Title 24-A, Title 24-A

1. Disclosure. Upon request, a carrier shall provide to a provider to which the carrier has decided not to offer the opportunity to participate or that the carrier has decided not to include as a participating provider in any of the carrier's provider networks a written explanati…

1. Surprise bill defined. As used in this section, unless the context otherwise indicates, "surprise bill" means a bill for health care services, including, but not limited to, emergency services, received by an enrollee for covered services rendered by an out-of-network provider…

1. Requirement. A carrier shall make available provider directories in accordance with this section. A. A carrier shall post electronically a current and accurate provider directory for each of its network plans with the information and search functions described in subsection 2.…

1. Independent dispute resolution process. The superintendent shall establish an independent dispute resolution process by which a dispute for a surprise bill for emergency services or a bill for covered emergency services rendered by an out-of-network provider in accordance with…

1. Reimbursement for ambulance services. With respect to a bill for covered services rendered by an ambulance service provider, a carrier shall reimburse the ambulance service provider or enrollee, as applicable, as follows. A. If the ambulance service provider participates in th…

The following provisions govern maintenance of certification requirements. [PL 2023, c. 40, §1 (NEW); PL 2023, c. 40, §2 (AFF).] 1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Hospital" means a…

The following requirements apply to health plans doing business in this State that require prior authorization by the plan of health care services or otherwise subject payment of health care services to review for clinical necessity, appropriateness, efficacy or efficiency. A car…

1. Prior authorization for new episode of care prohibited for 12 visits. A carrier may not require prior authorization for rehabilitative or habilitative services, including, but not limited to, physical therapy services, occupational therapy services or chiropractic services, fo…

A carrier offering or renewing a health plan that subjects payment of benefits for otherwise covered services to review for clinical necessity, appropriateness, efficacy or efficiency must meet the following requirements relating to quality of care. [PL 2007, c. 199, Pt. B, §14 (…

A carrier offering or renewing a managed care plan shall allow enrollees to choose their own primary care providers, as allowed under the managed care plan's rules, from among the panel of participating providers made available to enrollees under the managed care plan's rules. A …

Notwithstanding any other requirements of this Title, a carrier offering a health plan in this State subject to the requirements of the federal Affordable Care Act: [PL 2011, c. 364, §29 (NEW).] 1. Authorization or referral not required. May not require authorization or referral …

Nothing in this chapter may be construed to: [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).] 1. Purchase services with own funds. Prohibit an individual from purchasing any health care services with that individual's own funds, whether these services are cov…

A contract between a carrier offering or renewing a health plan and a provider for the provision of services to enrollees may not require the provider to indemnify the carrier for any expenses and liabilities, including, without limitation, judgments, settlements, attorney's fees…

The superintendent shall adopt rules and establish standards for health plans in order to carry out the purposes of this chapter. Rules adopted pursuant to this chapter are major substantive rules as defined in Title 5, chapter 375, subchapter II‑A.

1. Carriers. A carrier shall comply with all applicable requirements of the federal Affordable Care Act. 2. Superintendent. The superintendent may enforce and administer this section through all powers provided under this Title and Title 24. The superintendent may adopt and amend…

1. Qualified enrollee. An enrollee is eligible for coverage for participation in an approved clinical trial if the enrollee meets the following conditions: A. The enrollee has a life-threatening illness for which no standard treatment is effective; [PL 1999, c. 742, §19 (NEW); PL…

1. Formulary. If a health plan provides coverage for prescription drugs but the coverage limits such benefits to drugs included in a formulary, a carrier shall: A. Ensure participation of participating physicians and pharmacists in the development of the formulary; [PL 2017, c. 4…

1. Access to pain management services. A carrier shall develop a plan to provide adequate coverage of and access to a broad spectrum of pain management services, including, but not limited to, nonopioid, nonnarcotic medication for pain management and nonmedication pain management…

An enrollee or the enrollee's authorized representative has the right to an independent external review of a carrier's adverse health care treatment decision made by or on behalf of a carrier offering or renewing a health plan in accordance with the requirements of this section. …

1. Duty of ordinary care; cause of action. An enrollee may maintain a cause of action against a carrier offering or renewing a health plan in accordance with the following. A. A carrier has the duty to exercise ordinary care when making health care treatment decisions that affect…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Eye care provider" means a participating provider who is an optometrist licensed to practice optometry pursuant to Title 32, chapter 151, or an op…

1. Required coverage. A carrier offering a health plan in this State shall provide coverage for one early refill of a prescription for eye drops if the following criteria are met: A. The enrollee requests the refill no earlier than the date on which 70% of the days of use authori…

1. Definition. As used in this section, "prosthetic device" means an artificial device to replace, in whole or in part, an arm or a leg. 2. Required coverage. A carrier shall provide coverage for prosthetic devices in all health plans that, at a minimum, equals, except as provide…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Mobile health device" means a wearable device used to track health and wellness, including, but not limited to, a heart rate and respiratory monit…

1. Contracts with pharmacy providers. Notwithstanding section 2672, section 4307, subsection 3 and Title 32, chapter 117, subchapter 8, a carrier that provides coverage for prescription drugs as part of a health plan may not refuse to contract with a pharmacy provider that is qua…

1. Out-of-pocket expenses for coinsurance within health plan's total limit. If a carrier that provides coverage for prescription drugs does not include prescription drugs subject to coinsurance under the total out-of-pocket limit for all benefits provided under a health plan, the…

1. Coverage. A carrier that provides coverage for cancer chemotherapy treatment shall provide coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells that is equivalent to the coverage provided for intravenously admin…

1. Definition. As used in this section, "insulin" has the same meaning as in Title 32, section 13786‑D, subsection 1, paragraph A. 2. Limit on out-of-pocket costs. A carrier that provides coverage for prescription insulin drugs may not impose any deductible, copayment, coinsuranc…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "CDC guidelines" means guidelines related to the nonoccupational exposure to potential HIV infection, or any subsequent guidelines, published by th…

1. Definition. As used in this section, unless the context otherwise indicates, "chronic maintenance drug" has the same meaning as in Title 32, section 13786‑F, subsection 1. 2. Coverage required. A carrier offering a health plan in this State must make available coverage for an …

Beginning January 1, 2019, a carrier offering a health plan in this State shall establish, at a minimum, for all small group health plans as defined in section 2808‑B, subsection 1, paragraph G compatible with a health savings account authorized under federal law, a health plan d…

1. Services from out-of-network provider; lower prices. Beginning January 1, 2019, if an enrollee covered under a health plan other than a health maintenance organization plan elects to obtain a covered comparable health care service as defined in section 4318‑A, subsection 1, pa…

1. Rebates required. Carriers must provide rebates in the large group, small group and individual markets if the medical loss ratio under subsection 2 is less than the minimum medical loss ratio under subsection 3. 2. Medical loss ratio. For purposes of this section, the medical …

A carrier offering a health plan in this State in the individual, small group or large group market must offer to an individual or group in the State all health plans that are approved for sale in the applicable market and must accept any individual or group that applies for any …

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Dental plan" means a plan providing dental care services to an enrollee who is insured by a carrier. "Dental plan" does not include: (1) A health …

A carrier offering a health plan in the individual, small group or large group market, as those markets are defined under applicable federal law, may not: [PL 2019, c. 5, Pt. A, §25 (AMD).] 1. Establish lifetime limits. Establish lifetime limits on the dollar value of benefits fo…

Notwithstanding any other requirements of this Title, a carrier offering a health plan in this State shall, at a minimum, provide coverage for and may not impose cost-sharing requirements for preventive and primary health services as required by this section. [PL 2019, c. 653, Pt…

A carrier offering a health plan subject to the requirements of the federal Affordable Care Act that provides dependent coverage of children shall continue to make such coverage available for an adult child until the child turns 26 years of age, consistent with the federal Afford…

If a carrier offering a health plan provides or covers any benefits with respect to services in an emergency facility or setting, the plan must cover emergency services without prior authorization. Cost-sharing requirements, such as a deductible, copayment amount or coinsurance r…

Notwithstanding any other requirements of this Title, a carrier offering a health plan in this State shall, at a minimum, provide coverage that incorporates an essential health benefits package consistent with the requirements of this section. [PL 2019, c. 5, Pt. B, §1 (AMD).] 1.…

1. Transitional reinsurance program. The superintendent shall establish a transitional reinsurance program for calendar years 2014, 2015 and 2016 as required by Section 1341 of the federal Affordable Care Act. 2. Risk corridors. A carrier shall make any payments required under th…

1. Superintendent's authority preserved. Except as otherwise expressly provided by applicable law, the requirements established by this Title, Title 24 and rules adopted by the superintendent continue to apply to carriers and health plans and are not extinguished or modified in a…

A health plan that is exempt from certain requirements of the federal Affordable Care Act because it has grandfathered status is also exempt, to the same extent, from substantially similar provisions in this Title and Title 24 enacted after January 1, 2011, except to the extent t…

1. Pilot projects. Beginning March 1, 2012, the superintendent may authorize pilot projects in accordance with this subsection that allow a health insurance carrier that offers health plans in this State to implement payment reform strategies with providers through an accountable…

1. Required coverage. A carrier offering a health plan in this State shall provide coverage for laboratory fees up to $150 arising from human leukocyte antigen testing performed to establish bone marrow transplantation suitability in accordance with the following requirements: A.…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Abuse-deterrent opioid analgesic drug product" means a brand or generic opioid analgesic drug product approved by the federal Food and Drug Admini…