RSA 420-H:4 · Requirements

420-H:4 Requirements. – Enrollees, subscribers, certificate holders, and individual insureds shall receive in simple and concise written language at least the following information:

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I.

An explanation of benefits provided.

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II.

Any benefit limitations, reductions, exclusions or exceptions to covered services, including an explanation of any restrictions on a subscriber's access to network practitioners based upon the subscriber's choice of primary care physician. The explanation of restrictions shall include a section regarding "referrals to other providers or other medical specialists" that shall urge enrollees, subscribers, certificate holders, and individual insureds to inquire about their primary care provider's referral group within the insurer's network. Such explanation shall include a general statement regarding the existence of physician hospital organizations within the insurer's network, to which primary care providers may be associated.

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III.

The nature of any payments required of the beneficiary, enrollee or subscriber such as copayments or deductibles.

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IV.

The nature of any limitations on payment by the insurer, including limitations based on the use of network or out-of-network health care providers.

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V.

The credentials of any health care provider the health care plan holds out as a specialist denoting board eligibility or board certification for such specialty.

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VI.

For companies or insurers providing health insurance through a managed care system of health care delivery or reimbursement, a description of the grievance procedures as required pursuant to RSA 420-J:5.

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VII.

For enrollees, subscribers, certificate holders, or individual insureds whose health insurance is provided through a managed care system of health care delivery and reimbursement, an explanation of a covered person's option to receive direct access to certain obstetrical-gynecological care, pursuant to RSA 420-J:6-a. Source. 1994, 359:1. 1998, 216:1; 319:2. 2001, 207:16. 2002, 59:1, eff. June 25, 2002.

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