RSA 420-G:4-d · Essential Health Benefits

420-G:4-d Essential Health Benefits. –

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I.

All health coverage offered by health carriers to individuals or small employers shall include coverage for essential health benefits and provide essential health benefits in a plan substantially equivalent to New Hampshire's essential health benefit benchmark plan in effect for the plan year 2019.

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II.

If the federal government ceases to define essential health benefits, the commissioner shall define essential health benefits for New Hampshire by rulemaking pursuant to RSA 541-A. The New Hampshire essential health benefits shall include at least the following general categories and the items and services covered within the categories:

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(a)

Ambulatory patient services.

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(b)

Emergency services.

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(c)

Hospitalization.

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(d)

Maternity and newborn care.

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(e)

Mental health and substance use disorder services, including behavioral health treatment.

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(f)

Prescription drugs.

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(g)

Rehabilitative and habilitative services and devices.

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(h)

Laboratory services.

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(i)

Preventive and wellness services and chronic disease management.

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(j)

Pediatric services, including oral and vision care; provided, that health coverage that does not specifically include such pediatric services shall be deemed to have offered the essential health benefit under this subparagraph if the health carrier has obtained reasonable assurance that such pediatric services are provided to the purchaser of the health coverage.

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III.

In defining the essential health benefits under paragraph II, the commissioner shall:

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(a)

Ensure that such essential health benefit reflects an appropriate balance among the categories described in such subparagraph, so that benefits are not unduly weighted toward any category;

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(b)

Not define essential health benefits in a manner which would allow carriers to make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;

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(c)

Consider the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;

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(d)

Ensure that health benefits established as essential are not subject to denial to individuals against their wishes on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life;

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(e)

Ensure that a health plan shall not be treated as providing coverage for the essential health benefits unless the plan provides that:

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(1)

Coverage for emergency department services shall be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the provision of services which is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and

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(2)

If such services are provided out-of-network, the cost-sharing requirement, such as a copayment amount or coinsurance rate is the same requirement which would apply if such services were provided in-network; and

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(f)

Ensure that the New Hampshire essential benefits are at least actuarially equivalent to the essential health benefits previously established by the federal government.

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(g)

Ensure essential health benefits are provided in a plan substantially equivalent to New Hampshire's essential health benefit benchmark plan in effect for plan year 2019. Source. 2019, 220:4, eff. Sept. 10, 2019.

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