New Hampshire Health Insurance Enforcement and Consumer Protections Grant Award

Cycle I Grant Application Summary

New Hampshire Grantee: New Hampshire Department of Insurance

Award Date: October 31, 2016

Total Award: $1,120,164

Baseline Award: $476,998

Selected Market Reforms Amount: $510,000

Workload Award Amount: $133,166

• Section 2707 - The New Hampshire Department of Insurance will create template tools to evaluate prescription drugs within benefit plans to include analysis of Federal and State requirements, via an automated process. Results from the use of the tool will identify the provisions that do not meet the requirements of non-discrimination for prescription drugs and associated CMS-identified health conditions, and generate an automated response for corrective action. New Hampshire will also create template tools that will evaluate Essential Health Benefits (EHBs) within benefit plans, via an automated process. Validation will include an automated checklist. The tool will identify the provisions that do not meet the requirements of EHBs, and generate an automated response for corrective action. Additionally, New Hampshire will hire a pharmacologist to advise the Department of Insurance on specific drugs, by therapeutic category, that are vital to treatment and outcomes to patients with severe diagnosis, such as Diabetes, Human Immunodeficiency Virus (HIV), and Behavioral Mental Illness Disorders, in order to assist New Hampshire in the recognition of discriminatory practices designed to discourage or preclude diagnosed individuals from plan selection or limit prescription costs that impair positive patient outcomes. The pharmacist will also review carrier formularies, therapeutic programs, step therapy procedures, pre-determination procedures, and cost sharing and tier designs that may be discriminatory. Finally, the New Hampshire Department of Insurance will develop reference tools for use by compliance examiners in assessing whether a health insurance issuer is discriminating in its formulary design and therapeutic protocols and will assess the feasibility for the creation of additional testing tools to facilitate compliance practices.

• Section 2713 - The New Hampshire Department of Insurance will create template tools to evaluate preventive health services within benefit plans, to include analysis of Federal and State requirements, via an automated process. The tool will identify the provisions that do not meet the requirements of preventive health services and generate an automated response for corrective action. New Hampshire will evaluate whether covered members are receiving these services as expected. In addition to use of services, the Department of Insurance will analyze payments made by health insurance issuers and any resulting patient liabilities due to cost sharing to explore whether there are situations that have led to a shortage of preventive care received. Additionally, New Hampshire will create consumer-friendly outreach information in multiple formats for consumers about the preventative health services that are fully covered by Affordable Care Act (ACA) compliant health insurance policies, including one page summaries of key preventive health services topics to be used as reference material. The material will be posted on New Hampshire’s website.

• Section 2726 - The New Hampshire Department of Insurance will perform market conduct examinations focusing on behavioral health services more broadly than is currently reviewed. New Hampshire will develop an online data collection tool with reporting functions that will be used to identify patterns and trends to assist with market analysis and regulatory oversight and review. The Department of Insurance will create tools that will evaluate parity within benefit plans, to include analysis of non-quantitative requirements of the Mental Health Parity and Addiction Equity Act (MHPAEA), as well as quantitative requirements, via an automated process. Additionally, New Hampshire will use its all payer claims database to compare the use of mental health and substance use disorder benefits of people covered by regulated entities. The Department of Insurance will develop targeted education and outreach programs based on historical patterns of care, and evaluate the use of health care services based on diagnoses and the care delivered. New Hampshire will develop a standard set of examination protocols/interrogatories for Quantitative and Non-quantitative treatment limits for market conduct reviews using guidance developed by the National Association of Insurance Commissioners (NAIC) and will execute market conduct examinations using the newly developed standard set of examination protocols. New Hampshire will also develop a complete and verifiable inventory of New Hampshire mental health and substance use disorder (MH/SUD) licensed providers and the type of services they offer. The Department of Insurance will create a tool which will enable health insurance issuers to accurately and consistently submit MH/SUD network provider information in order for the Department to evaluate adequate member access to essential community providers. New Hampshire will also create a provider complaint database to allow health care providers to electronically submit their complaints about the health care delivery system as they relate to matters of insurance.