[RSA 420-J:29 effective 6 months after finalization of federal guidance under United States Presidential Executive Order 14221 pursuant to 2026, 5:2.]
420-J:29 Required Information. –
The machine-readable files made available to the public by a health plan shall include:
I. An in-network rate machine-readable file that includes the required information under this paragraph for all covered items and services, except for prescription drugs that are subject to a fee-for-service reimbursement arrangement, which shall be reported in the prescription drug machine-readable file pursuant to paragraph III. The in-network rate machine-readable file shall include:
(a) For each coverage option offered by a health plan, the name and the 14-digit health insurance oversight system (HIOS) identifier, or, if the 14-digit HIOS identifier is not available, the 5-digit HIOS identifier, or if no HIOS identifier is available, the employer identification number (EIN).
(b) A billing code, which in the case of prescription drugs must be an NDC, and a plain language description for each billing code for each covered item or service under each coverage option offered by a carrier.
(c) All applicable rates, which may include one or more of the following: negotiated rates, underlying fee schedule rates, or derived amounts. If a health plan does not use negotiated rates for provider reimbursement, then the carrier shall disclose derived amounts to the extent these amounts are already calculated in the normal course of business. If the health plan uses underlying fee schedule rates for calculating cost sharing, then the carrier shall include the underlying fee schedule rates in addition to the negotiated rate or derived amount. Applicable rates, including for both individual items and services and items and services in a bundled payment arrangement, shall be:
(1) Reflected as dollar amounts, with respect to each covered item or service that is furnished by an in-network provider. If the negotiated rate is subject to change based upon participant, beneficiary, or enrollee-specific characteristics, these dollar amounts shall be reflected as the base negotiated rate applicable to the item or service prior to adjustments for participant, beneficiary, or enrollee-specific characteristics.
(2) Associated with the national provider identifier (NPI), tax identification number (TIN), and place of service code for each in-network provider.
(3) Associated with the last date of the contract term or expiration date for each provider-specific applicable rate that applies to each covered item or service.
(4) Indicated with a notation where a reimbursement arrangement other than a standard fee-for-service model, such as capitation or a bundled payment arrangement, applies.
II. An out-of-network allowed amount machine-readable file, including:
(a) For each coverage option offered by a health plan, the name and the 14-digit HIOS identifier, or, if the 14-digit HIOS identifier is not available, the 5-digit HIOS identifier, or, if no HIOS identifier is available, the EIN.
(b) A billing code, which in the case of prescription drugs shall be an NDC, and a plain language description for each billing code for each covered item or service under each coverage option offered by a carrier.
(c) Unique out-of-network allowed amounts and billed charges with respect to covered items or services furnished by out-of-network providers during the 90-day time period that begins 180 days prior to the publication date of the machine-readable file, except that a health plan shall omit such data in relation to a particular item or service and provider when compliance with this paragraph would require the carrier to report payment of out-of-network allowed amounts in connection with fewer than 20 different claims for payments under a single plan or coverage. Consistent with RSA 420-J:32, II, nothing in this paragraph requires the disclosure of information that would violate any applicable health information privacy law. Each unique out-of-network allowed amount shall be:
(1) Reflected as a dollar amount, with respect to each covered item or service that is furnished by an out-of-network provider.
(2) Associated with the NPI, TIN, and Place of Service Code for each out-of-network provider.
III. A prescription drug machine-readable file, including:
(a) For each coverage option offered by a health plan, the name and the 14-digit HIOS identifier, or, if the 14-digit HIOS identifier is not available, the 5-digit HIOS identifier, or, if no HIOS identifier is available, the EIN.
(b) The NDC, and the proprietary and nonproprietary name assigned to the NDC by the FDA, for each covered item or service that is a prescription drug under each coverage option offered by a carrier.
(c) The negotiated rates, which shall be:
(1) Reflected as a dollar amount, with respect to each NDC that is furnished by an in-network provider, including an in-network pharmacy or other prescription drug dispenser.
(2) Associated with the NPI, TIN, and place of service code for each in-network provider, including each in-network pharmacy or other prescription drug dispenser.
(3) Associated with the last date of the contract term for each provider-specific negotiated rate that applies to each NDC.
(d) Historical net prices that are:
(1) Reflected as a dollar amount, with respect to each NDC that is furnished by an in-network provider, including an in-network pharmacy or other prescription drug dispenser.
(2) Associated with the NPI, TIN, and place of service code for each in-network provider, including each in-network pharmacy or other prescription drug dispenser.
(3) Associated with the 90-day time period that begins 180 days prior to the publication date of the machine-readable file for each provider-specific historical net price that applies to each NDC, except that a health plan shall omit such data in relation to a particular NDC and provider when compliance with this paragraph would require the carrier to report payment of historical net prices calculated using fewer than 20 different claims for payment. Consistent with RSA 420-J:32, II, nothing in this paragraph requires the disclosure of information that would violate any applicable health information privacy law.