CHAPTER 18
HB 640-FN - FINAL VERSION
20may99.....1120h
2/3/00 3137s
2000 SESSION
HOUSE BILL 640-FN
AN ACT establishing certain standards of accountability for health maintenance organizations and other entities providing health insurance through a managed care system.
This bill creates an independent external consumer appeal process to review certain determinations made by managed care entities. The bill requires health carriers that conduct utilization review and licensed utilization review entities to employ a medical director who shall be licensed as a physician. The bill prohibits contracts between health carriers and participating providers from including provisions that create financial incentives to deny medically necessary care. The bill requires that health insurers disclose certain information necessary for consumers to hold managed care entities accountable for health care treatment decisions. The bill also extends the jurisdiction of the board of medicine to include disciplinary action over medical directors for misconduct.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
20may99.....1120h
2/3/00 3137s
99-0783
01/09
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand
AN ACT establishing certain standards of accountability for health maintenance organizations and other entities providing health insurance through a managed care system.
Be it Enacted by the Senate and House of Representatives in General Court convened:
18:1 New Paragraph; Medical Directors. Amend RSA 329:17 by inserting after paragraph III-a the following new paragraph:
III-b.(a) Any referral by the insurance commissioner under RSA 420-J:5-e, VII or any complaint alleging that a medical director has committed misconduct as set forth in paragraph VI of this section shall be received and reviewed by the board in accordance with the provisions of this section for potential disciplinary action. For the purposes of this paragraph, "medical director" means a physician licensed under this chapter who is employed by a health carrier or medical utilization review entity and is responsible for the utilization review techniques and methods of the health carrier or medical utilization review entity and their administration and implementation.
(b) Any complaint received by the board regarding an insurance coverage decision by a medical director shall be forwarded by the board to the insurance commissioner for review.
18:2 Medical Review Subcommittee; Medical Director. Amend RSA 329:17, V-a to read as follows:
V-a. A medical review subcommittee of 7 members shall be nominated by the board of medicine and appointed by the governor and council. The subcommittee shall consist of one member of the board of medicine and 6 other persons, no more than 5 of whom shall be physicians, one of whom shall be a medical director as defined in paragraph III-b of this section. Any public member of the subcommittee shall be a person who is not, and never was, a member of the medical profession or the spouse of any such person, and who does not have, and never has had, a material financial interest in either the provision of medical services or an activity directly related to medicine, including the representation of the board or profession for a fee at any time during the 5 years preceding appointment. The subcommittee members shall be appointed for 3-year terms, and shall serve no more than 2 terms. Upon referral by the board, the subcommittee shall review disciplinary actions reported to the board under paragraphs II-V of this section, except that matters concerning a medical director involved in a current internal or external grievance pursuant to RSA 420-J shall not be reviewed until the grievance process has been completed. Following review of each case, the subcommittee shall make recommendations to the board. Funds shall be appropriated from the general fund for use by the subcommittee to investigate allegations under paragraphs I-V of this section. The board shall employ a physician as a medical review subcommittee administrator who shall serve at the pleasure of the board. The salary of the medical review subcommittee administrator shall be established by the board in accordance with duties, experience, and amount of time required for the position.
18:3 New Section; Medical Directors Required. Amend RSA 420-E by inserting after section 2 the following new section:
420-E:2-a Medical Director. Every medical utilization review entity licensed by the department under this chapter shall employ a medical director licensed under RSA 329.
18:4 New Paragraph; Definition Added. Amend RSA 420-J:3 by inserting after paragraph XXV the following new paragraph:
XXV-a. "Medical director" means a physician licensed under RSA 329 and employed by a health carrier or medical utilization review entity who is responsible for the utilization review techniques and methods of the health carrier or medical utilization review entity and their administration and implementation.
18:5 New Paragraph; Medical Director Required. Amend RSA 420-J:6 by inserting after paragraph IV the following new paragraph:
V. Each health carrier that conducts utilization review shall employ a medical director who shall have responsibility for all utilization review techniques and methods and their administration and implementation. Nothing in this section shall be construed to preclude a medical director from consulting with or relying on the advice of a physician licensed in this state or any other state. Nothing in this section shall be construed as creating any civil liability to the medical director for the medical director's alleged negligent performance of the aforementioned responsibilities for utilization review.
18:6 Information Provided to Covered Persons. Amend RSA 420-J:5, II(a) - (e) to read as follows:
(a) A description of the internal grievance procedure required under RSA 420-J:5 for adverse determinations and other matters [which] and a description of the process for obtaining external review under RSA 420-J:5-a - RSA 420-J:5-e. These descriptions shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons.
(b) A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner.
(c) Upon written denial of a requested medical service or claim by the health carrier, a statement of the covered person's right to access the internal grievance process and the process for obtaining external review. This statement shall also include a written explanation of any adverse determination, with the name and credentials of the health carrier medical director, including board status and the state or states where the person is currently licensed, and the relevant clinical rationale used to make the adverse determination. If the person making the adverse determination is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person. Nothing in this section shall be construed to require a health carrier to provide proprietary information protected by third party contracts.
(d) Staff assistance in filing an internal grievance.
(e) [If requested by the consumer or health care provider acting on behalf of the consumer, a written explanation of any adverse determination, with the name and credentials of the health carrier medical director or designee, including board status and the state or states where the person is currently licensed, and the relevant clinical rationale used to make the adverse determination. Nothing in this section shall be construed to require a health carrier to provide proprietary information protected by third party contracts] Any clinical review criteria that are used by the health carrier or its designee utilization review entity as the basis of an adverse determination shall be disclosed to the treating provider and the covered person. Such disclosure shall be accompanied by the following notice: "The materials provided to you are criteria used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract."
18:7 Second Level Grievance; Notice Required. Amend RSA 420-J:5, V(a)(3) to read as follows:
(3) The review panel shall issue a written decision to the covered person within 5 business days of completing the review meeting. Upon concurrence of the covered person, a copy of the decision shall be forwarded to the insurance department. The decision shall include the titles of the members of the review panel; a statement of the review panel's understanding of the nature of the grievance, including issues raised by the covered person, and all pertinent facts; the rationale for the review panel's decision; reference to evidence or documentation considered by the review panel in making the decision; if an adverse decision is made, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination; and a statement of the covered person's right to file an external appeal as provided in RSA [420-J:5, VIII] 420-J:5-a - RSA 420-J:5-e. The statement of appeal rights shall include a description of the process for obtaining external review of a determination, a copy of the written procedures governing external review, including the required time frames for requesting external review, and notice of the conditions under which expedited external review is available.
. 18:8 Review Panel; Notice Required. Amend RSA 420-J:5, V(b)(3) to read as follows:
(3) The review panel shall issue a written decision to the covered person within 5 business days of completing the review meeting. The decision shall include the titles of the members of the review panel; a statement of the review panel's understanding of the nature of the grievance and all pertinent facts; the rationale for the review panel's decision; reference to evidence or documentation considered by the review panel in making the decision; if an adverse decision is made, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination; and a statement of the covered person's right to file an external appeal as provided in RSA [420-J:5, VIII] 420-J:5-a - RSA 420-J:5-e. The statement of appeal rights shall include a description of the process for obtaining external review of a determination, a copy of the written procedures governing external review, including the required time frames for requesting external review, and notice of the conditions under which expedited external review is available.
18:9 Expedited Internal Grievance Review. Amend RSA 420-J:5, VI(e) to read as follows:
(e) In any case where the expedited review process does not resolve a difference of opinion between the health carrier and the covered person or the provider acting on behalf of the covered person, the covered person or the provider acting on behalf of the covered person may submit a written grievance, unless the provider is prohibited from filing a grievance by federal or other state law. A health carrier shall review it as a second level grievance. In conducting the review, the health carrier shall [adhere to time frames that are reasonable under the circumstances] make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the grievance is submitted.
18:10 New Paragraph; Notice Required. Amend RSA 420-J:5, by inserting after paragraph IX the following new paragraph:
X. If the covered person has requested first or second level, standard or expedited review and the health carrier has not issued a decision within the required time frames, then the health carrier shall promptly provide the covered person with a statement of the covered person's right to file an external appeal as provided in RSA 420-J:5-a - RSA 420-J:5-e. The statement of appeal rights shall include a description of the process for obtaining external review of a determination, a copy of the written procedures governing external review, including the required time frames for requesting external review, and notice of the conditions under which expedited external review is available.
18:11 New Paragraph; Definition Added. Amend RSA 420-J:3 by inserting after paragraph III the following new paragraph:
III-a. "Authorized representative" means a person to whom a covered person has given consent to represent the covered person in an external review. Authorized representative may include the covered person's treating provider.
18:12 New Paragraph; Definition Added. Amend RSA 420-J:3 by inserting after paragraph XXIII the following new paragraph:
XXIII-a. "Independent review organization" means an entity that employs or contracts with clinical peers to conduct independent external reviews of health carrier determinations.
18:13 New Sections; External Review. Amend RSA 420-J by inserting after section 5 the following new sections:
420-J:5-a Right to External Review.
I. 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:
(a) The subject of the request for external review is an adverse determination;
(b) The covered person has completed the internal review procedures provided by the health carrier pursuant to RSA 420-J:5, III through VI, or the health carrier has agreed to submit the determination to independent external review prior to completion of internal review, or the covered person has requested first or second level, standard or expedited review and has not received a decision from the health carrier within the required time frames;
(c) The covered person or the covered person's authorized representative has submitted the request for external review in writing to the commissioner within 180 days of the date of the health carrier's second level denial decision provided pursuant to RSA 420-J:5, V or VI, or if the health carrier has failed to make a first or second level, standard or expedited review decision that is past due, within 180 days of the date the decision was due;
(d) The covered person's cost for the service, supply or drug that is the subject of the adverse determination is, or is anticipated in a 12-month period to be, equal to or in excess of $400;
(e) The health carrier determination does not relate to any category of health care services that is excluded from the external review provisions of this chapter pursuant to paragraph II; and
(f) The request for external review is not based on a claim or allegation of provider malpractice, professional negligence, or other professional fault excluded from the external review provisions of this chapter pursuant to paragraph III.
II. Determinations relating to the following health care services shall not be reviewed under this chapter, but shall be reviewed pursuant to the review processes provided by applicable federal or state law:
(a) Health care services provided through medicaid, the state Children's Health Insurance Program (Title XXI of the Social Security Act), medicare or services provided under these programs but through a contracted health carrier.
(b) Health care services provided to inmates by the department of corrections.
(c) Health care services provided pursuant to a health plan not regulated by the state, such as self-funded plans administered by an administrative services organization or third-party administrator or federal employee benefit programs.
III. The external review procedures set forth in this chapter shall not be utilized to adjudicate claims or allegations of health care provider malpractice, professional negligence, or other professional fault against participating providers or medical directors.
420-J:5-b Standard External Review. Standard external review shall be conducted as follows:
I. Within 7 business days after the date of receipt of a request for external review, the commissioner shall complete a preliminary review of the request to determine whether:
(a) The individual is or was a covered person under the health benefit plan;
(b) The determination that is the subject of the request for external review meets the conditions of eligibility for external review stated in RSA 420-J:5-a, I; and
(c) The covered person has provided all the information and forms required by the commissioner that are necessary to process a request for an external review.
II. Upon completion of the preliminary review pursuant to paragraph I, the commissioner shall immediately notify the covered person or the covered person's authorized representative in writing:
(a) Whether the request is complete; and
(b) Whether the request has been accepted for external review.
III. If the request is not complete, the commissioner shall inform the covered person or the covered person's authorized representative what information or documents are needed to make the request complete and to process the request. The covered person or the covered person's authorized representative shall submit such information or documentation within 10 days of being notified that the request was incomplete.
IV. If the request for external review is accepted, the commissioner shall:
(a) Include in the notice provided to the covered person pursuant to paragraph II a statement that if the covered person wishes to submit new or additional information or to present oral testimony via teleconference, such information shall be submitted, and the oral testimony shall be scheduled and presented, within 20 days of the date of issuance of the notice. However, the notice shall also explain that oral testimony shall be permitted only in cases when the commissioner determines, based on evidence provided by the covered person, that it would not be feasible or appropriate to present only written testimony.
(b) Immediately notify the health carrier in writing of the request for external review and its acceptance.
V. If the request for external review is not accepted, the commissioner shall inform the covered person or the covered person's authorized representative and the health carrier in writing of the reason for its non-acceptance.
VI. At the time a request for external review is accepted, the commissioner shall select and retain an independent review organization that is certified pursuant to RSA 420-J:5-d, I to conduct the external review. The commissioner shall not select the same independent review organization for each external review, but shall rotate among the certified independent review organizations, using all organizations equally. The commissioner may select and retain an independent review organization regardless of the rotation if the commissioner determines that the use of such independent review organization is necessary for the fair adjudication of the case in question.
VII. Within 10 days after the date of issuance of the notice provided pursuant to subparagraph IV(b), the health carrier or its designated utilization review organization shall provide to the selected independent review organization and to the covered person all information in its possession that is relevant to the adjudication of the matter in dispute, including but not limited to:
(a) The terms of agreement of the health benefit plan, including the evidence of coverage, benefit summary, or other similar document;
(b) All relevant medical records, including records submitted to the carrier by the covered person, the covered person's authorized representative, or the covered person's treating provider;
(c) A summary description of the applicable issues, including a statement of the health carrier's final determination;
(d) The clinical review criteria used and the clinical reasons for the determination;
(e) The relevant portions of the carrier's utilization management plan;
(f) Any communications between the covered person and the health carrier regarding the internal or external review; and
(g) All other documents, information, or criteria relied upon by the carrier in making its determination.
VIII. Failure by the health carrier or the covered person to provide the documents and information required in paragraph IV(a) or VII within the specified time frame shall not delay the conduct of the external review.
IX. The selected independent review organization shall review all of the information and documents received from the carrier pursuant to paragraph VII and any other information submitted by the covered person or the covered person's authorized representative or treating provider with the request for external review or pursuant to subparagraph IV(a) and any testimony provided. In addition to the information provided by the health carrier and the covered person or the covered person's authorized representative or treating provider, the independent review organization may consider any applicable, generally accepted clinical practice guidelines, studies or research, including those developed or conducted by the federal government, national or professional medical societies, boards, and associations. The independent review organization shall consider anew all previously determined facts, allow the introduction of new information, and make a decision that is not bound by decisions or conclusions made by the health carrier during internal review.
X. The selected independent review organization shall render a decision upholding or reversing the determination of the health carrier and notify the covered person or the covered person's authorized representative and the health carrier in writing within 20 days of the date that any new or additional information from the covered person is due pursuant to subparagraph IV(a). This notice shall include a written review decision that contains a statement of the nature of the grievance, references to evidence or documentation considered in making the decision, findings of fact, and the clinical and legal rationale for the decision, including, as applicable, clinical review criteria and rulings of law.
420-J:5-c Expedited External Review. Expedited external review shall be conducted as follows:
I. Expedited external review shall be available when the covered person's treating health care provider certifies to the commissioner that adherence to the time frames specified in RSA 420-J:5-b would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.
II. Except to the extent that it is inconsistent with the provisions of this paragraph, all requirements for the conduct of standard external review specified in RSA 420-J:5-b shall apply to expedited external review.
III. At the time the commissioner receives a request for an expedited external review, the commissioner shall immediately make a determination whether the request meets the standard set forth in paragraph I for expedited external review, as well as the reviewability requirements set forth in RSA 420-J:5-b, I. If these conditions are met, the commissioner shall immediately notify the health carrier. If the request is not complete, the commissioner shall immediately contact the covered person or the covered person's authorized representative and attempt to obtain the information or documents that are needed to make the request complete.
IV. The commissioner shall select and retain an independent review organization that is certified pursuant to RSA 420-J:5-d, I to conduct the expedited external review.
V. The health carrier or its designated utilization review organization shall provide or transmit the documents and information specified in RSA 420-J:5-b, VII to the selected independent review organization by telephone, facsimile, or any other available expeditious method within one business day of receiving the commissioner's notice of the request for expedited external review pursuant to paragraph III.
VI. When handling a review on an expedited basis, the selected independent review organization shall make a decision and notify the carrier and the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the expedited external review is requested.
VII. If the notice provided pursuant to paragraph VI was not in writing, within 2 business days after the date of providing that notice, the selected independent review organization shall:
(a) Provide written confirmation of the decision to the covered person or the covered person's authorized representative and the health carrier; and
(b) Include the information set forth in RSA 420-J:5-b, X.
VIII. An expedited external review shall not be provided for determinations made by the health carrier on a retrospective basis.
IX. A covered person shall not be held liable to either the health plan, the hospital, the physician, or the services provider for the cost of services in excess of the applicable copayment, coinsurance, or deductible incurred, pending the independent review organization's determination of an expedited external review.
420-J:5-d Certification of Independent Review Organizations.
I. The certification of independent review organizations shall be conducted as follows:
(a) The commissioner shall certify independent review organizations eligible to be selected to conduct external reviews under this section to ensure that an independent review organization satisfies the minimum qualifications established under paragraph II.
(b) The commissioner shall develop an application form for initially certifying and recertifying independent review organizations to conduct external reviews.
(c) Independent review organizations wishing to be certified shall submit the application form and include all documentation and information necessary for the commissioner to determine whether the independent review organization satisfies the minimum qualifications established under paragraph II.
(d) The commissioner may determine that accreditation by a nationally recognized private accrediting entity with established and maintained standards for independent review organizations that meet or exceed the minimum qualifications established under paragraph II is sufficient for certification under this paragraph.
(e) The commissioner shall maintain and periodically update a list of certified independent review organizations.
(f) Whenever the commissioner determines that an independent review organization no longer satisfies the minimum qualifications established under paragraph II, the commissioner shall terminate the certification of the independent review organization and remove it from the list of certified independent review organizations that is maintained by the commissioner pursuant to subparagraph I(e).
II. To be certified under paragraph I to conduct external reviews, an independent review organization shall meet the following minimum qualifications:
(a) It shall develop and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process.
(b) It shall establish and maintain a quality assurance program that:
(1) Ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner;
(2) Ensures the selection of qualified and impartial clinical peer reviewers to conduct external reviews on behalf of the independent review organization with suitable matching of reviewers to specific cases;
(3) Ensures the confidentiality of medical and treatment records; and
(4) Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this section.
(c) It shall agree to maintain and provide to the commissioner such information as may be required to fulfill the provisions and purposes of this section.
(d) It shall assign clinical peer reviewers to conduct external reviews who are physicians or other appropriate health care providers and who:
(1) Are experts in the treatment of the covered person's medical condition that is the subject of the external review;
(2) Are knowledgeable about the recommended health care service or treatment through actual clinical experience;
(3) Hold a non-restricted license in a state of the United States and, for physicians, a current certification by a specialty board recognized by the American Board of Medical Specialties in the area or areas appropriate to the subject of the external review;
(4) Have no history or disciplinary actions or sanctions that have been taken or are pending by any hospital, governmental agency, or regulatory body; and
(5) Have agreed to disclose any potential conflict of interest.
(e) It shall be free of any conflict of interest. To meet this qualification, an independent review organization may not own or control or in any way be owned or controlled by a health carrier, a national, state, or local trade association of health carriers, or a national, state, or local trade association of health care providers. In addition, in order to qualify to conduct an external review of a specific case, neither the independent review organization selected to conduct the external review nor any clinical peer reviewer assigned by the independent organization to conduct the external review may have a material professional, familial or financial interest in any of the following:
(1) The health carrier that is the subject of the external review;
(2) Any officer, director, or management employee of the health carrier that is the subject of the external review;
(3) The health care provider or the health care provider's medical group or independent practice association recommending the health care service or treatment that is the subject of the external review;
(4) The facility or institution at which the recommended health care service or treatment would be provided;
(5) The developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose treatment is the subject of the external review; or
(6) The covered person or the covered person's authorized representative.
(f) Its charges for services provided shall be competitive and reasonable.
(g) For the purpose of allowing in-state health care providers to act as clinical peer reviewers in the conduct of external reviews, the commissioner may determine, in specific cases, that an affiliation with a hospital, an institution, an academic medical center, or a health carrier provider network does not in and of itself constitute a conflict of interest which is sufficient to preclude that provider from acting as a clinical peer reviewer, so long as the affiliation is disclosed to the covered person or the covered person's authorized representative.
(h) The following organizations shall not be eligible for certification to conduct external reviews:
(1) Professional or trade associations of health care providers;
(2) Subsidiaries or affiliates of such provider associations;
(3) Health carrier or health plan associations; and
(4) Subsidiaries or affiliates of health plan or health carrier associations.
420-J:5-e General Provisions Regarding External Review.
I. 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 organizations of the cost limitation for conducting an external review. The cost for an external review may exceed $1,500 if the commissioner determines an additional cost is necessary to ensure the fair adjudication of the case in question.
II. The external review decision of the independent review organization shall be binding on the health carrier and shall be enforceable by the commissioner pursuant to the penalty provisions of RSA 420-J:14. The external review decision of the independent review organization shall be binding on the covered person except to the extent the covered person has other remedies available under federal or state law. The external review process shall not be considered an adjudicative proceeding within the meaning of RSA 541-A, and the external review decision of the independent review organization shall not be subject to rehearing and appeal pursuant to RSA 541.
III. An independent review organization shall maintain all standards of confidentiality. The records and internal materials prepared for specific reviews by an independent review organization under this section shall be exempt from public disclosure under RSA 91-A.
IV. An external review organization acting in good faith shall have immunity from any civil or criminal liability or professional discipline as a result of acts or omissions with respect to any external review, unless the acts or omissions constitute willful and wanton misconduct.
V. The right to external review under this chapter shall not be construed to change the terms of coverage under a health benefit plan nor shall the health carrier retaliate against the covered person for exercising his or her right to an independent external review.
VI. When requested by the covered person, the commissioner shall provide consumer assistance in pursuing the internal grievance procedures under RSA 420-J:5 and the external review process under RSA 420-J:5-a - 420-J:5-e.
VII. The commissioner shall report annually to the governor and the legislature on the number of grievances subjected to external review, the number of decisions resolved wholly or partially in favor of the covered person, and the number of decisions resolved wholly or partially in favor of the health carrier. Such reports shall also include a separate statement of the number of cases in which the external review was terminated as a result of a reversal by the health carrier of its adverse determination after the receipt of new or additional information from the covered person or the covered person's authorized representative and the number of cases in which the covered person and the health carrier agreed to resolve the dispute prior to a final determination by the independent review organization.
VIII. If, based on the evidence presented during the external review process, the commissioner determines that the health carrier's medical director, in the conduct of his or her duties, may have committed misconduct as set forth in RSA 329:17, VI, the commissioner shall document such findings and transmit them in a separate report to the board of medicine.
18:14 New Paragraphs; Provider Contract Standards. Amend RSA 420-J:8 by inserting after paragraph VII the following new paragraphs:
VIII. No contract between a health carrier and a participating provider shall contain any payment or reimbursement provision the terms of which creates an inducement for the provider to not provide medically necessary care to covered persons. Nothing in this section shall be construed to prohibit the use of payment arrangements between a health carrier and a participating provider or provider group which involve capitation, withholds or other arrangements.
IX. The health carrier shall provide to covered persons, in the evidence of coverage, a description for the types of financial arrangements contained in its contracts with participating providers. Such descriptions shall be set forth in clear, understandable language.
X. Every contract between a health carrier and a participating provider shall provide that the health carrier may not remove a health care provider from its network or refuse to renew the health care provider with its network for participating in a covered person's internal grievance procedure or external review.
18:15 New Paragraph; Clinical Review Criteria. Amend RSA 420-J:6 by inserting after paragraph IV the following new paragraph:
V. The clinical review criteria used by the health carrier or its designee utilization review entity shall be:
(a) Developed with input from appropriate actively practicing practitioners in the health carrier's service area;
(b) Updated at least biennially and as new treatments, applications, and technologies emerge;
(c) Developed in accordance with the standards of national accreditation entities;
(d) Based on current, nationally accepted standards of medical practice; and
(e) If practicable, evidence-based.
18:16 Clinical Review Criteria. RSA 420-E:4, VI is repealed and reenacted to read as follows:
VI. Any clinical review criteria that are utilized shall be:
(a) Developed with input from appropriate actively practicing practitioners in the health carrier's service area;
(b) Updated at least biennially and as new treatments, applications, and technologies emerge;
(c) Developed in accordance with the standards of national accreditation entities;
(d) Based on current, nationally accepted standards of medical practice; and
(e) If practicable, evidence-based.
18:17 Repeal. RSA 420-J:5, VIII and IX, relative to external process and annual report, are repealed.
18:18 Effective Date. This act shall take effect 180 days after its passage.
(Approved: March 7, 2000)
(Effective Date: September 3, 2000)
LBAO
99-0783
2/11/99
HB 640-FN - FISCAL NOTE
AN ACT establishing certain standards of accountability for health maintenance organizations and other entities providing health insurance through a managed care system.
FISCAL IMPACT:
The Insurance Department stated this bill may increase state revenue by $1,800 in FY 2000, by $3,900 in FY 2001, by $4,000 in FY 2002 and by $4,200 in FY 2003. State expenditures may increase by $6,200 in FY 2000, by $13,000 in FY 2001, by $13,500 in FY 2002 and by $14,000 in FY 2003. County and local expenditures may increase by an indeterminable amount in FY 2000 and each year thereafter. There will be no fiscal impact on county and local revenue.
METHODOLOGY:
The Department assumed additional responsibilities can be absorbed within the existing budget. The Department indicated there are certain costs that health plans might incur in complying with an external review program. In addition, when a plan decision is overturned, the plan is then responsible for the cost of additional care. Research estimates these costs for plans in California to be three cents per member, per month, or approximately .03% of premium. When plan premiums increase, this increases state revenue due to the impact on premium tax. Premium increases also affect state, county and local expenditures due to the impact on the cost of health insurance coverage on employees. The total premium collected by HMO's for its fully insured products was estimated to be approximately $600 million. Premiums paid by the state were estimated to be approximately $40 million. Inflation is assumed at 4%. The increase in county and local government expenditures cannot be determined.