Section Ins 2201.09 - 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 ( 42USC? 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; or3. 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 the liability of the replacing carrier exceed what its liability would have been if the mental health services had been received from a contracting mental health provider who is reimbursed on a fee-for-service basis.N.H. Admin. Code § Ins 2201.09
#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
Amended by Volume XXXVI Number 41, Filed October 13, 2016, Proposed by #11194, Effective 12/5/2016, Expires 12/5/2026.