Definitions; Balance Billing in Cases of Emergency Services; Balance Billing in Cases of Non-emergency Services Performed by Nonparticipating Providers at Certain Participating Health Care Facilities; Dispute Resolution Regarding the Fair Value of Health Care Items or Services
Section 358-T:1. Definitions
In this chapter:
I. “Covered benefits” means “covered benefits” as defined in RSA 420-J:3.
II. “Covered person” means “covered person” as defined in RSA 420-J:3.
III. “Emergency medical condition” means “emergency medical condition” as defined in RSA 420-J:3.
IV. “Emergency services” means “emergency services” as defined in RSA 420-J:3.
V. “Facility” means “facility” as defined in RSA 420-J:3.
VI. “Heath benefit plan” means a policy, contract certificate or agreement entered into, offered or issued by a health carrier or group health plan, as defined in 42 U.S.C. section 300gg-91(a), to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
VII. “Health care provider” or “provider” means “health care provider” or “provider” as defined in RSA 420-J:3.
VIII. “Health carrier” means “health carrier” as defined in RSA 420-J:3.
IX. “Nonparticipating emergency facility” means “nonparticipating emergency facility” as defined in RSA 420-J:3.
X. “Nonparticipating provider” means “nonparticipating provider” as defined in RSA 420-J:3.
XI. “Participating provider or facility” means “participating provider or facility” as defined in RSA 420-J:3.
Section 358-T:2. Balance Billing in Cases of Emergency Services
If a covered person with benefits covering emergency services under a health benefit plan is furnished emergency services, then:
I. In the case that the hospital emergency department or independent freestanding emergency department is a nonparticipating emergency facility, the hospital emergency department or independent freestanding emergency department shall not bill, and shall not hold liable, the covered person for a payment amount for such emergency services that is more than the cost-sharing requirement for such services under the covered person’s health benefit plan; and
II. In the case that such emergency services are furnished by a nonparticipating provider, the health care provider shall not bill, and shall not hold liable, such covered person for a payment amount for such emergency services that is more than the cost-sharing requirement for such services under the covered person’s health benefit plan.
Section 358-T:3. Balance Billing in Cases of Non-emergency Services Performed by Nonparticipating Providers at Certain Participating Health Care Facilities
I. Subject to paragraph II, if a covered person is furnished health care items or services, other than emergency services, by a nonparticipating provider at a participating facility for which benefits are provided under the covered person’s health benefit plan, then such provider shall not bill, and shall not hold liable, such covered person for a payment amount for such item or service furnished by such provider with respect to a visit at such facility that is more than the cost-sharing requirement for such item or service under the covered person’s health benefit plan.
II. Paragraph I shall not apply with respect to items or services, other than items or services that qualify as ancillary services under 42 U.S.C. section 300gg-132(b)(2) and (3), furnished by a nonparticipating provider to a covered person if the provider satisfies the notice and consent criteria under 42 U.S.C. section 300gg-132(c) and (d).
Section 358-T:4. Dispute Resolution Regarding the Fair Value of Health Care Items or Services
In the event of a dispute between a nonparticipating provider or nonparticipating emergency facility and a health carrier relative to the fair value of emergency health care items or services with respect to which balance billing is prohibited under RSA 358-T:2 or in the event of a dispute between a nonparticipating provider and a health carrier relative to the fair value of health care items or services with respect to which balance billing is prohibited under RSA 358-T:3, the insurance commissioner shall make available, as provided in RSA 420-J:8-e, an independent dispute resolution process to determine the fair value payment amount.