Title 24-A, Title 24-A

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…

1. Services provided by a naturopathic doctor. A carrier offering a health plan in this State shall provide coverage for health care services performed by a naturopathic doctor licensed under Title 32, chapter 113‑B, subchapter 3 when those services are covered services under the…

1. Nondiscrimination. An individual may not, on the basis of race, color, national origin, sex, sexual orientation, gender identity, age or disability, be excluded from participation in, be denied benefits of or otherwise be subjected to discrimination under any health plan offer…

1. Required coverage. A carrier offering a health plan in this State that provides coverage for maternity services shall provide coverage for abortion services for an enrollee in accordance with this section. 2. Limits; copayment. A health plan that provides coverage for the serv…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Clinical practice guidelines" means a systematically developed statement to assist prescriber and enrollee decisions about appropriate health care…

1. Services provided by a physician associate. A carrier offering a health plan in this State shall provide coverage for health care services performed by a physician associate licensed under Title 32, section 2594‑E or 3270‑E when those services are covered services under the he…

Notwithstanding any requirements of this Title to the contrary, a carrier offering a health plan in this State shall provide, at a minimum, coverage as required by this section for screening, testing and immunization for COVID-19. [PL 2021, c. 28, Pt. A, §3 (NEW).] 1. Definitions…

1. Services provided by a certified registered nurse anesthetist. A carrier offering a health plan in this State shall provide coverage for health care services performed by a certified registered nurse anesthetist licensed under Title 32, chapter 31 when those services are cover…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Dependent child" has the same meaning as in section 4233‑B, subsection 1. [PL 2021, c. 520, §8 (NEW).] B. "Disability" means a physical, mental, i…

1. Required coverage. Except as provided in subsection 2, a carrier offering a health plan in this State shall provide coverage for medically necessary dental procedures in accordance with the following for an enrollee who has been diagnosed with cancer. A. Coverage must be provi…

1. Nonquantitative treatment limitation; definition. For the purposes of this section, "nonquantitative treatment limitation" means a limitation that is not expressed numerically but otherwise limits the scope or duration of benefits for treatment. 2. Compliance with federal ment…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Experimental fertility procedure" means a procedure for which the published medical evidence is not sufficient for the American Society for Reprod…

1. Required coverage. A carrier offering a health plan in this State shall provide coverage for pasteurized donor breast milk provided to an infant eligible for coverage under the health plan if a physician or physician associate licensed under Title 32, chapter 36 or 48 or an ad…

1. Division established. The Consumer Health Care Division, referred to in this section as the "division," is established within the Bureau of Insurance. The division shall work in coordination with other bureau sections and staff to accomplish the duties set forth in subsection …

1. Establishment. The Health Insurance Consumer Assistance Program, referred to in this section as "the consumer assistance program," is established to provide support for consumers, including prospective consumers, of health insurance, referred to in this section as "consumers,"…

1. Independent health care provider defined. For the purposes of this section, "independent health care provider" means an independent health care practitioner or group of independent health care practitioners with 6 or fewer health care practitioners, but does not include a heal…

As used in this subchapter, unless the context otherwise indicates, the following terms have the following meanings. [PL 1999, c. 609, §20 (NEW).] 1. Bonus. "Bonus" means a payment a carrier makes to a downstream entity beyond any salary, fee-for-service payment, capitation or re…

1. Authority for safe harbor. Notwithstanding any other provisions of this Title or Title 24, including, without limitation, sections 4341 and 4342, an arrangement between a carrier and a downstream entity with which the carrier has contracted to provide or arrange for the provis…

1. Permissible downstream risk arrangements. Downstream entities that do not exceed the risk threshold described in section 4334 may enter into downstream risk arrangements only if: A. The requirements of section 4332, subsection 1 and sections 4335 and 4336 are met; and [PL 1999…

1. Substantial insurance risk. Substantial insurance risk is risk based on the use or costs of referral services only, when the downstream entity is at risk for more than 25% of potential payments by the carrier to the downstream entity. 2. Substantial enrollment risk. Substantia…

Full copies of contracts and summary descriptions of contracts must be provided to the superintendent. The following provisions must be included in contracts between a carrier and a downstream entity: [PL 1999, c. 609, §20 (NEW).] 1. Enrollee not liable. A provision in all releva…

1. Disclosure to superintendent. Each carrier shall provide information concerning the carrier's downstream risk arrangements as required or requested by the superintendent. The disclosure must contain the following information in sufficient detail to enable the superintendent to…

1. Physician groups. A carrier that contracts with a downstream entity that places the individual physician members at substantial financial risk for services they do not furnish shall disclose to the superintendent any incentive plan between the downstream entity and the entity'…

The superintendent may waive downstream risk arrangements from licensure requirements that exceed the risk threshold described in section 4334 if the downstream risk arrangement meets the contractual and disclosure requirements established under section 4332 and the criteria set …

If a carrier applies for a waiver under section 4332, subsection 2, the carrier may demonstrate the financial viability and condition of the downstream entity through the terms of the contract, including one or more of the following: [PL 1999, c. 609, §20 (NEW).] 1. Books, accoun…

Each carrier and downstream entity requesting a waiver shall file with the superintendent a plan for managing financial exposure under those downstream risk arrangement contracts and thereafter operate in substantial conformance with the terms of that plan and of the correspondin…

The superintendent may deny a request for waiver based on any of the following characteristics: [PL 1999, c. 609, §20 (NEW).] 1. Transfer of 30% of annual aggregate premium. A contract by which 30% or more of the carrier's annual aggregate premium with respect to a contract, plan…

The superintendent may deny a request for waiver based on any of the following characteristics: [PL 1999, c. 609, §20 (NEW).] 1. Carrier controlled. An arrangement with a downstream entity that has control of the carrier. "Control" has the same meaning as defined in section 222, …