N.H. Admin. Code § Ins 3401.05

Current through Register No. 45, November 7, 2024

Section Ins 3401.05 - Powers and Duties of and Restrictions on Purchasing Alliances

(a) A purchasing alliance shall:

(1) Offer health benefit plans that are available to all small employers in the alliance's service area;

(2) Establish administrative and accounting procedures for operating the alliance, for providing services to member small employers and enrollees and for preparing an annual budget;

(3) Establish conditions of participation for small employers that conform to the requirements of this part and RSA 420-G and include, but are not limited to, the following:

a. Assurances that the member small employer is a valid small employer group and is not formed for the purpose of securing health benefits coverage; and

b. Prepayment of premiums or other mechanisms to assure that payment will be made for coverage;

(4) Provide that each eligible employee is permitted to enroll in any health benefit plan offered by the participating carrier or carriers so long as the health benefit plan provides coverage where he or she works or lives;

(5) Establish conditions of participation for the participating carrier or carriers;

(6) Establish conditions of participation for producers;

(7) Place into its contracts between the alliance and member small employers the following:

a. A provision stating that, for administrative purposes, the alliance shall be the policyholder or contract holder of the health benefit plan on behalf of member small employers, their eligible employees and eligible dependents; and

b. A provision stating that the participating carrier shall issue a certificate of coverage, or equivalent document, specifying the essential features of the health benefit plan's coverage to each enrolled eligible employee.

(8) Transmit enrollment and eligibility information to the participating carrier or carriers on a timely basis;

(9) Maintain a trust account or accounts for deposit of all moneys received and collected for the operation of the alliance;

(10) The alliance, its board members, employees and agents shall have a fiduciary duty with respect to all moneys received or owed to it to assure payments of its obligations and a full accounting to its members and the commissioner; and

(11) Assure the offering of the same premiums and prices on negotiated health care coverage to all member classes equally, and treat all members within a class equally with regard to membership and administrative fees and benefits of membership;

(b) A purchasing alliance may:

(1) Receive, review, and act on grievances against participating carriers by member small employers or enrollees;

(2) Undertake any activity necessary to administer the alliance, including marketing and publicizing the alliance, and assuring that the participating carrier or carriers, contractors, participating small employers, and enrollees are in compliance with alliance requirements;

(3) Establish contracts with the participating carrier or carriers to provide health coverage to alliance members;

(4) Establish contracts with small employer members;

(5) Contract with qualified, independent third parties for services necessary to carry out the powers and duties of the alliance;

(6) Enter into all other contracts as are necessary to carry out the powers and duties of the alliance;

(7) Appoint a beneficiary advisory council to evaluate alliance functions and the performance of the participating carrier or carriers in order to assess the efficacy of the operations for member small employers and enrollees;

(8) Appoint advisory committees, as necessary, to provide technical assistance in the operation of the program and in carrying out the purposes of this part;

(9) Assess member small employers a fee for costs incurred or anticipated in connection with the operation of the alliance;

(10) Require as a condition of membership that all employers include all their eligible employees or a minimum percentage of employees in coverage purchased through the alliance;

(11) Require an employer that makes a membership application to the purchasing alliance that would entail enrolling fewer than 100 percent of the employer's eligible employees or dependents to demonstrate that the enrollment section is based on factors other than risk selection;

(12) Reject or allow a carrier to reject an employer from membership, or drop or allow a carrier to drop a member small employer, if the member fails to pay premiums or engages in fraud or material misrepresentation in connection with a health benefit plan purchased through the alliance;

(13) Contract with licensed insurance producers to market and service coverage made available through the alliance to its members. Compensation for producers shall not vary based on the actual or expected health status or medical utilization of the group to which coverage is sold;

(14) Define a set of standardized health benefit plans which the alliance shall contract to purchase from the participating carrier or carriers;

(15) Exclude a carrier or freeze enrollment in a carrier for failure to achieve established quality, access or information reporting standards of the alliance;

(16) Require that member employers and their eligible employees continue to pay administrative fees that are part of the contract with the alliance if a member employer or enrollee cancels prior to completion of a contract period;

(17) Negotiate with the participating carrier or carriers the premium rates charged for coverage offered through the alliance consistent with the rating restrictions contained in RSA 420-G;

(18) Request such information from the participating carrier or carriers as is necessary to carry out the powers and duties of this part;

(19) Sue or be sued, including taking action necessary for securing legal remedies on behalf of the alliance, member small employers, or enrollees;

(20) Apply for loans or loan guarantees from the New Hampshire business finance authority under RSA 162-A for the purpose of funding startup costs;

(21) Receive and accept loans, grants, funds, or anything of value from a public or private entity including:

a. Employer premiums;

b. Employer participation fees;

c. Employer late fees;

d. Employer reinstatement fees;

e. Producer fees paid by the employer;

f. Interest earned on accounts;

g. Funds paid by the participating carrier or carriers for a pooled marketing effort;

h. Public sector and private sector grants, gifts, loans or donations; or

i. Other lawful sources;

(22) The alliance may also receive and accept contributions of property, labor, or any other thing of value;

(23) Expend funds to pay:

a. The participating carrier or carriers under their contracts;

b. Third parties for services provided under contract;

c. Employer billing adjustments;

d. Producer fees;

e.The alliance's administrative expenses; and

f. All other expenditures duly authorized by the board;

(24) Develop standard enrollment procedures for enrolling small employers and their eligible employees and dependents;

(25) Establish procedures for annual or rolling open enrollment periods;

(26) Establish procedures and mechanisms for billing and collection of premiums from member small employers, including any share of the premium paid by employee enrollees;

(27) Develop model contracts which detail for potential contractors the requirements of the alliance and provide a copy of the contract to interested carriers;

(28) Develop and make available a list of objective criteria that shall be met by the participating carrier or carriers in order to be eligible to participate in the alliance;

(29) Provide to alliance members clear, standardized information on each participating carrier or carriers and the qualified health benefit plans offered by each participating carrier or carriers, including information on:

a. Price;

b. Benefits;

c. Enrollee costs;

d. Quality;

e. Patient satisfaction;

f. Enrollment; and

g. Grievance procedures and rights and responsibilities.

(30) Provide qualified health benefit plan comparison sheets to participating members and their employees with information regarding coverage that may be obtained through the participating carrier or carriers;

(31) Require the participating carrier or carriers to maintain health care data;

(32) Specify in contracts with the participating carrier or carriers how all premiums shall be transmitted and the frequency of that transmission and how penalties and grace periods on late payments of premiums shall be calculated;

(33) Review information and recommendations from consumers, employers, participating carriers or health care providers and other sources and, issue periodic reports or recommendations to the commissioner to improve the delivery of health services and the purchasing of health coverage; and

(34) Exercise all powers reasonably necessary to carry out the powers granted and duties imposed under this part.

(c) A purchasing alliance shall not:

(1) Purchase health care services, assume risk for the cost or provision of health care services, or otherwise contract with health care providers for the provision of health care services to enrollees;

(2) Exclude from membership in the alliance a small employer, eligible employee or eligible dependent of an eligible employee who is in the service area of the alliance and who agrees to pay fees for membership and the premium for health coverage through the alliance and who abides by the bylaws and rules of the alliance;

(3) Prohibit the participation of small employers, or differentiate classes of membership, based on industry type, experience, gender, family status, education, health status, income, or other means in conflict with the rating methodology specified in RSA 420-G:4;

(4) Charge a fee not directly related to the operation of the alliance or for non-health coverage related activities;

(5) As a condition of membership, require a small employer, eligible employee, or eligible dependent to subscribe to limited health coverage or non-health coverage related products or services;

(6) Engage in any competitive act or practice that results in the selection of member small employers and enrollees based on industry type, experience, gender, family status, education, health status, income, small employer size, or other factors in conflict with the rating methodology specified in RSA 420-G:4; or

(7) Require or take any action inconsistent or in conflict with state laws or rules.

(d) The contracts entered into by the alliance shall:

(1) Establish performance standards for specific contractual elements;

(2) Set liquidated damages for breach of the contract;

(3) Require the participating carrier or carriers to notify the member small employer of cancellation of the policy;

(4) Require the member small employer in the event of cancellation to arrange for continuation and conversion coverage for its employees to the extent provided under federal and state law; and

(5) Contain a provision stating that if after timely receipt of the premium payment from the employer, the alliance fails to make the premium payment to the insurer, with the result that coverage is terminated, that the alliance shall be liable for benefits to the same extent as the insurer or carrier would have been liable if coverage had not been terminated.

N.H. Admin. Code § Ins 3401.05

#7434, INTERIM, eff 2-1-01, EXPIRED: 7-31-01

New. #7583, eff 11-1-01; ss by #9564, eff 10-19-09