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1 Managed Care Law; Network Adequacy; Periodic Evaluation of Mental Health Network Adequacy. Amend RSA 420-J:7 to read as follows:
420-J:7 Network Adequacy.
I. A health carrier shall maintain a network that is sufficient in numbers, types, and geographic location of providers to ensure that all services to covered persons will be accessible without unreasonable delay.
II. The commissioner shall adopt rules under RSA 541-A for a health carrier's network adequacy . Such rules shall establish, but not be limited to:
(a) Waiting times for appointments for non-emergency care.
(b) Choice of and access to providers for specialty care, specifically addressing the needs of the chronically ill, mentally ill, persons with substance use disorder, developmentally disabled or those with a life threatening illness.
(c) Standards for geographic accessibility, which shall include standards for access to the provision of durable medical equipment requiring a prescription. However, such standards shall not restrict an insurer's ability to provide prescriptions for durable medical equipment that are shipped to the patient by postal service or other common or private carrier, and shall not apply to durable medical equipment devices used exclusively for the administration of medication.
(d) Hours of operation for the carrier, including any entities performing prior approval or pre-authorization functions.
(e) Standards for addressing in-network access to hospital based providers, such as anesthesiologists, radiologists, pathologists, and emergency medicine physicians
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III. The health carrier shall keep, at its place of business, a detailed description of the health carrier's compliance with rules adopted pursuant to RSA 420-J:7, II as well as its procedures for monitoring network adequacy.
IV. Annually, the health carrier shall submit a report to the commissioner demonstrating compliance with the rules for network adequacy.
V. The commissioner shall make available to the public information regarding each health carrier's managed care network.
VIII.(a) Any health carrier violating any of the provisions of this section may be subjected to an administrative fine as follows:
(1) Not to exceed $1,000 per covered life for a first violation.
(2) Not to exceed $2,500 per covered life for a second violation within a 5-year period.
(3) Not to exceed $5,000 per covered life for a third violation within a 5-year period.
(b) The commissioner also may suspend or revoke the certificate of authority or license of a health carrier found to have violated any of the provisions of this section.
(c) If a health carrier, insurer, or other organization are found to have violated any of the provisions of this section 3 or more times within a 5-year period, any person aggrieved may initiate an action against such health carrier and may recover court costs and reasonable attorney's fees as the prevailing party, provided however, that nothing in this section shall supercede or replace existing rights or remedies under any other law.
2 Effective Date. This act shall take effect 60 days after its passage.
Text to be added highlighted in green.
1 Managed Care Law; Network Adequacy; Periodic Evaluation of Mental Health Network Adequacy. Amend RSA 420-J:7 to read as follows:
420-J:7 Network Adequacy.
I. A health carrier shall maintain a network that is sufficient in numbers, types, and geographic location of providers to ensure that all services to covered persons will be accessible without unreasonable delay.
II. The commissioner shall adopt rules under RSA 541-A to define a health carrier's network adequacy for primary care and mental and behavioral health care . Such rules shall establish, but not be limited to:
(a) Waiting times for appointments for non-emergency care.
(b) Choice of and access to providers for specialty care, specifically addressing the needs of the chronically ill, mentally ill, persons with substance use disorder, developmentally disabled or those with a life threatening illness.
(c) Standards for geographic accessibility, based on availability of in-person appointments within reasonable drive times not to exceed 30 minutes, which shall include standards for access to the provision of durable medical equipment requiring a prescription. However, such standards shall not restrict an insurer's ability to provide prescriptions for durable medical equipment that are shipped to the patient by postal service or other common or private carrier, and shall not apply to durable medical equipment devices used exclusively for the administration of medication.
(d) Hours of operation for the carrier, including any entities performing prior approval or pre-authorization functions.
(e) Standards for addressing in-network access to hospital based providers, such as anesthesiologists, radiologists, pathologists, and emergency medicine physicians ; and
(f) The network adequacy criteria set forth in paragraph VII .
II-a. For purposes of defining a health carrier's network adequacy under paragraph II, providers that fall into the following categories shall not be counted in determining the adequacy of a health carrier network:
(a) A provider who is not accepting new patients.
(b) A provider who does not have availability for new intakes within 30 days for non-emergent adequacy determinations or 48 hours for emergent network adequacy determinations.
(c) A provider who is located out-of-state or out of the drive time measurement range set forth in subparagraph II (c).
III. The health carrier shall keep, at its place of business, a detailed description of the health carrier's compliance with rules adopted pursuant to RSA 420-J:7, II as well as its procedures for monitoring network adequacy.
IV. Annually, the health carrier shall submit a report to the commissioner demonstrating compliance with the rules for network adequacy.
V. The commissioner shall make available to the public information regarding each health carrier's managed care network.
VI. The commissioner shall provide an annual report on the findings associated with network adequacy review to the chairpersons of the house and senate committees having jurisdiction over insurance issues.
VII. Every 3 years, the department shall engage an independent third party to conduct a review of network adequacy, considering multiple points, to include, but not be limited to:
(a) Measurement of new appointment availability.
(b) Measurement of the number of new appointments available within 7 and 14 days from date contacted by patient.
(c) Measurement of the percentage of in person and virtual appointments, with available in person appointments not to be lower than 70 percent.
(d) Measurement of available clinicians at a statewide and county/MSA level, including but not necessarily limited to, psychiatry, therapy, child, geriatric and testing services, and other relevant data as determined by the department.
VIII.(a) Any health carrier violating any of the provisions of this section may be subjected to an administrative fine as follows:
(1) Not to exceed $1,000 per covered life for a first violation.
(2) Not to exceed $2,500 per covered life for a second violation within a 5-year period.
(3) Not to exceed $5,000 per covered life for a third violation within a 5-year period.
(b) The commissioner also may suspend or revoke the certificate of authority or license of a health carrier found to have violated any of the provisions of this section.
(c) If a health carrier, insurer, or other organization are found to have violated any of the provisions of this section 3 or more times within a 5-year period, any person aggrieved may initiate an action against such health carrier and may recover court costs and reasonable attorney's fees as the prevailing party, provided however, that nothing in this section shall supercede or replace existing rights or remedies under any other law.
2 Effective Date. This act shall take effect 60 days after its passage.