N.H. Admin. Code § Ins 403.04

Current through Register No. 49, December 5, 2024

Section Ins 403.04 - Standard Wellness Plan

The standard wellness plan shall include the following benefit structure as described herein and as set forth in Appendix A:

(a) Benefits shall include:

(1) Full coverage for preventive care services;

(2) Primary care visits covered with a $20.00 per visit copay;

(3) Specialist visits covered with a $50.00 per visit copay;

(4) Full coverage for inpatient and outpatient hospital care, including diagnostic laboratory work, after the deductible has been met;

(5) Skilled nursing facility care for a period of up to 100 days within each policy year, subject to the deductible;

(6) Rehabilitation facility care for a period of up to 60 days within each policy year, subject to the deductible;

(7) Full coverage for diagnostic laboratory work;

(8) Diagnostic radiology, including x-rays, MRI's, CT scans, and PET scans, subject to the deductible, except for mammograms which are preventive care shall not be subject to the deductible;

(9) Outpatient surgery performed in a physician's office, subject to the office visit copay of $20 for a primary care provider and $50 for a specialist;

(10) Outpatient surgery performed in a hospital or surgical center, subject to the deductible;

(11) Urgent care facility care, subject to a $100 per visit copay for the facility charge with other covered services subject to the tier 1 or tier 2 deductible for facilities that are hospital owned. If the urgent care facility is not hospital owned, the services shall be subject to the tier 1 deductible;

(12) Emergency care facility care, subject to a $200 per visit copay for the emergency room facility charge. Other covered services, including radiology and laboratory work, delivered at the emergency room shall be subject to the tier 1 deductible;

(13) Ambulance services, subject to the deductible;

(14) Short-term therapy, including physical therapy, speech therapy, and occupational therapy, subject to a $50 per visit copay;

(15) Mental health and substance abuse services, subject to a $20 per visit copay for office visits and subject to the inpatient and outpatient deductible when the services are provided at a hospital or outpatient care facility;

(16) Durable medical equipment, subject to the deductible and limited to a calendar year maximum of $3,000;

(17) Prescription drugs including covered medications, diabetic supplies and contraceptive devices purchased at a network pharmacy, subject to:

a. The following copays:

1. A $10 copay for generic drugs;

2. A $35 copay for non-generic formulary drug brands; and

3. A $50 copay for non-formulary brand drugs.

b. Drugs that are considered maintenance shall be available for a supply greater than 30 days;

c. The copay shall be applied to each 30 day supply of the drugs except when drugs are purchased through a mail-order facility that offers a reduction of copay(s) for purchasing through the mail-order facility; and

d. For formulary brand and non-formulary brand at least 2 brand drugs shall be available for each therapeutic class covered under the HealthFirst benefit plan.

(18) Full coverage for screening and brief intervention for alcohol and drug abuse;

(19) Full coverage for body mass index screening; and

(20) Colonoscopy, subject to a $250 copay.

(b) The standard wellness plan shall use hospital tiering of acute care hospitals to determine the amount of the hospital deductible, so that:

(1) The deductible for tier 1 facilities shall be $2,500 per member and $5,000 per family; and

(2) The deductible for tier 2 facilities shall be $4,000 per member and $8,000 per family.

(c) The annual out of pocket maximum for the standard wellness plan shall be $5,000 per member and $10,000 per family. There shall not be a lifetime maximum amount.

(d) A separate annual out-of-pocket maximum for prescription drugs may be offered with an annual out-of-pocket of $5,000 per member and $10,000 per family. There shall not be a lifetime maximum amount.

(e) The standard wellness plan shall comply with all state laws and rules related to small group accident and health insurance coverage, including, but not limited to state mandated benefits in RSA 415, 420-B, 420-J and Ins 1900.

(f) The use of a telecommunications or telehealth system shall be defined by the insurer and may substitute for an in-person visit for consultations, office and outpatient visits, psychiatric diagnostic interviews, individual psychotherapy, individual medical nutrition therapy, end-stage renal disease (ESRD) services, and pharmacologic management. Telehealth shall not be used for group visits.

(g) The care navigator shall be included in the benefit design; and

(h) The care navigator shall specifically describe:

(1) The application of the care navigator in the HealthFirst benefit plan; and

(2) How the care navigator shall be used in each applicable benefit description.

N.H. Admin. Code § Ins 403.04

#9511, eff 7-10-09