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.