HB303: (New Title) relative to life, accident, and health technicals and relative to minimum standards for claim review.

CHAPTER 276

HB 303 - FINAL VERSION

20mar03... 0471h

05/29/03 1737s

24jun03... 2101CofC

30jun03... 2310eba

2003 SESSION

03-0712

01/09

HOUSE BILL 303

AN ACT relative to life, accident, and health technicals and relative to minimum standards for claim review.

SPONSORS: Rep. D. Flanders, Belk 30; Sen. Flanders, Dist 7

COMMITTEE: Commerce

AMENDED ANALYSIS

This bill makes certain technical corrections in the laws relating to life, accident, and health insurance.

This bill also clarifies the minimum standards for claim review and denials.

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Explanation: Matter added to current law appears in bold italics.

Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

20mar03... 0471h

05/29/03 1737s

24jun03... 2101CofC

30jun03... 2310eba

03-0712

01/09

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Three

AN ACT relative to life, accident, and health technicals and relative to minimum standards for claim review.

Be it Enacted by the Senate and House of Representatives in General Court convened:

276:1 Individual Health Insurance; Definition; Covered Lives. RSA 404-G:2, V is repealed and reenacted to read as follows:

V. "Covered lives" shall include all persons who are:

(a) Covered under an individual health insurance policy issued or delivered in New Hampshire;

(b) Covered under a group health insurance policy that is issued or delivered in New Hampshire;

(c) Covered under a group health insurance policy evidenced by a certificate of insurance that is issued or delivered in New Hampshire;

(d) Protected, in part, by a group excess loss insurance policy where the policy or certificate of coverage has been issued or delivered in New Hampshire, and where coverage has been purchased by a group health insurance plan subject to the Employee Retirement Income Security Act of 1974, Public Law No. 93-406 (ERISA).

276:2 New Paragraph; Individual Health Insurance; Definition Added. Amend RSA 404-G:2 by inserting after paragraph V the following new paragraph:

V-a. "Group excess loss insurance" means coverage purchased by an employer against the risk that any one claim made against the employer's health plan will exceed a specified dollar amount or coverage purchased by an employer against the risk that the employer's total liability for the health plan will exceed a specified amount.

276:3 Coverage for Mental or Nervous Conditions; Clarification. Amend RSA 415:18-a, III(b) to read as follows:

(b) Each insurer, including health maintenance organizations [contemplated under] pursuant to RSA 420-B [and self-insured benefit plans, funds or programs], that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses 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 and whose principal place of employment is in this state, benefits arising from treatment, diagnosis and evaluation of mental illnesses and disorders for services rendered at a community mental health center or psychiatric residential program approved by the department of health and human services. Those benefits shall be subject to terms and conditions at least as favorable as those which apply to the benefits for the treatment of other illnesses. The ratio of the benefits to the full reasonable charges for the services of such a center or program shall be substantially the same as the ratio of the benefits for services of physicians for other illnesses to the fees reasonably and customarily charged for the services of such physicians for other illnesses.

276:4 Minimum Standards for Claim Review; Accident and Health Insurance. Amend RSA 415-A:4-a, I(c)(2) to read as follows:

(2) A statement of the claimant's or the representative of the claimant's right to access the internal grievance process and the process for obtaining external review. The notification shall also include a written explanation of any claim denial[, with the name and credentials of the carrier or other licensed entity medical director, including board status and the state or states where the person is currently licensed,] and the relevant clinical rationale used to make the claim denial. If the claim denial is based upon a determination that the claim is experimental or investigational or not medically necessary or appropriate, the licensee shall include with the notification the name and credentials of the carrier or other licensed entity, the medical director, including board status and the state or states where the person is currently licensed. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person. Nothing in this section shall be construed to require a carrier or other licensed entity to provide proprietary information protected by third party contracts;

276:5 Minimum Standards for Claim Review; Accident and Health Insurance. RSA 415-A:4-a, I(c)(5) is repealed and reenacted to read as follows:

(5) If clinical review criteria was relied upon in making the benefit determination, a reference to the specific clinical review criteria, a statement that such clinical review criteria was relied upon in making the claim denial, and a copy of the clinical review criteria shall be provided free of charge to the claimant or the claimant's representative, upon request. If a copy of the clinical review criteria is requested, the clinical review criteria shall be accompanied by the following notice: "The materials provided to you are criteria used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract;" and

276:6 Minimum Standards for Claim Review; Accident and Health Insurance. Amend RSA 415-A:4-a, II(a) and (b) to read as follows:

(a) The determination of a claim involving urgent care shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours after receipt of the claim, 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 licensee shall notify the claimant or claimant's representative within 24 hours of receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. [The 72-hour period shall be tolled until such time as the claimant submits the required information.] The claimant or the 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 benefit determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.

(b) The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim, provided that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment. [In the event the claimant or claimant's representative fails to provide sufficient notice or sufficient information, the licensee shall notify the claimant or claimant's representative within 24 hours of the receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim If the determination relates to a reduction or termination of coverage for a course of treatment beyond the end of the period of time or number of treatments previously approved, coverage for the services shall not be terminated during the pendency of the determination proceeding.]

276:7 Minimum Standards for Claim Review; Accident and Health Insurance. RSA 415-A:4-a, II(c) is repealed and reenacted to read as follows:

(c) The determination of all other claims for preservice benefits shall be made within a reasonable time period appropriate to the medical circumstances, but in no event more than 15 days after receipt of the claim. This period may be extended one time by the licensee for up to 15 days; provided, that the licensee both determines that such an extension is necessary due to matters beyond the control of the licensee and notifies the claimant or claimant's representative, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the licensee expects to render a decision. If such an extension is necessary due to a failure of the claimant or claimant's representative to provide sufficient information to determine whether, or to what extent, benefits are covered as payable, the notice of extension shall specifically describe the required additional information needed, and the claimant or claimant's representative shall be given at least 45 days from receipt of the notice within which to provide the specified information. Notification of the benefit determination following a request for additional information shall be made as soon as possible, but in no case later than 15 days after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.

276:8 Minimum Standards; Licensure of Medical Utilization Review Entities. RSA 420-E:4, IV is repealed and reenacted to read as follows:

IV. Notification of claim benefit determinations shall be made within the following time periods:

(a) The determination of a claim involving urgent care shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours after receipt of the claim, 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 licensee shall notify the claimant or claimant's representative within 24 hours of receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. 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 benefit determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.

(b) The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim; provided, that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment.

(c) The determination of all other claims for preservice benefits shall be made within a reasonable time period appropriate to the medical circumstances, but in no event more than 15 days after receipt of the claim. This period may be extended one time by the licensee for up to 15 days; provided, that the licensee both determines that such an extension is necessary due to matters beyond the control of the licensee and notifies the claimant or claimant's representative, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the licensee expects to render a decision. If such an extension is necessary due to a failure of the claimant or claimant's representative to provide sufficient information to determine whether, or to what extent, benefits are covered as payable, the notice of extension shall specifically describe the required additional information needed, and the claimant or claimant's representative shall be given at least 45 days from receipt of the notice within which to provide the specified information. Notification of the benefit determination following a request for additional information shall be made as soon as possible, but in no case later than 15 days after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.

(d) The determination of a post service claim shall be made within 30 days of the date of filing. In the event the claimant fails to provide sufficient information to determine the claim, the carrier shall notify the claimant within 15 days as to what additional information is required to process the claim and the claimant shall be given at least 45 days to provide the required information. The 30-day period for claim determination shall be tolled until such time as the claimant submits the required information.

276:9 Minimum Standards; Licensure of Medical Utilization Review Entities. Amend RSA 420-E:4, V(c) to read as follows:

(c) The notification shall include a statement of the claimant's right or the right of the claimant's representative to access the internal grievance process and the process for obtaining external review. The notification shall also include a written explanation of any claim denial[, with the name and credentials of the carrier or other licensed entity medical director; including board status and the state or states where the person is currently licensed,] and the relevant clinical rationale used to make the claim denial. If the claim denial is based upon a determination that the claim is experimental or investigational or not medically necessary or appropriate, the licensee shall include with the notification the name and credentials of the carrier or other licensed entity, the medical director, including board status and the state or states where the person is currently licensed. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person. Nothing in this section shall be construed to require a carrier or other licensed entity to provide proprietary information protected by third party contracts.

276:10 Minimum Standards; Licensure of Medical Utilization Review Entities. RSA 420-E:4, V(f) is repealed and reenacted to read as follows:

(f) If clinical review criteria was relied upon in making the benefit determination, a reference to the specific clinical review criteria, a statement that such clinical review criteria was relied upon in making the claim denial, and a copy of the clinical review criteria shall be provided free of charge to the claimant or claimant's representative, upon request. Any disclosure of clinical review criteria shall be accompanied by the following notice: "The materials provided to you are criteria used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract."

276:11 Utilization Review. RSA 420-J:6, III is repealed and reenacted to read as follows:

III. Notification of claim denial shall be made within the following time periods:

(a) The determination of a claim involving urgent care shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours after receipt of the claim, 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 licensee shall notify the claimant or claimant's representative within 24 hours of receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. 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 benefit determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.

(b) The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim, provided that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment.

(c) The determination of all other claims for preservice benefits shall be made within a reasonable time period appropriate to the medical circumstances, but in no event more than 15 days after receipt of the claim. This period may be extended one time by the licensee for up to 15 days, provided that the licensee both determines that such an extension is necessary due to matters beyond the control of the licensee and notifies the claimant or claimant's representative, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the licensee expects to render a decision. If such an extension is necessary due to a failure of the claimant or claimant's representative to provide sufficient information to determine whether, or to what extent, benefits are covered as payable, the notice of extension shall specifically describe the required additional information needed, and the claimant or claimant's representative shall be given at least 45 days from receipt of the notice within which to provide the specified information. Notification of the benefit determination following a request for additional information shall be made as soon as possible, but in no case later than 15 days after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.

(d) The determination of a post service claim shall be made within 30 days of the date of filing. In the event the claimant fails to provide sufficient information to determine the claim, the carrier shall notify the claimant within 15 days as to what additional information is required to process the claim and the claimant shall be given at least 45 days to provide the required information. The 30-day period for claim determination shall be tolled until such time as the claimant submits the required information.

276:12 Individual Health Insurance Market; Eligibility. Amend RSA 404-G:5-e, I(c) and (d) to read as follows:

(c) The individual has a history of any medical or health condition that is on a list adopted by the association; [or]

(d) The individual is an "eligible individual" as defined in section 2741(b) of the Public Health Service Act; or

(e) The individual has been certified as eligible for either federal trade adjustment assistance or for pension benefit guarantee corporation, as prescribed by the federal Trade Adjustment Assistance Reform Act of 2002 and the association, in accordance with procedures set forth in its plan of operation, is offering coverage in the high risk pool to such eligible persons at the time of the individual's application.

276:13 High Risk Pool Eligibility. RSA 404-G:5-e, I (d)-(e) are repealed and reenacted to read as follows:

(d) The individual is an "eligible individual" as defined in section 2741(b) of the Public Health Service Act;

(e) The individual has been certified as eligible for either federal trade adjustment assistance or for pension benefit guarantee corporation, as prescribed by the federal Trade Adjustment Assistance Reform Act of 2002 and the association, in accordance with procedures set forth in its plan of operation, is offering coverage in the high risk pool to such eligible persons at the time of the individual's application; or

(f) The individual has received an offer of coverage from a carrier of individual health insurance that contains a rider or endorsement excluding coverage for a specified condition pursuant to RSA 420-G:5, II.

276:14 Effective Date.

I. Section 13 of this act shall take effect August 29, 2003 at 12:01 a.m.

II. The remainder of this act shall take effect July 1, 2003.

(Approved: July 18, 2003)

(Effective Date: I. Section 13 shall take effect August 29, 2003 at 12:01 a.m.

II. Remainder shall take effect July 1, 2003)