Implementation of NH Protections Against Balance Billing and State Dispute Resolution Process

The State of New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 David J. Bettencourt Keith E. Nyhan Commissioner Deputy Commissioner BULLETIN Docket #INS 25-004-AB TO: Health Insurance Carriers, Third Party Administrators, and Selffunded Health Plans FROM: Commissioner David J. Bettencourt DATE: January 13, 2025 RE: Dispute Resolution Process Beginning January 1, 2025, the state laws regarding balance billing and the dispute resolution process available in instances where balance billing is prohibited have changed. During the 2024 legislative session, the enactment of SB 173 revised state statutes relating to protections from balance billing and instituted a new state dispute resolution process. State law and the federal “No Suprises Act” both protect consumers by prohibiting health care providers and facilities from balance billing consumers when the consumer receives care from an out-of-network provider or facility for emergency services, or care from an out-of-network provider at an innetwork facility. In these situations, an out-of-network provider or facility must negotiate the fee to be paid by the health insurance carrier and initiate the dispute resolution process if an agreement cannot be reached. Previously, the state level dispute resolution system was limited to more specific circumstances. For situations involving anesthesiology, radiology, emergency medicine, or pathology services rendered by an out-of-network provider at an innetwork facility, the Insurance Commissioner was responsible for resolving the dispute through a hearing. In all other instances, the federal dispute resolution process applied. Under the new law, all disputes involving emergency care, or care provided by an out-of-network provider at an in-network facility, have the option of using either the state or the federal dispute resolution process. The new state dispute resolution process mirrors the federal dispute resolution system in most respects but improves upon some of the inefficiencies experienced in the federal system. The Department has drafted new proposed rules that provide further details regarding the process and is in the process of initiating rulemaking. The draft rules are available on our website at https://www.insurance.nh.gov/sites/g/files/ehbemt861/files/inline- Implementation of NH Protections Against Balance Billing and State Telephone 603-271-2261 • Fax 603-271-1406 • TDD Access: Relay NH 1-800-735-2964 nh.gov/insurance documents/sonh/ins-2706-surprise-medical-bills-draft-of-proposed-rule.pdf. Please note that the new state dispute resolution process is only available for care provided on January 1, 2025, or later. Although the new state law does not apply to self-funded health plans, self-funded health plans have the ability under the new law to voluntarily opt-in to the state process. Any self-funded health plan can opt-in at any time by submitting the Optin Form for Self-funded Plans available on the Department’s website. The Department will post a list of the self-funded health plans that have opted-in to the state process. Providers and facilities can only initiate the state dispute resolution process with a self-funded health plan if that plan has opted in. The new law allows providers and facilities to decide which dispute resolution process they would like to use, the state or the federal. Providers and facilities must make this choice prior to initiating the Open Negotiation period. If the provider or facility decides to use the state process, they must use the “Notice of Open Negotiation” forms specific to the state process. All required forms are available on the Department’s website at https://www.insurance.nh.gov/about-us/life-health­ division. The Department is in the process of developing further technical guidance regarding the submission process for the state dispute resolution process and will be posting additional information on this website soon. The new law also specifies how the covered person’s cost sharing should be calculated when care is provided by an out-of-network provider rendering emergency care or care at an in-network facility. In such instances, the health carrier shall calculate the covered person’s cost sharing using the Qualified Payment Amount (QPA), unless the billed amount or the allowed amount is less than the QPA. In such instances, cost sharing for services covered shall be calculated using the lesser of the billed amount or allowed amount. Questions related to this Bulletin should be directed to Consumer Services, New Hampshire Insurance Department by email to consumerservices@ins.nh.gov or by telephone at 603-271-2261. 2