Section 420-G:4-a Rating Factor for Qualified Wellness or Disease Management Programs.
I. In addition to the rating factors permitted in RSA 420-G:4, an insurer that offers a health benefit plan to individuals or small groups that includes a qualified wellness or disease management program may employ a rating factor that reflects the expected level of participation in the program and the anticipated effect the program will have on utilization or medical claim costs. The maximum differential attributed to this factor, as measured by ratio, shall not exceed 1.25 to 1.
II. Program materials shall be submitted to the commissioner for approval as a qualified program prior to the insurer's implementation of the rating factor. A qualified wellness or disease management program shall meet the following standards, to the extent applicable:
(a) The program shall meet the requirements set forth in the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) for bona fide wellness programs.
(b) The program shall provide significant financial incentives to covered employees or individuals for participating in the program and may also include special financial incentives to providers of wellness or disease management services.
(c) The program shall provide to covered employees or individuals for whom it is unreasonably difficult to satisfy the program's applicable standards reasonable alternative methods for achieving program participation.
III. The methodology proposed by the insurer for establishing rating factors for individuals or small groups shall be submitted to the commissioner for approval prior to implementation. The methodology shall specify how the rating factor will vary based on the anticipated efficacy of the program in reducing expected utilization or medical claim costs. The methodology may take into consideration:
(a) The anticipated average percentage of employees or individuals eligible to participate in the program.
(b) The anticipated efficacy of the financial incentives in producing high levels of program participation.
(c) The level of program participation achieved in prior coverage periods.
(d) The expected success rate for program participants.
(e) Clinical studies.
(f) The insurer's experience in the use of the program.
Source. 2004, 43:1, eff. May 3, 2004.