New Hampshire Regulations

The New Hampshire Insurance Department released a document that compiled the information of SUD Treatment providers in network for Marketplace beneficiaries.

The New Hampshire Insurance Department released a powerpoint presentation on parity. The report detailed the concept of parity, Quantitative and non-quantitative treatment limitations, common violations, and the appeals process.

The New Hampshire Insurance Department released the medical filings checklist, including requirements for the mental health and substance use disorder benefits, for individual health plans and small group plans. These must be completed by insurers and submitted to the New Hampshire Insurance Department. Insurers are required to attest that they comply with The Federal Parity Law and the relevant sections of state law (pgs. 9, and 22 in both checklists).

The New Hampshire Insurance Department released their findings from their 2015 Market Conduct Examinations of Anthem, Cigna, and Harvard Pilgrim regarding each insurer’s handling of SUD claims. A presentation and press release was released that gave an overview of the results, and a guide was also published to assist individuals in reading the reports.

The New Hampshire Insurance Department performed a market conduct examination of Harvard Pilgrim related to its coverage of substance use disorders. The examination contained the following:

• The most significant observation was the overall lack of SUD and behavioral health provider that contract within NH, causing deficiencies in network adequacy.
• Behavioral Health and SUD benefits are managed by United Behavioral Health (UBH)/Optum Behavioral. The carrier failed to produce documentation specific to compliance audits and examination results of UBH/Optum’s records, procedures and performance of delegated functions. NHID required Harvard produce these records within 30 days of the final report
• A corrective Action Plan to address the UBH/Optum website was requested by the examiner within 30 days of finalization of the report. This plan should outline the carrier’s timeline to prominently post an up to date listing of all SUD and Behavioral health providers.
• NHID directed Harvard to provide their policies and procedures for quality oversight of the online provider directory
• Independent Review Organizations were unable to provide an opinion on the legitimacy of three prior authorization requests denials due to Harvard redacting information from the files prior to sending them to the IRO. The IRO also disagreed with the denial for three prior authorization reviews. NHID recommended a follow up with all six consumers.
• Overall quantity of claims and percentage of SUD claims weren’t quantifiable due to conflicting data sets. Harvard was required to address claims data through expanded interrogatories and NCQA oversight examination was to be scheduled
• NHID required that, within 30 days of the final report, Harvard provide information on the clinical basis of dosage limitation imposed on Narcan and Evzio that were contrary to manufacturer’s dosing guidelines (both drugs are forms of naloxone, an overdose reversal medication).
• Examiners concluded they would re-address one of Optum’s behavioral health utilization review guidelines to confirm compliance with New Hampshire law
• The Medical Management criteria for behavioral health policies were provided on the Harvard’s website under the Provider tab, but not the Member tab. NHID required Harvard ensure this information, including Utilization review and Clinical guidelines, was easily accessible to consumers
• Harvard and UBH/Optum failed to provide documentation of oversight of the committee responsible for policy development of behavioral health benefits. NHID included medical management processes for policy and procedure development and oversight under this committee. NCQA oversight examination was to be scheduled.
• NHID found that Harvard required all mental health and drug and alcohol rehabilitation services must receive prior authorization through the Behavioral Health Access Center and be provided by contract providers. This requirement was not imposed on all medical/surgical benefits. Harvard was required to submit evidence this was not a parity violation.
• Examiners found variances in reimbursement rates and fees between Medical/surgical providers and Behavioral Health providers. According to documentation dated as “2013,” Behavioral Health providers were reimbursed at rates approximately 85% of the rates for Medical/surgical providers. However, 2013 was out of the scope of the examination period, but Harvard stated the rates in the documentation were still current. Due to the confusion, NHID recommended reimbursement methodology and rates be re-addressed and NCQA oversite to be scheduled. NHID also recommended Harvard provide evidence that their reimbursement methodology and rates were not a parity violation.
• Examiners recommended Harvard Pilgrim be cited for inability to facilitate the examination in a timely manner.

The New Hampshire Insurance Department (NHID) performed a market conduct examination of Cigna related to its coverage of substance use disorders. The examination contained the following:

• The most significant observation was the overall lack of SUD and behavioral health providers that contract within NH, causing deficiencies in network adequacy. However, Cigna had a process in place to address this issue.
• An Independent Review Organization reviewed all SUD prior authorization medical necessity denials and agreed with the denials. The IRO determined the criteria used for the evaluation as medically reasonable
• NHID directed Cigna to make Medical Policies and Clinical Utilization Management Guidelines more easily accessible to consumers on its website. Cigna was directed to provide NHID with instructions that outline the steps a consumer would take to obtain the policies and guidelines on the website within 30 days of the final report.
• NHID directed Cigna to make prior authorization information more easily accessible on its website. Cigna had 30 days to deliver to NHID instructions that outline the steps a consumer would take to obtain the prior authorization information on its website.
• NHID directed Cigna to review their provider reimbursement rates and fee schedules to ensure they were not limiting access to behavioral health services. This was due to a finding that in-network Medical/surgical services were reimbursed on an assigned diagnosis related group or case rate basis and on per diem basis, but only reimburses facility-based behavioral health services on a per diem basis. NHID was concerned this could allow for greater benefit consideration for medical/surgical services versus behavioral health services. Cigna was to  report back with detailed explanation to prove the difference is not a parity violation.

The New Hampshire Insurance Department (NHID) performed a market conduct examination of Anthem related to its coverage of substance use disorders. The examination contained the following:

• There was a deficiency in the behavioral health providers available in Anthem’s network, primarily due to a shortage of providers working in the state
• Anthem’s website did not accurately display an up-to-date listing of behavioral health providers available; NHID required Anthem to address this within 30 days
• NHID required Anthem to submit their protocols for ensuring that its provider directories are accurate and current and describe how often they verify this
• 6 of the 34 denied prior authorization medical necessity reviews for substance use disorder treatment that NHID examined should have been approved
• Anthem’s dosing limitations for methadone and Evzio (naloxone) were not in line with the manufacturer’s guidelines
• Anthem must create a protocol for correcting any disparities they may find in how they apply quantitative treatment limitations to behavioral health services
• Anthem was not covering depression screenings without cost sharing, as required by federal law
• Anthem did not make its Medical Necessity information, including Utilization Review policies and Clinical Guidelines , easily accessible to the public
• Prior authorization information was not easily accessible on Anthem’s website
• There was a disparity in reimbursement rates that NHID wanted clarification from Anthem explaining how it was not a parity violation

The New Hampshire Insurance Department released the Resource Guide for Addition and Mental Health Care Consumers. The guide is meant to help consumers and providers better understand mental health and substance use disorder benefits and rights and steps to overcome coverage obstacles.

The New Hampshire Insurance Department released a report (pdf | Get Adobe® Reader®) on reimbursement rates for substance use disorder providers. Claims with a primary diagnosis of substance use disorder were pulled from major commercial carriers from October 2014 through September 2015. The study found that commercial insurers pay health care providers less than Medicare rates for treating patients with a substance use disorder. This is a press release (pdf | Get Adobe® Reader®) on the report.

The New Hampshire Insurance Commissioner released a press release (pdf | Get Adobe® Reader®) announcing the formation of an advisory committee focused on access to behavioral health services, including treatment for substance use disorders, through private insurance coverage.

The New Hampshire Insurance Department issued a bulletin (pdf | Get Adobe® Reader®) updating the process for non-grandfathered individual and small group health plans to become qualified health plans. This bulletin provides more background and additional requirements in comparison to the 2015 bulletin below.

The bulletin requires plans to submit an attestation saying that they are in compliance with the Federal Parity Law . It also requires carriers use a network adequacy template to ensure members have access to a sufficient number of providers. Plans must also be in compliance with state requirements for pervasive developmental disorders and autism treatment services.

The New Hampshire Insurance Department released a PowerPoint presentation (pdf | Get Adobe® Reader®) and a document (pdf | Get Adobe® Reader®) detailing their preliminary findings of their 2015 investigation of insurance coverage of opiate substance use disorders. The findings focus on prevalence rates and medical claims between large employer self-insured and fully insured plans. This report is a component of ongoing market conduct exams analyzing utilization review procedures, claims denials, and prior authorization.

The New Hampshire Insurance Department issued a bulletin (pdf | Get Adobe® Reader®) notifying enrollees of fully-insured health and dental insurance plans the right to independent external review when claims or requested services are denied based on medical necessity determinations. Behavioral health care denials resulting from adverse medical necessity determinations are likely to be parity violations.

Carriers are required to provide their enrollees with the New Hampshire Insurance Department’s documents “Managed Care Consumer Guide to External Appeal” and ‘Request for Independent External Appeal of a Health Care Decision.’ The documents are available at this link.

The New Hampshire Insurance Department issued a press release (pdf | Get Adobe® Reader®) announcing that it “has begun a targeted examination” of insurers coverage of substance use disorder services from January 1, 2015 to September 30, 2015. The press release specifically mentions that the Department will be reviewing how insurance plans handle prior authorization, claims denials, and utilization review procedures.

The release clarified that the Department has the power to order insurers to correct any violations, to pay fines, or even to cease operations in the state, for severe violations.

The release states that the Department plans to issue a report on the findings of this examination in January 2016.

The New Hampshire Insurance Department issued a bulletin (pdf | Get Adobe® Reader®) that clarified what is required of individual plans and small employer fully-insured plans subject to the Affordable Care Act (ACA) regarding autism coverage. It stated that the annual maximums in the section of the state insurance law about autism coverage cannot be considered limits on how much plans must cover because the ACA forbids annual dollar limits.

The bulletin clarifies that because one of the parity sections of the state insurance law lists autism as a “biologically-based mental illness,” autism coverage is an essential health benefit and plans must comply with the Federal Parity Law for autism services (the parity sections of the state insurance law are summarized at the bottom of this page under “New Hampshire Parity Law.”)

The New Hampshire Insurance Department issued a bulletin (pdf | Get Adobe® Reader®) explaining the process for non-grandfathered individual and small group health plans to become qualified health plans. Section 4D focuses on mental health parity compliance.

In order to become a qualified health plan, the New Hampshire Insurance Department requires all plans must submit an attestation saying that they are in compliance with the Federal Parity Law. Plans must also be in compliance with state requirements for pervasive developmental disorders and autism treatment services.

The New Hampshire Insurance Department released a summary (pdf | Get Adobe® Reader®) of mandated benefits that must be included in fully insured plans issued in New Hampshire. Mandated benefits include:

• Court ordered psychiatric and psychological services
• Coverage for certain biologically based mental illnesses, pervasive developmental disorders, autism, and chemical dependency
• Services delivered at a community mental health center or psychiatric residential treatment

The document specifies that health maintenance organizations must cover 2 visits to an in-network psychiatrist or other mental health care provider for diagnosis and 3 subsequent visits annually without utilization review.

The New Hampshire Insurance Department issued a bulletin (pdf | Get Adobe® Reader®) that explained to plans how to determine if they are considered large employer fully-insured plans or small employer fully-insured plans in terms of complying with the Federal Parity Law. It explained that for the purposes of complying with the Federal Parity Law, plans must define their size according to federal law, which would result in some plans that are considered small employer fully-insured plans by New Hampshire law to be re-classified as large employer fully-insured plans. It specified that these plans must comply with the Federal Parity Law. However, it also stated that because of “guaranteed issue” law, plans must offer all small employers the option to purchase a plan that complies with the Federal Parity Law.

The New Hampshire Insurance Department contracted with Compass Health Analytics to examine (pdf | Get Adobe® Reader®) the implications of HB 569, which added the subsection to one of the sections of the state insurance law about parity (summarized at the bottom of this page under “New Hampshire Parity Law,” “Autism Coverage”). The primary intention of the examination was to determine the annual costs associated with plan compliance with the requirements of this bill. The examination found that it would raise annual costs for plans by $2 million to $4 million, or a .2% to .4% increase in premiums.