards for the implementation of the medicaid pharmacy benefit, the primary focus of which shall be the education of providers and medicaid recipients to maximize the quality of care provided.

(1) The clinical operation of the pharmacy benefit management program;

(2) Which medications are subject to prior authorization, pursuant to He-C 5010.08(d); and

(3) The criteria required for prior authorization to be granted, pursuant to He-C 5010.08(d).

(d) The DUR board shall develop a retrospective DUR program in accordance with the following:

(1) The DUR board shall recommend to the commissioner the standards for the mechanized drug claims processing and information retrieval system;

(2) The DUR board shall recommend to the commissioner parameters for the PBM’s performance of ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among prescribers, pharmacists, and recipients; and

(3) The DUR board shall review recommendations of the PBM’s pharmacist and physician, which shall be based upon evidence-based and peer-reviewed medical literature or at least one of the following compendia:

a. American Hospital Formulary Service Drug Information;

b. United States Pharmacopoeia-Drug Information; or

c. American Medical Association Drug Evaluations.

(e) In accordance with 42 USC 1396r-8(g)(3)(C), the DUR board shall recommend ongoing educational interventions for:

(1) Prescribers and pharmacists, targeted toward over use, under use, or misuse of pharmacy services or benefits; and

(2) Individuals identified in the course of retrospective drug use reviews performed under (d) above.

(f) Recommendations made pursuant to (e) above shall include:

(1) Information to prescribers and pharmacists concerning the DUR board’s duties, functions, and responsibilities;

(2) Written, oral, or electronic reminders concerning patient-specific or drug-specific information, or both, with suggested changes in prescribing or dispensing practices, communicated in a manner designated to ensure the privacy of patient-related information;

(3) The use of face-to-face discussions between health care professionals who are experts in rational drug therapy and prescribers and pharmacists who have been targeted for educational intervention; and

(4) The intensified review or monitoring of prescribers or pharmacists who have been targeted for review under this section.

(g) The DUR board shall re-evaluate interventions as described in (f) above, after a period of time which the DUR board has determined is sufficient, based on the specific circumstances of the prescribing practice under review, to determine if the interventions improved the quality of drug therapy, to evaluate the success of the interventions, and to recommend modifications as necessary.

(h) The DUR board shall prepare an annual report to be provided to the commissioner.

(i) The annual report in (h) above shall include:

(1) A description of the activities of the DUR board, including the nature and scope of the prospective and retrospective DUR programs;

(2) A summary of the interventions used;

(3) An assessment of the impact of these interventions on quality of care; and

(4) An estimate of the cost savings generated as a result of such programs.

(j) The DUR board shall advise the commissioner on the criteria for the pharmacy lock-in program defined in He-W 570.01 and described more particularly at He-W 570.07.

(k) Other reports and data shall be provided by the DUR board to the commissioner at such time and in such format as he or she requests.

Source. #5529, eff 12-16-92; amd by #5608, eff 4-6-93; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09 (from He-C 5010.08); ss by #12460, eff 1-13-18

He-C 5010.08 Public Hearing Requirements. In furtherance of He-C 5010.07(c) above, the DUR board shall:

(a) Hold a public hearing, in accordance with RSA 91-A, 2002, 281:9, III, as repealed and reenacted by 2003, 319:176, and 2009, 19:1, to afford opportunity for the public to present its views regarding the components of the prior authorization process and any changes thereto;

(b) Give public notice of the DUR board hearing agenda as it relates to prior authorized medications and any meeting date, time, and location in a public notice advertisement in a publication of daily statewide circulation at least 30 days in advance of the public meeting;

(c) Make available at least 15 days in advance of the public hearing, the specific proposed criteria or proposed changes to the list of medications subject to prior authorization;

(d) Conduct the hearing in accordance with the following:

(1) A record of the public hearing shall be kept by electronic recording or other method that will provide a verbatim record;

(2) The presiding officer at the public hearing shall be the medicaid pharmacy director or the individual designated by the medicaid pharmacy director to preside at the hearing;

(3) The presiding officer shall open the public hearing by describing in general terms the purpose of the hearing and procedures governing its conduct; and

(4) Testimony at the public hearing shall adhere to the following requirements:

a. Anyone wishing to submit written testimony or exhibits at the public hearing shall submit them to the presiding officer, provided such testimony or exhibit is signed and dated by the individual submitting it;

b. Anyone wishing to testify at the public hearing shall submit in writing to the presiding officer the person’s name, address, and whom, if anyone, that person represents;

c. The presiding officer shall call each person to present testimony; and

d. The presiding officer shall rule any comments, questions, or discussions that the presiding officer determines not to be relevant to the subject of the public hearing out of order, and proceed to the next speaker; and

(e) Recommend to the commissioner the components of the prior authorization process and any changes thereto after considering the following, to the extent reasonably available:

(1) Review of evidence-based comparative effectiveness reviews addressing medications, to include consideration of diagnosis, disease states, drug interactions, diagnostic testing, complicating medical factors, and potential for abuse or misuse;

(2) Identification of the availability of more cost effective, alternative medications;

(3) Clinical advantages, disadvantages, and medical necessity for medications identified in (2) above;

(4) Identification of drug contraindications that would affect the quality of care provided to recipients;

(5) Efficacy of available pharmaceuticals;

(6) Appropriate clinical use of medications for recipients considering their individual clinical circumstances including but not limited to age, gender, race, comorbidities, and allergies; and

(7) Comments on components of the prior authorization process submitted by the public for consideration.

Source. #5529, eff 12-16-92; amd by #5608, eff 4-6-93; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09; ); ss by #12460, eff 1-13-18

He-C 5010.09 Independence of the DUR Board. The DUR board’s relationship to the SURS program, to the board of medicine, and to the board of pharmacy shall be as follows:

(a) The DUR board shall not directly participate in any SURS operation or activities except to the extent that educational materials prepared by the DUR board are provided to the department, as they are to providers, recipients, and the public;

(b) The DUR board shall not involve itself as an entity in any individual cases relating to professional conduct or practice standards that might be before the board of medicine, the board of pharmacy, or other regulatory or oversight boards or bodies; and

(c) If the DUR board finds evidence of continuing fraud, abuse, or gross misuse by medicaid providers after the implementation of educational interventions pursuant to He-C 5010.08(c), they shall be referred to the department for further action.

Source. #5529, eff 12-16-92; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09 ss by #12460, eff 1-13-18

PART He-C 5011 COUNTY REIMBURSEMENT OF FUNDS, CREDIT ALLOCATION FOR FISCAL YEAR 2009

Statutory authority: RSA 167:18-a, III(b)

He-C 5011.01 - 5011.04

Source. #9190, INTERIM, eff 7-1-08, EXPIRED: 12-28-08

APPENDIX A

Rule	Title	Publisher; How to Obtain; and Cost
He-C 5004.05(d), (e), and (f)	Centers for Medicare and Medicaid’s, “Appendix K: Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers” (March 2020)	Publisher: Centers for Medicare and Medicaid Cost: Free of Charge The incorporated document is available at: https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/home-community-based-services-public-health-emergencies/emergency-preparedness-and-response-for-home-and-community-based-hcbs-1915c-waivers/index.html#:~:text=Appendix%20K%20is%20a%20standalone%20appendix%20that%20may,authority%20in%20order%20to%20respond%20to%20an%20emergency.

Rule

Title

Publisher; How to Obtain; and Cost

He-C 5004.05(d), (e), and (f)

Centers for Medicare and Medicaid’s, “Appendix K: Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers” (March 2020)

Publisher: Centers for Medicare and Medicaid

Cost: Free of Charge

The incorporated document is available at: https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/home-community-based-services-public-health-emergencies/emergency-preparedness-and-response-for-home-and-community-based-hcbs-1915c-waivers/index.html#:~:text=Appendix%20K%20is%20a%20standalone%20appendix%20that%20may,authority%20in%20order%20to%20respond%20to%20an%20emergency.

APPENDIX B

Rule	Specific State Statute the Rule Implements

He-C 5001	RSA 167:63-65
He-C 5002	RSA 167:63-65
He-C 5003.01 - 5003.02	RSA 167:6, IX; Section 1902 (a) (10) (A) (ii) (XV), Ticket to Work and Work Incentives Improvement Act

He-C 5004.01-5004.03	RSA 167:4-d,
He-C 5004.04	42 CFR 440.230(d)
He-C 5004.05	RSA 167:4-d; 42 CFR 440.230
He-C 5004.06	RSA 161:2-VI
He-C 5004.07	RSA 161:4, X(m)
He-C 5004.08	RSA 161:4, X(l)
He-C 5004.09	42 CFR 440.230(d); RSA 541-A; 21, VIII
He-C 5004.10	42 CFR 440.230(d); 42 CFR 431.107; RSA 126-A:5, VII
He-C 5004.11	42 CFR 455; 42 CFR 456
He-C 5004.12	42 CFR 433.139
He-C 5004.13	42 CFR 447.15; RSA 161:4, VI(a); RSA 167:4-d, III (b) and (c)

He-C 5010 All sections	Laws of 2009, 19:1

He-C 5010.01	42 CFR 456.716; Section 4401 of OBRA 1990
He-C 5010.02	42 CFR 456, Subpart K
He-C 5010.03	42 CFR 456.716(a) & (b); Section 1396r-8(g)(3)(B) of the SS Act
He-C 5010.04	42 CFR 456.716(b); Section 1396r-8(g)(3)(B) of the SS Act
He-C 5010.05	42 CFR 456.716(a)
He-C 5010.06	42 CFR 456.716(b)
He-C 5010.07	Section 1396r-8(g)(3)(C) & (D) of the SS Act; 42 CFR 456.712
He-C 5010.08	Section 1396r-8(g)(3)(C) & (D) of the SS Act; 42 CFR 456.716(d); 42 CFR 456.709
He-C 5010.09	42 CFR 456.714
He-C 5011.01 and 5011.02	RSA 167:18-a
He-C 5011.03	RSA 167:18-a, III(a)(1)
He-C 5011.04	RSA 167:18-a, III(a)(1) and (b)