RSA 420-B:8-n · Point of Service Plans

420-B:8-n Point of Service Plans. –

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I.

A health maintenance organization may offer a point-of-service plan in accordance with the requirements of this section. A point-of-service plan is a health maintenance organization contract which includes coverage for both in-network services and coverage for services provided by non-contracted providers.

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II.

A point-of-service plan offered by a health maintenance organization shall:

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(a)

Provide incentives for enrollees to use in-network covered services.

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(b)

Offer out-of-network covered services only if those services are also covered on an in-network basis.

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(c)

Cover out-of-network emergency services as if they had been provided in-network.

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III.

A point-of-service plan offered by a health maintenance organization may:

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(a)

Limit or exclude specific types of services, other than emergency services, from coverage when obtained out-of-network.

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(b)

Include provisions for member cost sharing, annual out-of-pocket limits and annual and lifetime benefit allowances for out-of-network covered services which are separate from any limits and allowances applied to in-network covered services.

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(c)

Cover at the out-of-network benefit level, services provided by a participating provider for which proper authorization or referral was not obtained.

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IV.

Subject to the provisions of RSA 420-G, a health maintenance organization may limit the groups to which point-of-service plans are offered. If a point-of-service plan is offered to a group, it must be offered to all eligible members of the group.

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V.

A health maintenance organization may not expend more than 20 percent of its total annual health care expenditures on out-of-network covered services. If compliance with this requirement is not demonstrated on a quarterly basis on the health maintenance organization's quarterly financial report, the commissioner may prohibit the health maintenance organization from offering a point-of-service plan to new groups until compliance has been demonstrated.

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VI.

A health maintenance organization shall comply with all applicable form and rate filing requirements. In complying with said requirements, the health maintenance organization shall:

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(a)

Design the benefit levels for in-network covered services and out-of-network covered services to achieve the desired level of in-network utilization;

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(b)

Provide or arrange for adequate systems to:

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(1)

Process and pay claims for out-of-network covered services;

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(2)

Meet the requirements for point-of-service plans under this section; and

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(3)

Generate accurate financial and regulatory reports on a timely basis in order for the commissioner to evaluate experience with the point of service plan and monitor compliance with the requirements of this section.

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VII.

An explanation of benefits shall be provided to enrollees who obtain services at the out-of-network benefit level which is adequate to permit the enrollee to determine his or her financial liability under the plan.

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VIII.

All point-of-service contracts and certificates shall contain a provision permitting the enrollee to assign any benefits provided for medical or dental care on an expense-incurred basis to the provider of care. An assignment of benefits under this paragraph does not affect or limit the payment of benefits otherwise payable under the contract or certificate.

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IX.

Subscriber contracts and member handbooks shall contain a clear and concise explanation of the point of service plan. The explanation shall include:

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(a)

The method of reimbursement;

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(b)

The required co-payments, co-insurance and deductibles, as applicable;

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(c)

Other uncovered costs or charges;

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(d)

The services that an enrollee is permitted to obtain at the out-of-network benefit level; and

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(e)

Instructions for submitting claims for services obtained at the out-of-network benefit level. Source. 2002, 207:8, eff. May 16, 2002.

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