CHAPTER Ins 2200
HEALTH MAINTENANCE ORGANIZATIONS
Statutory
Authority: RSA 400-A:15; RSA 420-B:21
PART Ins
2201 DOMESTIC HEALTH MAINTENANCE
ORGANIZATIONS
Ins 2201.01
Purpose. The purpose of
this rule is to delineate a system for regulation that is fair and efficient,
and promotes the continued solvency of health maintenance organizations.
Source. #9335, eff 12-5-08
Ins 2201.02 Applicability and Scope.
(a) No health maintenance
organization shall:
(1) Provide or arrange for health care service to enrolled participants
in exchange primarily for a prepaid per capita or aggregate fixed sum without
being licensed in accordance with the provisions of these parts; or
(2) Commence operations except as provided in Ins 2201.04 that
shall occur on that date on which any contracts for health services are
available to members or on which evidences of coverage are issued.
(b) This part shall apply to any health
maintenance organization regardless of whether services are to be delivered
through physicians or other health professionals:
(1)
Who are employees of the health maintenance organization;
(2)
Who are organized on a group practice basis;
(3)
Who are organized on an individual practice basis; or
(4)
Under any other arrangements.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #5944, eff 1-1-95, EXPIRED: 1-1-03
New. #9335, eff 12-5-08
Ins 2201.03 Definitions.
(a) For the purposes of this part, the definitions
appearing in RSA 420-B:1 shall apply.
(b) With respect to the following words or
phrases used in this part, not defined in RSA 420-B:1, the following
definitions shall apply:
(1)
"Active recipient of mental health services" means an insured,
subscriber or member of a replacing carrier's health insurance benefit plan who
received mental health services from a mental health provider while covered by
a prior carrier's benefit plan provided such services were for a purpose other
than monitoring medications and were received at least as often as:
a.
In the case of outpatient services:
1.
For 2 separate days during the 30 day period immediately prior to the
effective date of the replacing carrier's plan;
2.
For 3 separate days during the 90 day period immediately prior to the
effective date of the replacing carrier's plan; or
3.
For 5 separate days within the 12 month period immediately preceding the
effective date of the replacing carrier's plan; and
b. In
the case of inpatient services, one inpatient confinement during the 12 month
period immediately prior to the effective date of the replacing carrier's plan.
(2) "Complaints" means the grievances
of persons concerning the services of the health maintenance organization.
(3) "Controlling interest" means the
possession, either directly or indirectly, of the power of a person or persons
to direct or cause the direction of the management and policies of the health
maintenance organization, whether through the ownership of voting stock, or by
contract, other than commercial contract for goods or management services, or
through official position or positions of, or corporate office or offices held
by, the person or persons, or otherwise.
(4)
"Mental health
provider" means any professional or institution listed under RSA 415:18-a,
IV.
(5)
"Presumed controlling interest" means the existence of a
controlling interest when any person, directly
or indirectly, owns, controls, holds, with the present power to vote more than
5 percent of the voting stock of the health maintenance organization, or holds
proxies representing more than 5 percent of the voting stock of any other
person or persons.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
Ins 2201.04 Certificate of Authority.
(a) Any health maintenance organization operating
pursuant to Ins 2201.03(b)(1) of this part shall submit an application for a
certificate of authority as a health maintenance organization by filing an
original and 2 copies of the following documents:
(1)
If the applicant is not domiciled in this state, a power of attorney
duly executed and appointing the commissioner and his successors in office, and
duly authorized deputies, as true and lawful attorney for the applicant for
service of process in this state pursuant to RSA 420-B:4;
(2)
Payment by check or other draft of required application fees as set
forth in RSA 400-A:29;
(3)
Basic organizational documents, articles of incorporation and all
amendments thereto;
(4)
Copies of all by-laws, rules and regulations of the applicant;
(5)
Copies of the organizational chart of the applicant, including the
titles, names, and salaries, if any, of officers and key management personnel
dealing in marketing, administration, enrollment, grievance procedures, quality
assurance, contract negotiations, and financial matters;
(6)
A list of members of the board of directors, or similar policymaking
body of the applicant, with the name, principal occupation, and employer of
each;
(7)
A description of the applicant's proposed system for handling complaints
that shall include procedures for the registration of complaints and procedures
for the resolution of complaints;
(8)
Financial reports for the prior 3 fiscal years;
(9) Financial reports submitted by insurance companies or hospital, medical, or
health service corporations applying for a certificate of authority to operate
a health maintenance organization as a subsidiary or affiliate pursuant to RSA
420-B:19 shall be restricted in subject matter to the finances of such
subsidiary or affiliate;
(10)
Financial statements projecting the results of the applicant's
operations for the next 3 years from the date of application, on a quarterly
basis for years one and 2 and annually for year 3, including the following:
a.
Balance sheet;
b. Statement
of income from all sources, and expenses;
c.
Cash flow;
d.
Present and anticipated capital expenditures;
e.
Repayment schedules for existing or anticipated loans or alternative
financing arrangements;
f.
Statement indicating when the applicant estimates that income from
enrollments and other operations will equal expenses; and
g.
Detailed statements underlying assumptions used and the bases thereof.
(11) A
detailed statement of the health maintenance organization's plan to establish
and maintain reserves or other funds necessary to cover any risks projected and
not otherwise assumed by another entity, carrier or reinsurer.
(12) A detailed statement of current and projected
reserve-establishment calculations, as well as amounts, purpose and uses of the
reserves, and assumptions and bases therefor, including, but not limited to,
identification of reserves set aside to meet uncovered reinsurance items.
(13)
Copies of all reinsurance, conversion, or other arrangements with other
insurers, health providers, medical service corporations, hospital service
corporations, health service corporations, governmental agencies or
organizations or other health maintenance organizations that provide payment
schedules for contracted-for health care services, or made directly to
provide services, in the event the health maintenance organization is unable or
ceases to provide contracted-for health services for any reason.
(14) A
copy of the applicant's official notification of status as a federally qualified
health maintenance organization, if it is so designated.
(15) A
statement of insurance or funded self-insurance for:
a. Protection against loss of property and liability of the applicant;
b. Workers' compensation to protect against claims arising from work-related
injuries of the applicant's employees; and
c. Medical malpractice liability insurance for the applicant and its
providers.
(16) A
listing of shareholders or other equity holders, or members with holdings of 5
percent or more of capital shares, partnership interest, or other evidence of
equity holdings. The listing shall be by
name, address, number and percentage of shares or other interest held, and any
other affiliations with the applicant.
(17) A listing of the applicant's legal,
accounting, and actuarial representatives by name and address.
(18) A
statement that fidelity bond coverage exists for all officers and employees
entrusted with the handling of funds for the applicant.
(19)
A statement of enrollment practices and procedures.
(20) An
enrollment projection of members per month for the next 3 years from the date
of application, on a quarterly basis for years one and 2, and annually for year
3, including:
a. The current total enrollment of the applicant;
b. The current categories of membership of the applicant:
1. Private;
2. Group;
3. Non-group;
4. Medicaid;
5. Medicare;
6. Federal employees; and
7.
State employees; and
c. A detailed statement of assumptions used, and the bases therefor; and
(21) A
description of the geographical area to be served, including:
a. Present population
figures for each city or town within the current area; and
b. Projections of future
population trends for each city and town within the current area for the next 5
years from the date of application.
(b) The application documents
shall be compiled in the order in which they are required.
(c)
The applicant shall state the reasons for the absences of any items
required, but not
included in the application.
(d) In the event that the
commissioner finds the application incomplete, the commissioner shall provide
the applicant written notice specifying the additional documents or information
required under this part.
(e)
The
applicant shall have 30 days from receipt of the notice in which to file the
additional material required by (d) above or the application shall be deemed
rejected.
(f) Prior to the issuance of a certificate of
authority to operate a health maintenance organization, an applicant may:
(1) Engage in such activities as are necessary to the gathering of
information for applications for certification as a federally qualified health
maintenance organization, and for certification pursuant to RSA 420-B and these
parts;
(2) Make contact with
potential enrolled participants and/or their employers for the purposes of
determining the feasibility of establishing a health maintenance organization
in a given area, and for the purpose of generally acquainting the potential
enrolled participants and/or their employers with the general benefits of the applicant's proposed
program; and
(3) Engage in the establishment of physical
facilities for the operation of the health maintenance organization.
(g)
In no event,
shall an applicant make a commitment to render services or initiate a contract
between the applicant and enrolled participants and/or their employers until a
certificate of authority has been issued by the department.
(h) The
applicant company may continue to operate until such time as its
application shall be denied.
(i)
The applicant
company shall not be subject to the restrictions of Ins 2201.04(b) above, of this
part unless it has failed to file an application within the time limits set
forth in Ins 2201.04(b) of this part.
(j) Before issuing a certificate of authority to
an applicant, the commissioner shall be satisfied, by examination and evidence
that the applicant has complied, and will continue to comply with the
requirements of RSA 420-B and this part.
(k) The commissioner shall act
upon an application for a certificate of authority within 90 days after the
filing of a completed application.
(l) The commissioner shall deny an applicant a
certificate of authority if the examination and evidence find that:
(1) The applicant is unsafe, unreliable, not entitled to confidence,
and in unsound financial condition; and
(2) The issuing of a certificate of
authority would not be in the public interest.
(m)
The
commissioner shall notify the applicant, in writing, of such denial, stating
the reasons therefor.
(n) If the applicant wishes a hearing before the commissioner concerning
the denial of the certificate of authority, it may make an application for such
hearing pursuant to RSA 400-A:17 and the hearing shall be conducted in
accordance with the provisions of RSA 400-A and Ins 200.
(o) Each
certificate of authority issued under this part shall remain in effect until
revoked or suspended by the commissioner, provided that the health maintenance
organization commences operations within one year after the date on which the
certificate of authority was issued.
(p)
Failure to commence operations within the period in (o) above shall
invalidate the certificate of authority and a new application shall be submitted before another
certificate of authority will be issued.
(q) Grounds
for revocation or suspension of certificate of authority shall include:
(1)
An unsound financial condition;
(2) Business policies or methods are unsound or improper;
(3) Management conditions that render the further transaction of
business hazardous to the public or to its members;
(4) The committing of acts prohibited by RSA 420-B:12; and
(5) Officers or agents that have refused to submit to an examination
as provided for in RSA 420-B:10.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
Ins
2201.05 Evidences of Coverage and
Advertising. All evidences of
coverage and advertising shall be made in accordance with Ins 400, Ins 2600 and
Ins 3100.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
Ins 2201.06 Periodic and Special Reporting.
(a) The health maintenance organization shall
provide concurrent notice to the commissioner of any of the following events or
occurrences:
(1) Plans to purchase, lease, construct,
renovate, operate, or maintain medical facilities;
(2) Any loans made with an annual aggregate from
one creditor exceeding one percent of the health maintenance organization's
liabilities, including:
a. The amount of the loan(s);
b. The term(s) of repayment;
c. Security given, if any; and
d. Any guarantees or sureties provided.
(3) Any contracts entered into with an insurance
company or health service corporation, excluding contracts for fringe benefits
for organization employees; and
(4) Any grants to be received from public or
private sources exceeding on an annual basis from any one source one percent of
the health maintenance organization's assets.
(b) The health maintenance organization shall
provide monthly reports to the commissioner concerning membership changes in
group and non-group categories.
(c)
The health maintenance organization shall file a report of all changes
in controlling interest within 30 days of its occurrence.
(d)
Each health maintenance organization shall, within 5 business days after
the occurrence, inform the commissioner of any extraordinary loss or claim that
has the potential to render it incapable of meeting its obligations as they
become due.
(e)
The health maintenance organization shall maintain and provide to the
department upon request, the following information:
(1) Plans to purchase, lease, construct,
renovate, operate, or maintain medical facilities;
(2) Any loans made with an annual aggregate from
one creditor exceeding one percent of the health maintenance organization's
liabilities, including:
a. The amount of the loan(s);
b. The term(s) of repayment;
c. Security given, if any; and
d. Any guarantees or sureties provided.
(3) Any contracts entered into with an insurance
company or health service corporation, excluding contracts for fringe benefits
for organization employees; and
(4) Any grants to be received from public or
private sources exceeding on an annual aggregate basis from any one source one
percent of the health maintenance organization's assets.
(f)
Every health maintenance organization shall file with the commissioner,
within 30 days of occurrence, a report of all changes in controlling interest
of the health maintenance organization.
(g)
Every health maintenance organization shall, within 5 business days
after the occurrence, inform the commissioner of any extraordinary loss or
claim that has the potential to render it incapable of meeting its obligation
as it becomes due.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
Ins 2201.07
Annual Reports.
(a) Every health maintenance organization shall annually
file with the commissioner and with the commissioner of health and welfare,
within 120 days after the close of its fiscal year, 3 copies of a report,
verified by an official of the organization, showing the health maintenance
organization's financial condition on the last day of the preceding fiscal
year.
(b) Each health maintenance organization shall
submit the following materials to the commissioner as documentation of its
annual report:
(1)
A financial statement, to be either in the form of the National
Association of Insurance Commissioners, NAIC, blank accompanied by a statement
certified by an independent public accountant, or in the form of the NAIC blank
itself certified by an independent public accountant;
(2)
Any changes, occurring during the preceding fiscal year, in information
that had been submitted with the health maintenance organization's application
for a certificate of authority;
(3)
Details of services provided by the health maintenance organization on a
fee-for-service or charitable basis;
(4)
A listing of all complaints received by the health maintenance
organization from members during the period of the preceding fiscal year, with
a description of the complaint, and how it was resolved; and
(5)
A statement of all investments made by the health maintenance
organization, as provided in the NAIC blank form referred to in Ins
2201.08(b)(1).
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss
by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
Ins 2201.08
Licensing of Producers.
All producers of health maintenance organizations shall be licensed
pursuant to RSA 402-J.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
Ins 2201.09
Federal Legislation and Regulation. The health maintenance organization shall provide to the commissioner, within a
reasonable period after enactment, copies of all federal laws and regulations
pertaining to health maintenance organizations, and a statement of the effect
those laws or regulations have on the health maintenance organization.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
Ins 2201.10
Continuity of Benefits.
(a) The transition, under the employment-related
group health insurance plan, from a traditional indemnity or nonprofit health
service corporation mode of coverage to a health maintenance organization
shall:
(1) Be effected in every case without application of waiting periods or
exclusions or limitations based on health status as conditions of enrollment or
transfer; and
(2) Provide all basic health services, as defined in section 1302(1) of
the Health Maintenance Organization Act of 1973 (42USCA 300e-1(1) as amended,
that exist under the applicable traditional indemnity or nonprofit health
service corporation mode of coverage from which transfer is made.
(b) Whenever there is a replacement of a
carrier's benefit plan by the benefit plan of another carrier, the insureds,
subscribers or members who were active recipients of mental health services
under the prior carrier's plan shall be entitled to continue to receive mental
health services from the same mental health provider who provided the services
received while the insured, subscriber or member was an active recipient of
mental health services under the prior carrier's plan.
(c) The entitlement to receive services pursuant
to (b) above shall:
(1)
Continue for one year following the effective date of the new carrier's
benefit plan;
(2)
Override any provisions in the replacing carrier's plan requiring the
insured, subscriber or member to receive mental health services from mental
health providers who have contracted with the replacing carrier to be part of
the replacing carrier's provider network;
(3)
Override any provisions in the replacing carrier's plan that reduce or
eliminate benefits for mental health services whenever such services are
received from a mental health provider who has not contracted to be part of the
replacing carrier's network;
(4)
Be provided to any insured, subscriber or member who, during an open
enrollment period, changed from a benefit plan sponsored by the employer to
another benefit plan sponsored by the same employer;
(5)
Be subject to any provisions of the replacing carrier's plan requiring
mental health services to be medically necessary, as defined in the replacing
carrier's plan;
(6)
Be subject to any provisions of the replacing carrier's plan requiring
mental health services to be preauthorized by the replacing carrier or its
utilization review agent;
(7)
Be subject to the provision of proof of receipt of prior services while
the prior carrier's plan was in effect as follows:
a.
The insured, subscriber or member shall be responsible for providing
such proof in the form of:
1.
An explanation of benefits form from the prior carrier;
2.
A letter from the provider who provided the services attesting to the fact
that services were provided together with the dates such services were
rendered; or
3.
Any other documentation which the replacing carrier determines to be
acceptable as proof; and
(8)
Be subject to verification that the provider of services under the prior
carrier is protected by a malpractice policy with coverage of at least
$1,000,000 per single incident and at least $3,000,000 in the aggregate.
(d) While the entitlement provided pursuant to
(b) above is in effect, benefits shall be paid by the replacing carrier as if
the insured, subscriber or member were receiving mental health services from a
mental health provider who has contracted with the replacing carrier.
(e) The replacing carrier shall not be required
to make direct benefit payments to a non-network provider nor shall this
provision operate in any way to increase the liability of the replacing carrier
above what its liability would be if the mental health services were received
from a contracting mental health provider who is reimbursed on a
fee-for-service basis.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
Ins 2201.11
Tax Exemptions. Health
maintenance organizations that qualify as tax exempt organizations for federal
income tax purposes under section 501(c) of the United States Internal Revenue
Code shall be considered tax exempt for the purposes of payment of premium
taxes pursuant to RSA 420-B:17.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5655, eff 7-1-93; ss by #5945, eff 1-1-95; ss by #7018, INTERIM, eff
7-1-99, EXPIRED: 10-29-99
New. #9335, eff 12-5-08
APPENDIX
|
Rule |
Statute |
|
|
|
|
Ins
2201.01 |
RSA
400-A:15, |
|
Ins
2201.02 |
RSA
400-A:15, |
|
Ins
2201.03 |
RSA
400-A:15, |
|
Ins
2201.04 |
RSA
400-A:15, |
|
Ins
2201.05 |
RSA
400-A:15, |
|
Ins
2201.06 |
RSA
400-A:15, |
|
Ins
2201.07 |
RSA
400-A:15, |
|
Ins
2201.08 |
RSA
400-A:15, |
|
Ins
2201.09 |
RSA
400-A:15, |
|
Ins
2201.10 |
RSA
400-A:15, |
|
Ins
2201.11 |
RSA
400-A:15, |