NH Rev Stat § 420-B:8-n (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-B - Health Maintenance Organizations|Section 420-B:8-n - Point of Service Plans.

    420-B:8-n Point of Service Plans. –||I. A health maintenance organization may offer a point-of-service plan in accordance with the requirements of this section. A point-of-service plan is a health maintenance organization contract which includes coverage for both in-network services and coverage for services provided by non-contracted providers.||II. A point-of-service plan offered by a health maintenance organization shall:||(a) Provide incentives for enrollees to use in-network covered services.||(b) Offer out-of-network covered services only if those services are also covered on an in-network basis.||(c) Cover out-of-network emergency services as if they had been provided in-network.||III. A point-of-service plan offered by a health maintenance organization may:||(a) Limit or exclude specific types of services, other than emergency services, from coverage when obtained out-of-network.||(b) Include provisions for member cost sharing, annual out-of-pocket limits and annual and lifetime benefit allowances for out-of-network covered services which are separate from any limits and allowances applied to in-network covered services.||(c) Cover at the out-of-network benefit level, services provided by a participating provider for which proper authorization or referral was not obtained.||IV. Subject to the provisions of RSA 420-G, a health maintenance organization may limit the groups to which point-of-service plans are offered. If a point-of-service plan is offered to a group, it must be offered to all eligible members of the group.||V. A health maintenance organization may not expend more than 20 percent of its total annual health care expenditures on out-of-network covered services. If compliance with this requirement is not demonstrated on a quarterly basis on the health maintenance organization's quarterly financial report, the commissioner may prohibit the health maintenance organization from offering a point-of-service plan to new groups until compliance has been demonstrated.||VI. A health maintenance organization shall comply with all applicable form and rate filing requirements. In complying with said requirements, the health maintenance organization shall:||(a) Design the benefit levels for in-network covered services and out-of-network covered services to achieve the desired level of in-network utilization;||(b) Provide or arrange for adequate systems to:||(1) Process and pay claims for out-of-network covered services;||(2) Meet the requirements for point-of-service plans under this section; and||(3) Generate accurate financial and regulatory reports on a timely basis in order for the commissioner to evaluate experience with the point of service plan and monitor compliance with the requirements of this section.||VII. An explanation of benefits shall be provided to enrollees who obtain services at the out-of-network benefit level which is adequate to permit the enrollee to determine his or her financial liability under the plan.||VIII. All point-of-service contracts and certificates shall contain a provision permitting the enrollee to assign any benefits provided for medical or dental care on an expense-incurred basis to the provider of care. An assignment of benefits under this paragraph does not affect or limit the payment of benefits otherwise payable under the contract or certificate.||IX. Subscriber contracts and member handbooks shall contain a clear and concise explanation of the point of service plan. The explanation shall include:||(a) The method of reimbursement;||(b) The required co-payments, co-insurance and deductibles, as applicable;||(c) Other uncovered costs or charges;||(d) The services that an enrollee is permitted to obtain at the out-of-network benefit level; and||(e) Instructions for submitting claims for services obtained at the out-of-network benefit level.|||Source. 2002, 207:8, eff. May 16, 2002.|