New Hampshire Administrative Code

(a) An advertisement shall not state or imply that a governmental agency has approved an insurer or a policy, or has examined an insurer's financial condition and found it satisfactory, unless such is the fact. (b) An advertisement shall not state or imply that any individual, gr…

(a) Each insurer shall maintain at its home or principal office a complete file that contains: (1) Every printed, published or prepared advertisement of individual policies; and (2) Typical printed, published or prepared advertisements for blanket, franchise and group policies th…

Any advertisement which the insurer uses to solicit leads for prospective applicants shall disclose that an agent for the insurer will contact the applicant if such is the fact. Notes N.H. Admin. Code § Ins 2604.16 #9333, eff 12-5-08 Amended by Volume XXXVI Number 36, Filed Septe…

Any insurer who knowingly violates any requirement of this part shall be subject to the penalty provisions of RSA 400-A:15. Notes N.H. Admin. Code § Ins 2604.17 #9333, eff 12-5-08 Amended by Volume XXXVI Number 36, Filed September 8, 2016, Proposed by #11173, Effective 12/5/2016,…

The purpose of these rules is to establish standards for determining whether a carrier's provider network is sufficient in numbers, types, and geographic location of providers to ensure that covered persons will have access to health care services without unreasonable delay. Note…

These rules shall apply to all insurers offering or issuing policies of health and dental insurance in the state of New Hampshire when the plan design and benefits include a provider network with differential payment or coverage associated with use of an in-network provider. Note…

(a) "Commissioner" means the insurance commissioner. (b) "Covered benefits" means those health care services and other medical services, including dental benefits, to which a covered person is entitled under the terms of a health benefit plan. (c) "Covered person" means a policyh…

(a) Each health carrier offering a network plan shall maintain a network of primary care providers, dental providers, specialists, institutional providers, and other ancillary health care personnel that is sufficient in numbers and types of providers to ensure that all covered he…

(a) To constitute reasonable access to health care services, a provider network shall supply access consistent with the geographic accessibility standards in Ins 2701.06 to the services listed in Ins 2701.07. (b) To be deemed adequate for each of the listed services, the network …

(a) Geographic access standards shall be calculated based on population densities of persons under the age of 65. Geographic access standards shall be measured in terms of distance or travel times for a person under normal conditions from specific zip codes. (b) A carrier shall m…

(a) The purpose of this section is to classify services into 3 categories, core, common, and specialized, for the purposes of network adequacy reviews. (b) The following services shall be classified as "Core" services for purposes of network adequacy review: (1) Alcohol or drug t…

(a) The department shall grant a carrier an exception to the standards for geographic accessibility in Ins 2701.06 where: (1) A health carrier demonstrates that an insufficient number of qualified providers or facilities are available in the county to meet the geographic accessib…

(a) Standard waiting times for appointments shall be measured from the initial request for an appointment. (b) For behavioral health services, the carrier shall ensure that covered persons may obtain an initial appointment with an in-network provider within: (1) Six hours for a n…

(a) Each health carrier shall establish policies and procedures through which a member with a condition that requires care from a specialist may obtain a referral to a network specialist or specialist group practice, subject to the utilization review procedures used by the health…

(a) Each health carrier shall, by July 1 or at the time its plans and rates for the upcoming plan year are filed with the department for review, include a network provider listing for each of the health benefit plans that the carrier offers in this state using a template provided…

(a) For each of its network plans, a health carrier shall electronically post and maintain a current and accurate provider directory in accordance with the following requirements and with the information and search functions described in (c) below: (1) In making the directory ava…

If the commissioner determines that a health carrier has not contracted with a sufficient number of participating providers to assure that covered persons have accessible health care services in a geographic area or that a health carrier's health care certification of compliance …

(a) The commissioner, upon the commissioner's own initiative or upon request by an insurer, shall waive any requirement of this chapter if such waiver does not contradict the objective or intent of the rule and: (1) Applying the rule provision would cause confusion or would be mi…

The purpose of these rules is to implement the requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as amended, for group health insurance coverage that is provided to employers. Notes N.H. Admin. Code § Ins 2702.01 #9809, eff 11-8-10 Amended by Vol…

The requirements of this part shall apply to all health insurance issuers offering health insurance coverage in connection with a group health insurance plan that provides coverage to a group employer. Notes N.H. Admin. Code § Ins 2702.02 #9809, eff 11-8-10 Amended by Volume XXXV…

(a) "Group health insurance coverage" means, for the purpose of Ins 2702, health coverage sold under RSA 420-G:2IV. (b) "Mental health benefits" means benefits with respect to services for mental health conditions, as defined under the terms of group health insurance coverage, an…

Group health insurance coverage offered by an insurer in connection with a group health plan issued to an employer and that provides health coverage sold under RSA 420-G:2, IX must offer mental health and substance use disorder benefits coverage as required under RSA 415:18-a in …

(a) The commissioner, upon the commissioner's own initiative or upon request by an insurer, shall waive any requirement of this part if such waiver does not contradict the objective or intent of the rule and: (1) Applying the rule provision would cause confusion or would be misle…

(a) Determining "substantially all" and "predominant." For purposes of applying the general parity requirements, a type of financial requirement or quantitative treatment limitation is considered to apply to substantially all medical/surgical benefits in a classification of benef…

(a) General rule. Group health insurance coverage issued to a large group employer shall not impose a nonquantitative treatment limitation with respect to mental health or substance use disorder benefits in any classification unless, under the terms of the group health insurance …

(a) Criteria for medical necessity determinations. The criteria for medical necessity determinations made under group health insurance coverage issued to a large group employer with respect to mental health or substance use disorder benefits shall be made available by the health …

Pursuant to 29 CFR 2590, for group health coverage issued to an employer that is subject to a collective bargaining agreement ratified before October 3, 2008, the requirements of this rule shall take effect for the plan year that begins after the date on which the collective barg…

(a) Except as provided in (b) below, the external review requirements set forth in this rule shall apply to all health carriers that provide or perform utilization review. Any health carrier that makes an adverse determination concerning a covered person shall be considered to be…

For the purpose of this rule: (a) "Adverse determination" means a determination by a health carrier or its designee utilization review entity: (1) Concerning a requested admission, availability of care, continued stay or other health care service, supply or drug that is a covered…

(a) A covered person shall have the right to independent external review of a determination by a health carrier or its designee utilization review entity when all of the following conditions apply: (1) The subject of the request for external review is an adverse determination; (2…

(a) Health carriers shall provide to covered persons the insurance department's "Managed Care Consumer Guide to External Appeal" and the insurance department's "Request for Independent External Appeal of a Health Care Decision" in each of the following circumstances: (1) The publ…

Standard external review shall be conducted as follows: (a) Within 7 business days after the date of receipt of a request for external review, the department shall complete a preliminary review of the request to determine whether: (1) The individual is or was a covered person und…

Expedited external review shall be conducted as follows: (a) Expedited external review shall be available when the covered person's treating health care provider certifies to the department that adherence to the time frames specified in RSA 420-J:5-b would seriously jeopardize th…

(a) The certification of independent review organizations shall be conducted as follows: (1) An independent review organization seeking certification shall supply the following information: a. Name, address and telephone number of the organization; b. The name, address, and telep…

(a) An independent review organization assigned by the commissioner to conduct external reviews shall submit an annual report to the commissioner including the following information in the aggregate and separately for each health carrier: (1) The total number of requests for exte…

(a) The health carrier against which a request for external review is filed shall pay the cost of the external review. Except under the circumstances described below in this paragraph, such costs shall not exceed $1,500. The commissioner shall notify the independent review organi…

The purpose of this part is to provide for the regulation and registration of pharmacy benefits managers (PBMs) and to set forth rules which the commissioner deems necessary to carry out the provisions of RSA 402-N. Notes N.H. Admin. Code § Ins 2704.01 Derived From Volume XXXVII …

(a) "Annual report" means a report of the data required to be submitted annually in accordance with RSA 402-N:6. (b) "Commissioner" means the insurance commissioner. (c) "Covered benefits" means those health care services and other medical services to which a covered person is en…

(a) No person or entity shall manage the prescription drug coverage provided by a health carrier without registering with the department as a PBM. All PBMs shall complete and submit an application PBM-R "Application for Registration: Initial Application or Renewal Application" (M…

(a) All PBMs shall submit a renewal fee of $100 and complete and submit a renewal application PBM-R "Application for Registration: Initial Application or Renewal Application" (May 2020), available at: https://www.nh.gov/insurance/companies/applications/index.htm, by March 1 each …

(a) Every health carrier that provides prescription benefits as a covered benefit under a health benefit plan shall ensure that prescription benefit claims are adjusted and paid in accordance with the requirements of Ins 1001 and RSA 420-J:8-a. (b) Any health carrier or PBM shall…

(a) Any pharmacy that fills prescriptions as a covered benefit under a health benefit plan and is adversely affected by the failure of a health carrier or a PBM to comply with RSA 420-J:7-b, X or RSA 415:26 may file a complaint with the commissioner. (b) Complaints alleging viola…

A PBM shall be subject to the provisions of RSA 402-N:2, III for the following reasons: (a) Failure to comply with any provisions of this part or of RSA 402-N; (b) Failure to comply with any lawful order of the commissioner; (c) Committing an unfair or deceptive act or practice a…

(a) The commissioner shall prepare public reports with regard to the complaints received from pharmacies or the New Hampshire board of pharmacy under this part. (b) The public report shall contain the following information:(1) A unique numerical identifier for each complaint rece…

In accordance with RSA 400-A:16, III, RSA 402-N:6, II, and except as otherwise provided in this part, all information collected, obtained, or otherwise in the control or possession of the commissioner from any source relating to any investigation pursuant to this part shall be co…

(a) The commissioner shall examine a PBM pursuant to RSA 400-A:37 and RSA 402-N:7. The cost of the audit shall be paid by the PBM pursuant to RSA 402-N:7. Audits shall include premium collection, claims processing, and marketing practices. (b) The PBM shall have continuing access…

(a) The commissioner shall address any inquiries to the PBM concerning its PBM business. The PBM shall reply in writing within 10 working days to any inquiry made by the commissioner pursuant to RSA 400-A:16, II. (b) A PBM shall keep all complaints on file for a period of 5 years…