HB1194 (2006) Detail

(3rd New Title) relative to job protection for firefighters, rescue workers, and emergency medical personnel, and relative to health insurance claim review.


CHAPTER 304

HB 1194 – FINAL VERSION

08mar06… 1218h

05/03/06 2156s

24May2006… 2350cofc

24May2006… 2402eba

2006 SESSION

06-2351

06/03

HOUSE BILL 1194

AN ACT relative to job protection for firefighters, rescue workers, and emergency medical personnel, and relative to health insurance claim review.

SPONSORS: Rep. Wiley, Rock 5

COMMITTEE: Labor, Industrial and Rehabilitative Services

AMENDED ANALYSIS

This bill gives firefighters, rescue workers, and emergency medical personnel the right to take leave without pay from a place of employment when mobilized after the governor has declared a state of emergency unless certified as essential to an employer’s emergency relief efforts.

This bill also clarifies the procedures for medical insurance claim denials.

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Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

08mar06… 1218h

05/03/06 2156s

24May2006… 2350cofc

24May2006… 2402eba

06-2351

06/03

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Six

AN ACT relative to job protection for firefighters, rescue workers, and emergency medical personnel, and relative to health insurance claim review.

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

304:1 New Subdivision; State of Emergency Leave. Amend RSA 275 by inserting after section 65 the following new subdivision:

State of Emergency Leave

275:66 Leave Authorized in a State of Emergency.

I. When the governor or the general court declares a state of emergency under RSA 4:45, a member of a fire department, rescue squad, or emergency medical services agency who is called into service of the state or a political subdivision shall have the right to take leave without pay from his or her place of employment to respond to the emergency. No employer shall require an employee to use or exhaust his or her vacation or other accrued leave for the period of emergency service. The employee may choose to take vacation or other accrued leave for the period of emergency service.

II. A firefighter, rescue squad member, or emergency medical services member shall be called into service of the state or a political subdivision for purposes of this subdivision when his or her services are requested in writing by the director of emergency services, communications, and management or by the head of a local organization for emergency management established under RSA 21-P:39. The request shall be directed to the chief of the member’s fire department, rescue squad, or emergency medical services agency and a copy shall be provided to the member’s employer.

III. An employer may certify to the director of emergency services, communications, and management or to the head of the local emergency management agency that the employee is essential to the employer’s own emergency or disaster relief activities. Such certification shall exempt an employee from the provisions of this subdivision.

304:2 Accident and Health Insurance; Minimum Standards for Claim Review. Amend RSA 415-A:4-a, I(c) to read as follows:

(c) The notification of a claim denial shall be communicated in writing or by electronic means and shall include:

(1) The specific reason or reasons for the determination and shall refer to the specific provision of the policy or plan on which the determination is based;

(2) A statement of the claimant’s or the representative of the claimant’s right to access the internal grievance process and the process for obtaining external review. [The notification shall also include a written explanation of any claim denial and the relevant clinical rationale used to make the claim denial.];

(3) If the claim denial is based upon a determination that the claim is experimental or investigational or not medically necessary or appropriate[, the licensee shall include with the notification]:

(A) The name and credentials of the carrier or other licensed entity, the medical director, including board status and the state or states where the person is currently licensed. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person[. Nothing in this section shall be construed to require a carrier or other licensed entity to provide proprietary information protected by third party contracts]; and

(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant’s specific medical circumstances;

[(3)] (4) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the benefit determination, [a reference to the specific rule, guideline, protocol, or other similar provision; and] a statement that such [a] rule, guideline, protocol, or other similar provision was relied upon in making the claim denial [and that a copy of such rule, guideline, protocol, or other provision will be provided free of charge to the claimant or claimant’s representative upon request];

[(4) If the claim denial is based on a medical necessity or experimental treatment or other similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan or the policy to the claimant’s medical circumstances; ]

(5) If clinical review criteria [was] were relied upon in making the benefit determination[, a reference to the specific clinical review criteria], a statement that such clinical review criteria [was] were relied upon in making the claim denial. [and a copy of the clinical review criteria shall be provided free of charge to the claimant or the claimant’s representative, upon request. If a copy of the clinical review criteria is requested,] The recitation of the terms of the clinical review criteria required under RSA 415-A:4-a(c)(3)(B) shall be accompanied by the following notice: “The [materials] clinical review criteria provided to you are [criteria] used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract;” [and]

(6) A description of the plan’s grievance procedures and the time limits applicable to such procedures. In the case of a denial of a benefit concerning a claim involving urgent care or in the case of a denial of a claim related to continuation of an ongoing course of treatment for a person who has received emergency services, but who has not been discharged from a facility, a description of the expedited review applicable to such a claim shall be included in the determination. For all other claim benefit determinations, a description of the grievance process shall be specifically described in the determination.

304:3 Accident and Health Insurance; Appeal Procedure. Amend RSA 415-A:4-b, V(a) to read as follows:

(a) The carrier or other licensed entity shall provide a claimant with a written determination of the appeal that shall include:

(1) The specific reason or reasons for the determination, including reference to the specific provision[, rule, protocol, or guideline] of the policy or plan on which the determination is based;

(2) [A statement that the rule, protocol, or guideline governing the appeal will be provided without charge to the claimant upon request;] If the determination is based upon a finding that the claim is experimental or investigational or not medically necessary or appropriate:

(A) The name and credentials of the person reviewing the grievance, including board status and the state or states where the person is currently licensed; and

(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant’s specific medical circumstance;

(3) A statement describing all other dispute resolution options available to the claimant, including, but not limited to other options for internal review and options for external review, and options for bringing a legal action;

(4) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits;

(5) If an internal rule, guideline, protocol, or other similar [criterion] provision was relied upon in making the claim denial, [either the specific rule, guideline, protocol, or other similar criterion; or] a statement that such rule, guideline, protocol, or other similar [criterion] provision was relied upon in making the claim denial[, and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the claimant upon request];

(6) [If the claim denial is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the denial, applying the terms of the plan to the claimant’s medical circumstances, or a statement that such explanation will be provided free of charge upon request;

(7)] The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state insurance regulatory agency;” and

[(8)] (7) A statement describing the claimant’s right to contact the insurance commissioner’s office for assistance which shall include a toll-free telephone number and address of the commissioner.

304:4 Licensure of Medical Utilization Review Entities; Notification of Claim Denials. Amend RSA 420-E:4, V to read as follows:

V. The manner and content of notification of claim benefit determinations shall be as follows:

(a) The licensee shall notify the claimant or claimant’s representative in writing or electronically of the claim determination.

(b) If the claim benefit determination is a claim denial, the notice shall include:

(1) The [notification shall state the] specific reason or reasons for the determination and shall refer to the specific provision of the policy or plan on which the determination is based.

[(c) The notification shall include] (2) A statement of the claimant’s right or the right of the claimant’s representative to access the internal grievance process and the process for obtaining external review. [The notification shall also include a written explanation of any claim denial and the relevant clinical rationale used to make the claim denial.]

(3) If the claim denial is based upon a determination that the claim is experimental or investigational or not medically necessary or appropriate[, the licensee shall include with the notification]:

(A) The name and credentials of the carrier or other licensed entity, the medical director, including board status and the state or states where the person is currently licensed. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person[. Nothing in this section shall be construed to require a carrier or other licensed entity to provide proprietary information protected by third party contracts.]; and

(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant’s specific medical circumstances;

[(d)] (4) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the benefit determination, [the determination shall reference the specific rule, guideline, protocol, or other similar provision; and shall include] a statement that such [a] rule, guideline, protocol, or other similar provision was relied upon in making the claim denial [and that a copy of such rule, guideline, protocol, or other provision will be provided free of charge to the claimant or claimant’s representative upon request.];

[(e) If the claim denial is based on a medical necessity or experimental treatment or other similar exclusion or limit, the determination shall include an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan or the policy to the claimant’s medical circumstances.

(f)] (5) If clinical review criteria [was] were relied upon in making the benefit determination, [a reference to the specific clinical review criteria,] a statement that such clinical review criteria [was] were relied upon in making the claim denial[, and a copy of the clinical review criteria shall be provided free of charge to the claimant or claimant’s representative, upon request. Any disclosure of]. The recitation of terms of the clinical review criteria required under RSA 420-E:4, V(b)(3)(B) shall be accompanied by the following notice: “The [materials] clinical review criteria provided to you are used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract[.];

[(g)] (6) In the case of a denial of a benefit concerning a claim involving urgent care or in the case of a denial of a claim related to continuation of an ongoing course of treatment for a person who has received emergency services, but who has not been discharged from a facility, a description of the expedited review applicable to such a claim shall be included in the determination. For all other claim benefit determinations, a description of the grievance process shall be specifically described in the determination.

304:5 Effective Date.

I. Section 1 of this act shall take effect upon its passage.

II. The remainder of this act shall take effect 60 days after its passage.

Approved: June 19, 2006

Effective: I. Section 1 shall take effect June 19, 2006

II. Remainder shall take effect August 18, 2006

Links

HB1194 at GenCourtMobile

Action Dates

Date Body Type

Bill Text Revisions

HB1194 Revision: 9473 Date: Jan. 21, 2010, midnight

Docket