RSA 420-M:9 · Requirements for Participating Carriers

420-M:9 Requirements for Participating Carriers. –

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I.

To qualify as a participating carrier, a carrier shall demonstrate the following characteristics:

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(a)

That it is licensed and in good standing with the insurance department;

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(b)

That it has the ability to administer health coverage, to provide adequate service, and to comply with all contractual requirements of the alliance;

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(c)

That it has the ability to provide enrollees with access to covered services;

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(d)

That it has the ability to provide coverage for enrollees in any service area in which the carrier plans to participate through the alliance;

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(e)

That it has the ability to arrange and pay for quality health care services;

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(f)

That it has the ability to provide standard data required by the alliance, in a manner prescribed by the alliance, including information on:

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(1)

Plan performance;

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(2)

Enrollee satisfaction;

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(3)

Provider payment and incentive structures; and

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(4)

Such other data requirements prescribed by the alliance;

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(g)

That it has the ability to meet quality of care standards established by government and industry authorities; and

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(h)

That it is financially strong and has competent management.

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II.

Participating carriers that contract with or employ health care providers shall have the ability to accomplish the following in a manner satisfactory to the alliance:

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(a)

Review and report on the cost and quality of care covered;

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(b)

Review and report on the appropriateness of care covered; and

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(c)

Provide accessible health care services.

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III.

Each participating carrier shall:

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(a)

Meet the standards established by the alliance pursuant to this chapter;

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(b)

Provide data and information as required by the alliance;

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(c)

Comply with all laws and rules regarding underwriting, rating, claims handling, sales, solicitation, licensing, fair marketing, unfair trade practices, the provisions of this chapter, and other applicable state statutes;

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(d)

Enroll and terminate individuals in the manner specified by the alliance; and

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(e)

Comply with other requirements established by the alliance pursuant to this chapter.

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IV.

Nothing in this chapter shall prohibit participating carriers from contracting with particular health care providers or types, classes, or categories of health care providers, or setting reimbursement methodology.

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V.

In the event that the participating carrier elects to terminate its contract with the alliance, the participating carrier shall:

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(a)

Provide advance notice of its decision to the alliance; and

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(b)

Provide notice of the decision at least 180 days prior to the non-renewal of health coverage to the member employers and employee enrollees. Source. 2010, 346:1, eff. July 20, 2010.

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