“Alternative Care Settings” –  Governor Sununu Orders In-Network Payments Rates for Procedures Conducted at Out-of-Network Sites


By: Andrew Eills

April 19, 2020

In order to be paid for acute care procedures at negotiated rates, a contract between a health insurer and a hospital requires that these procedures be conducted within the hospital. Depending upon the contractual provision, if a procedure is rendered outside of the hospital, then either the rate paid by the insurer is lowered or the insurer does not have to make any payment at all.

The Covid-19 pandemic has forced hospitals to implement their emergency preparedness plans. Hospitals in New Hampshire are preparing for an expected surge in severe Covid-19 cases. This preparation requires hospitals to consider using alterative settings in which to conduct certain health care procedures that, under normal circumstances, will only be paid for if undertaken within an acute care hospital. But in implementing emergency preparedness plans, which include freeing up acute care capacity for the expected surge, New Hampshire hospitals have risked a loss of needed revenue . . . until now.

Effective April 9, 2020, Governor Sununu’s Emergency Order 30 requires health insurance payors to reimburse hospitals at acute care rates for procedures conducted in “alternative care settings” (“ACS”). ACSs include schools, auditoriums, and convention centers, as well as health facilities offering elective or non-acute care such as nursing homes, ambulatory surgery centers, and rehabilitation hospitals. https://www.governor.nh.gov/news-media/emergency-orders/documents/emergency-order-30.pdf

Emergency Order 30 specifically applies to all health insurance carriers, health benefit plans authorized under RSA 5-B, and all Medicaid Managed Care organizations serving NH residents. As a result of Emergency Order 30, all health care treatment conducted on patients transferred or diverted to an ACS as a result of an emergency preparedness plan must be reimbursed at the negotiated in-network rate. Simply put, an operation on a patient conducted out of the hospital will yield the same payment as if it were done in the hospital.

If the physician or other provider treating the patient is out-of-network, that provider will receive the same in-network payment rate normally reserved for the acute care, in-network hospital. To ensure clarity, the Emergency Order mandates that payments for procedures done in ACSs must be coded (treated) as if they were conducted in the hospital. Reimbursement at in-network rates are applicable to all procedures, not just those involving Covid-19.

We expect further guidance soon from the NH Department of Insurance. Emergency Order 30 remains in effect until the sooner of its rescission or the termination of the state of emergency.