Hb507: Relative To Certain Statutes That Set Minimum Requirements For Employee Benefit Plan Procedures Pertaining To The Filing of Benefit Claims, Notification of Benefit Determinations, and Appeal of Adverse Benefit Determinations.

CHAPTER 175

HB 507 - FINAL VERSION

25mar03...0427h

5jun03... 1961eba

2003 SESSION

03-0963

06/10

HOUSE BILL 507

AN ACT relative to certain statutes that set minimum requirements for employee benefit plan procedures pertaining to the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations.

SPONSORS: Rep. Fraser, Merr 37

COMMITTEE: Commerce

AMENDED ANALYSIS

This bill removes disability benefits or disability plans from certain statutes that set minimum requirements for employee benefit plan procedures pertaining to the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations.

This bill also directs the insurance commissioner to adopt rules to establish standards for processing benefit claims under group disability plans.

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Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

25mar03...0427h

5jun03... 1961eba

03-0963

06/10

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Three

AN ACT relative to certain statutes that set minimum requirements for employee benefit plan procedures pertaining to the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations.

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

175:1 Definitions; Employee Benefit Plan; Disability Benefits Excluded. Amend RSA 415-A:1, I-d to read as follows:

I-d. "Employee benefit plan" means employee benefit plans described in section 4(a) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1133 and 1135 and not exempted under section 4(b) of this Act other than those plans, or portions of them, that provide disability benefits.

175:2 Definitions; Post-service Claim; Disability Benefits Excluded. Amend RSA 415-A:1, IV to read as follows:

IV. "Post-service claim" means any claim for a health [or disability] benefit to which the terms of the plan do not condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining the medical care [or disability benefit]. "Post-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.

175:3 Minimum Standards for Claim Review; Disability Plans Removed. Amend the introductory paragraph of RSA 415-A:4-a to read as follows:

415-A:4-a Minimum Standards for Claim Review; Accident and Health Insurance. Any carrier that offers group health plans[,] and employee benefit plans[, and disability plans] shall establish and maintain written procedures by which a claimant may obtain a determination of claims and by which a claimant may appeal a claim denial.

175:4 Appeal Procedure; Disability Benefits Removed. Amend RSA 415-A:4-a, III to read as follows:

III. Any carrier or other licensed entity that offers group health plans[,] and employee benefit plans[, and disability plans] shall file with the department a copy of its claim determination procedure, including all forms used, and a copy of the materials designed to inform its members or insureds of the requirements of the claim determination and grievance procedure and the responsibilities and rights of the members or insureds under the plan each year. The carrier shall also file an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.

175:5 Appeal Procedure; Disability Benefits Removed. Amend the introductory paragraph of RSA 415-A:4-b to read as follows:

415-A:4-b Appeal Procedure. Every carrier or other licensed entity which offers group health insurance[,] or employee benefit plans[, or disability benefits] shall file with the insurance department, by April 1 of each year, and shall maintain a written procedure by which a claimant, or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and fair review of the claim denial. The written procedure filed with the insurance department shall include all forms used to process an appeal.

175:6 Manner and Content of Notification of Determination on Appeal; Disability Plans Removed. Amend RSA 415-A:4-b, V (b) - (e) to read as follows:

(b) A carrier or other licensed entity that offers group health plans[,] or employee benefit plans[, or disability plans] shall file with the commissioner a certificate of compliance by April 1 of each year stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective.

(c) A carrier or other licensed entity that offers group health plans[,] or employee benefit plans[, or disability plans] shall maintain written records documenting all grievances and appeals received during a calendar year, a general description of the reason for the appeal or grievance, the name of the claimant, the dates of the appeal or grievance and the date of resolution.

(d) A carrier or other licensed entity that offers group health plans[,] or employee benefit plans[, or disability plans] shall provide to consumers:

(1) A description of the internal grievance procedure for claim determinations and other matters. The description shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons;

(2) A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner; and

(3) A statement that the carrier or other licensed entity will provide assistance in preparing an appeal of an adverse benefit determination, and a toll-free telephone number to contact the carrier or other licensed entity.

(e) In any case where a carrier or other licensed entity that offers group health plans[,] or employee benefit plans[, or disability plans] provides 2 levels of appeal for the pre-service claim determinations, the first level shall be completed within 15 days and the second level completed within the 30-day time period beginning from the initial date of filing the appeal or grievance. With respect to a second level appeal involving a claim for continuation of services or urgent care, the carrier or other licensed entity shall make a decision and notify the claimant within 72 hours after the second level appeal is filed. For second level appeals involving a post-service claim, the carrier shall make a decision and notify the claimant within 60 days of the date the appeal was filed.

175:7 Adoption of Rules; Standards for Processing Group Disability Benefit Claims. Amend RSA 415-A:6 to read as follows:

415-A:6 Adoption of Rules.

I. Rules promulgated pursuant to this chapter shall be subject to notice and hearing pursuant to RSA 541-A. When a rule adopted pursuant to this chapter so provides, a policy of insurance issued subsequent to the rule's effective date and any optionally renewable policy of insurance renewed subsequent to the rule's effective date which does not comply with the rule shall, not less than 60 days after the rule's effective date, be construed, and the insurer or corporation shall be liable, as if the policy did comply with the rule.

II. The commissioner shall adopt rules to establish specific standards for processing benefit claims under group disability plans that shall be consistent with and not more restrictive than the United States Department of Labor Benefit Claims Procedure Regulation, 29 CFR 2560.503, as existing and thereafter amended, that sets standards for group disability plans under the Employee Retirement Income Security Act of 1974.

175:8 Managed Care Law; Definitions; Post Service Claim; Disability Removed. Amend RSA 420-J:3, XXVIII-a to read as follows:

XXVIII-a. "Post service claim" means any claim for a health [or disability] benefit to which the terms of the plan do not condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining the medical care or disability benefit. "Post-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.

175:9 Grievance Procedures; Carrier or Other Licensed Entity Limited. Amend the introductory paragraph RSA 420-J:5 to read as follows:

420-J:5 Grievance Procedures. Every carrier or other licensed entity subject to this chapter shall establish and shall maintain a written procedure by which a claimant or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and fair review of the claim denial. The written procedure filed with the insurance department shall include all forms used to process an appeal.

175:10 Manner and Content of Notification of Determination on Appeal; Disability Plans Removed. Amend RSA 420-J:5, V (b) - (d) to read as follows:

(b) A carrier or other licensed entity that offers group health plans [,] or employee benefit plans[, or disability plans] shall file annually with the commissioner, as part of its annual report required by RSA 420-J:5, V(g), a certificate of compliance stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective.

(c) A carrier or other licensed entity that offers group health plans[,] or employee benefit plans[, or disability plans] shall maintain written records documenting all grievances and appeals received during a calendar year, a general description of the reason for the appeal or grievance, the name of the claimant, the dates of the appeal or grievance and the date of resolution.

(d) A carrier or other licensed entity that offers group health plans [,] or employee benefit plans[, or disability plans] shall provide to consumers:

(1) A description of the internal grievance procedure required under RSA 420-J:5 for claim denials and other matters and a description of the process for obtaining external review under RSA 420-J:5-a-RSA 420-J:5-e. These descriptions shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons.

(2) A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner.

(3) A statement that the carrier or other licensed entity will provide assistance in preparing an appeal of an adverse benefit determination, and a toll-free telephone number to contact the carrier or other licensed entity.

175:11 Applicability. This act shall take effect upon the earlier of the following:

I. The effective date of the rules adopted under RSA 415-A:6, II, as inserted by section 7 of this act.

II. January 1, 2004.

175:12 Effective Date.

I. Section 11 of this act shall take effect upon its passage.

II. The remainder of this act shall take effect as provided in section 11 of this act.

(Approved: June 23, 2003)

(Effective Date: I. Section 11 shall take effect June 23, 2003

II. Remainder shall take effect as provided in section 11)