N.H. Admin. Code § Ins 3401.06

Current through Register No. 45, November 7, 2024

Section Ins 3401.06 - Requirements for Participating Carriers

(a) To qualify as a participating carrier, a carrier shall demonstrate all the following operating characteristics:

(1) That it is licensed and in good standing with the department of insurance;

(2) That it has the ability to administer health coverage, to provide adequate service, and to comply with all contractual requirements of the alliance;

(3) That it has the ability to provide enrollees with access to covered services;

(4) That it has the ability to provide coverage for enrollees in any service area in which the carrier plans to participate through the alliance;

(5) That it has the ability to arrange and pay for quality health care services;

(6) That it has the ability to provide standard data required by the alliance, in a manner prescribed by the alliance, including information on:

a. Plan performance;

b. Enrollee satisfaction;

c. Provider payment and incentive structures;

d. Such other standard surveys prescribed by the alliance; and

e. Meeting satisfaction measures established by the alliance;

(7) That it has the ability to meet quality of care standards established by government and industry authorities;

(8) That it is financially strong and has competent management;

(9) That it has a procedure in place to address enrollee grievances and appeals; and

(10) That it has the ability to achieve satisfactory enrollment levels within the service area in which the carrier is licensed.

(b) In evaluating the requirements for a participating carrier, the alliance shall consider:

(1) The minimum geographic service area and participation requirements, maximum thresholds for premium rates, and standards for determining whether a carrier operates efficiently;

(2) The ability of a carrier to provide high quality services within a service area;

(3) Pricing and the competitiveness of each bid from a carrier; and

(4) The effect of contracting with additional carriers on the administrative costs of the alliance and member small employers, the efficiency of the alliance, and the competitiveness of the premiums that will be paid to the participating carrier or carriers;

(c) A participating carrier or carriers that contract with or employ health care providers shall have mechanisms to accomplish all of the following, in a manner satisfactory to the alliance:

(1) Review the quality of care covered;

(2) Review the appropriateness of care covered; and

(3) Provide accessible health care services;

(d) Each participating carrier shall:

(1) Meet the standards established by the alliance pursuant to this part;

(2) Provide data and information as required by the alliance;

(3) Comply with all laws and rules regarding underwriting, rating, claims handling, sales, solicitation, licensing, fair marketing, unfair trade practices, the provisions of this part, and other applicable state statutes;

(4) Enroll and terminate individuals in the manner specified by the alliance; and

(5) Comply with other requirements established by the alliance pursuant to this part;

(e) Nothing in this part shall prohibit the participating carrier or carriers from contracting with particular health care providers or types, classes, or categories of health care providers, or setting reimbursement methodology.

(f) A participating carrier or carriers contracting to provide one or more such benefit plans through the alliance shall be deemed to be in compliance with the guaranteed issue and renewal requirements in RSA 420-G:6, III with respect to such benefit plan or plans so long as it actively markets, issues, and renews such plan or plans to all eligible employees of all member small employers of the alliance.

(g) In the event that the participating carrier or carriers elect to terminate its or their contracts with the alliance, the participating carrier or carriers shall:

(1) Provide advance notice of its or their decision to the alliance; and

(2) Provide notice of the decision at least 180 days prior to the non-renewal of health coverage to the member small employers and employee enrollees.

N.H. Admin. Code § Ins 3401.06

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

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