420-M:7. Powers and Duties of Purchasing Alliances; Restrictions on Purchasing Alliances.
I. A purchasing alliance shall:
(a) Offer health benefit plans that are available to all member employers;
(b) Establish administrative and accounting procedures for operating the alliance, for providing services to member employers and enrollees, and for preparing an annual budget;
(c) Develop standard enrollment procedures for enrolling employers and their eligible employees and dependents;
(d) Establish procedures for open enrollment periods;
(e) Establish conditions of participation for small employers that conform to the requirements of RSA 420-G and include, but are not limited to, the following:
(1) Assurances that the member employer is an employer group and is not formed for the purpose of securing health benefits coverage; and
(2) Prepayment of premiums or other mechanisms to assure that payment will be made for coverage;
(f) Establish membership criteria that allow any employer to participate in the alliance or that limit participation in the alliance to employers that are members of or affiliated with an association, trade group, or other entity that has been in existence for at least 10 years and was established and maintained for purposes other than the provision of health coverage;
(g) Provide that each eligible employee is permitted to enroll in any health benefit plan offered by any participating carrier so long as the health benefit plan provides coverage where he or she works or lives;
(h) Establish conditions of participation for participating carriers;
(i) Develop and make available a list of objective criteria that shall be met by a participating carrier offering coverage to alliance members;
(j) Establish conditions of participation for agents or brokers;
(k) Provide to alliance members clear, standardized information on the health benefit plan including information on:
(1) Price;
(2) Benefits;
(3) Enrollee costs;
(4) Quality;
(5) Patient satisfaction;
(6) Enrollment; and
(7) Grievance procedures and rights and responsibilities;
(l) Transmit enrollment and eligibility information to participating carriers on a timely basis;
(m) Specify in contracts with participating carriers how all premiums shall be transmitted and the frequency of that transmission and how penalties and grace periods on late payments of premiums shall be calculated;
(n) Have a fiduciary duty with respect to all moneys received or owed to it to assure payments of its obligations and a full accounting to its members and the commissioner; and
(o) Submit to the commissioner quarterly financial statements, annual reports, and proposed material changes in the policy and/or operations or the business plan.
II. A purchasing alliance may:
(a) Receive, review, and act on grievances against participating carriers by member employers or enrollees;
(b) Require participating carriers to maintain health care data;
(c) Maintain a trust account or accounts for deposit of all moneys received and collected for the operation of the alliance;
(d) Establish procedures and mechanisms for billing and collection of premiums from member employers, including collection of any share of the premium paid by employee enrollees;
(e) Review information and recommendations from consumers, employers, participating carriers, or health care providers and other sources, and issue periodic reports or recommendations to the commissioner to improve the delivery of health services and the purchasing of health coverage;
(f) Develop model contracts that describe for potential contractors the requirements of the alliance and provide a copy of the contract to interested carriers;
(g) Place into its contracts between the alliance and member employers the following:
(1) A provision stating that, for administrative purposes, the alliance shall be the policyholder or contract holder of the health benefit plan on behalf of member employers, their eligible employees, and eligible dependents; and
(2) A provision stating that the participating carrier shall issue a certificate of coverage, or equivalent document, specifying the essential features of the health benefit plan's coverage to each enrolled eligible employee;
(h) Undertake any activity necessary to administer the alliance, including marketing and publicizing the alliance, and assuring that participating carriers, contractors, participating employers, and enrollees are in compliance with alliance requirements;
(i) Establish contracts with participating carriers to provide health coverage to alliance members;
(j) Establish contracts with employer members;
(k) Contract with qualified, independent third parties for services necessary to carry out the powers and duties of the alliance;
(l) Appoint advisory committees, as necessary, to provide technical assistance in the operation of the program and in carrying out the purposes of this chapter;
(m) Assess member employers a fee for costs incurred or anticipated in connection with the operation of the alliance;
(n) Require as a condition of membership that employers include a minimum percentage of employees in coverage purchased through the alliance;
(o) Reject or allow a carrier to reject an employer from membership or drop or allow a carrier to drop a member employer if the member fails to pay premiums or engages in fraud or material misrepresentation in connection with a health benefit plan purchased through the alliance;
(p) Contract with licensed insurance agents or brokers to market and service coverage made available through the alliance to its members. Compensation for agents and brokers shall not vary based on the actual or expected health status or medical utilization of the group to which coverage is sold;
(q) Define a set of standardized requirements that the alliance shall use to purchase insurance from a carrier;
(r) Require that member employers and their eligible employees continue to pay administrative fees that are part of the contract with the alliance if a member employer or enrollee cancels prior to completion of a contract period or membership period established by the alliance;
(s) Negotiate the premium rates charged for coverage offered through the alliance and, for small employer members, ensure that rates are consistent with the rating restrictions contained in RSA 420-G;
(t) Request such information from participating carriers as is necessary to carry out the powers and duties of this chapter;
(u) Sue or be sued, including taking action necessary for securing legal remedies on behalf of the alliance, member employers, or enrollees;
(v) Apply for loans or loan guarantees from the New Hampshire business finance authority for the purpose of funding startup costs;
(w) Receive and accept loans, grants, funds, or anything of value from a public or private entity including:
(1) Employer premiums;
(2) Employer participation fees;
(3) Employer late fees;
(4) Employer reinstatement fees;
(5) Agent and broker fees paid by the employer;
(6) Interest earned on accounts;
(7) Funds paid by the participating carriers for a pooled marketing effort;
(8) Public sector and private sector grants, gifts, loans, or donations; or
(9) Other lawful sources;
(x) Receive and accept contributions of property, labor, or any other thing of value;
(y) Expend funds to pay:
(1) Participating carriers under their contracts;
(2) Third parties for services provided under contract;
(3) Employer billing adjustments;
(4) Agent and broker fees;
(5) The alliance's administrative expenses; and
(6) All other expenditures duly authorized by the board;
(z) Exercise all powers reasonably necessary to carry out the powers granted and duties imposed under this chapter; and
(aa) Enter into all other contracts as are necessary to carry out the powers and duties of the alliance.
III. A purchasing alliance shall not:
(a) Purchase health care services directly, assume risk for the cost or provision of health care services, or otherwise contract with health care providers for the provision of health care services to enrollees.
(b) Exclude from membership in the alliance an employer, eligible employee, or eligible dependent of an eligible employee who meets the alliance's membership criteria and who agrees to pay fees for membership and the premium for health coverage through the alliance and who abides by the bylaws and rules of the alliance.
(c) As a condition of membership, require an employer, eligible employee, or eligible dependent to subscribe to limited health coverage or non-health coverage related products or services.
(d) Engage in any act or practice that results in the selection of member employers and enrollees based on industry type, experience, gender, family status, education, health status, income, employer size, or other factors related to the risk profile of the group.
(e) Require or take any action inconsistent or in conflict with state laws or regulations.
Source. 2010, 346:1. 2011, 155:1, eff. Aug. 7, 2011.
