New Hampshire Healthcare
Compliance Guide

New Hampshire presents a generally favorable regulatory environment for healthcare companies, particularly those leveraging telehealth, though careful navigation of specific statutes and board rules is essential. The state has historically been proactive in adopting telehealth-friendly policies, especially in response to the COVID-19 pandemic, many of which have been made permanent. Key regulatory bodies include the New Hampshire Board of Medicine, Board of Nursing, Board of Pharmacy, and the Department of Health and Human Services. The business climate is generally pro-business, but healthcare operations are subject to stringent professional licensure and corporate practice regulations. Recent legislative actions, such as the permanent adoption of certain telehealth flexibilities, underscore the state's commitment to expanding access to care while maintaining quality and safety. For instance, RSA 318-E:1-10 outlines the framework for telehealth practice, emphasizing parity in coverage and reimbursement. The state does maintain a robust Corporate Practice of Medicine (CPOM) doctrine, which significantly influences business structuring for physician-owned or physician-led entities. Non-physician ownership of professional medical practices is generally prohibited, necessitating careful consideration of management services organization (MSO) models. Similarly, prescribing rules, particularly for controlled substances, align with federal guidelines but include state-specific nuances regarding initial evaluations and PDMP checks. Scope of practice for advanced practice registered nurses (APRNs) is broad, with full practice authority, which can be advantageous for telehealth models. Overall, New Hampshire offers a fertile ground for healthcare innovation, provided companies meticulously adhere to its well-defined regulatory framework.

New Hampshire enforces a robust Corporate Practice of Medicine (CPOM) doctrine, which prohibits corporations or other non-professional entities from practicing medicine or employing physicians to provide medical services. The legal basis for NH's CPOM doctrine is not explicitly defined by a single statute titled 'Corporate Practice of Medicine' but is derived from various professional licensing statutes and legal interpretations that reserve the practice of medicine for licensed individuals and professional corporations. For instance, RSA 329:17 states that 'No person shall practice medicine unless licensed to do so by the board.' This implies that a non-licensed entity cannot 'practice medicine' by employing licensed individuals to do so. The New Hampshire Board of Medicine has consistently interpreted these statutes to prohibit the direct employment of physicians by general business corporations. Consequently, only professional corporations (PCs) or professional associations (PAs) formed under RSA 294-A are generally permitted to practice medicine and employ licensed healthcare professionals. These professional entities must be owned and controlled by licensed professionals. Specifically, RSA 294-A:2 defines a 'professional corporation' as one 'organized under this chapter solely for the purpose of rendering professional services.' Ownership of such entities is typically restricted to licensed professionals of the same profession. This means that non-physicians generally cannot own or control entities that directly provide medical services. For telehealth companies, medspas, dental practices, and wellness clinics, this has significant implications. Direct employment of physicians by a non-professional entity is prohibited. This necessitates the use of alternative structures, most commonly the Management Services Organization (MSO) model, where a non-professional entity (the MSO) provides administrative and non-clinical support services to a physician-owned professional entity (PC). The MSO cannot control clinical decision-making, set physician fees, or interfere with the physician-patient relationship. Fee-splitting is also prohibited under RSA 329:17, V, which prevents licensed professionals from sharing fees with unlicensed individuals or entities for patient referrals or services. This further reinforces the need for carefully structured MSO agreements that delineate services and compensation clearly, ensuring the MSO's compensation is for legitimate management services and not tied to patient volume or clinical revenue in a way that constitutes illegal fee-splitting. Any structure must ensure that clinical autonomy and control remain firmly with the licensed professionals.

New Hampshire has adopted a progressive stance on telehealth, establishing a comprehensive framework that facilitates its use while ensuring patient safety and quality of care. A key aspect is the establishment of a valid provider-patient relationship via telehealth. Under RSA 318-E:2, V, a 'telehealth encounter' is defined, and a provider-patient relationship can be established through an initial telehealth consultation, provided it meets the standard of care. This means that an in-person visit is generally not required to establish the initial relationship for telehealth services. However, the provider must exercise appropriate professional judgment to determine if a telehealth encounter is suitable for the patient's condition. All modalities are permitted, including live interactive audio-visual (video), audio-only telephone, and asynchronous (store-and-forward), as long as they are appropriate for the service being rendered and meet the standard of care. RSA 318-E:2, IV defines 'telehealth' broadly to include these modalities. There are no specific telehealth registration requirements for providers beyond their standard professional licensure in New Hampshire. However, out-of-state providers must be licensed in New Hampshire to provide services to patients located in the state, as per RSA 329:17 for physicians and similar statutes for other professions. Informed consent is a critical requirement. RSA 318-E:3, I(c) mandates that providers obtain informed consent from the patient (or their legal guardian) prior to the delivery of telehealth services. This consent must include information about the services, the technology used, privacy practices, and the patient's right to withdraw consent. Providers must also verify the patient's identity and location. There are generally no geographic restrictions within New Hampshire for telehealth services, meaning a patient can be located anywhere within the state. However, providers must be mindful of their own licensure jurisdiction. Reimbursement parity is also a significant feature, as RSA 318-E:4 requires health plans to cover telehealth services at the same rate as in-person services, provided the service is medically necessary and appropriately delivered. This encourages the widespread adoption of telehealth. Providers must ensure that the technology used is secure and compliant with HIPAA regulations.

New Hampshire's prescribing rules for telehealth, particularly for controlled substances, align with federal guidelines while incorporating state-specific requirements. For non-controlled substances, providers licensed in New Hampshire can prescribe via telehealth once a valid provider-patient relationship has been established, consistent with the standard of care. For controlled substances, the landscape is more nuanced, especially after the expiration of federal COVID-19 Public Health Emergency (PHE) flexibilities. Generally, a prescription for a controlled substance requires an in-person medical evaluation, unless an exception applies, such as the Ryan Haight Online Pharmacy Consumer Protection Act of 2008's 'telemedicine exception.' This exception allows for prescribing controlled substances without an in-person exam if the practitioner has conducted at least one in-person medical evaluation of the patient, or if the patient is being treated by, and physically located in, a hospital or clinic where the practitioner is practicing. During the PHE, the DEA waived this requirement, allowing prescribing of controlled substances via telehealth without a prior in-person exam. As of the current regulatory environment (2025-2026), the DEA has proposed new rules that would largely reinstate the in-person requirement for Schedule II-V controlled substances, with some limited exceptions. New Hampshire's RSA 318-B:10 and RSA 318-B:10-a govern controlled substance prescribing. While not explicitly detailing telehealth-specific rules for initial controlled substance prescribing without an in-person visit, state boards generally defer to federal DEA regulations on this matter. Therefore, for Schedule II-V controlled substances, an in-person evaluation is typically required unless federal exceptions apply. PDMP checking is mandatory for controlled substance prescriptions. RSA 318-B:35 requires prescribers to consult the New Hampshire Prescription Drug Monitoring Program (NH PDMP) database prior to prescribing or dispensing an opioid or benzodiazepine to a patient for a period exceeding 72 hours. This check is crucial for identifying potential drug-seeking behavior and ensuring patient safety. There are no specific state-mandated quantity or refill limitations for controlled substances prescribed via telehealth that differ from in-person prescribing, beyond what is generally considered medically appropriate and consistent with federal guidelines (e.g., 90-day supply limits for Schedule II, no refills for Schedule II). Special rules apply to specific drug classes: for GLP-1s (e.g., Ozempic, Wegovy), these are not controlled substances, so telehealth prescribing follows general non-controlled substance rules. For testosterone (a Schedule III controlled substance), the in-person requirement for initial prescribing applies unless federal exceptions are met. For stimulants (e.g., Adderall, Ritalin, Schedule II), the in-person requirement is strictly enforced for initial prescriptions, and subsequent refills or adjustments may be managed via telehealth if a robust provider-patient relationship is established and maintained. Providers must ensure thorough documentation of the medical necessity and rationale for all controlled substance prescriptions.

New Hampshire grants full practice authority to Advanced Practice Registered Nurses (APRNs), including Nurse Practitioners (NPs), Certified Nurse Midwives (CNMs), and Clinical Nurse Specialists (CNSs). This means that APRNs in New Hampshire can practice independently, diagnose, treat, and prescribe medications (including controlled substances) without the need for a collaborative practice agreement or physician supervision, provided they meet specific education, certification, and experience requirements. This is codified in RSA 326-B:15, which outlines the scope of practice for APRNs. This full practice authority significantly enhances the operational flexibility for telehealth companies and other healthcare entities utilizing NPs. For Physician Assistants (PAs), the regulatory framework is different. PAs in New Hampshire operate under a 'supervision' model, although the degree of supervision has become more flexible. RSA 328-D:1 et seq. governs PA practice. While PAs do not have full independent practice authority like APRNs, the statute allows for a 'supervising physician' to delegate medical tasks to a PA. The supervision is generally defined as 'adequate supervision' rather than constant physical presence, allowing for remote supervision in many contexts, including telehealth. The specific tasks and level of supervision are often outlined in a practice agreement between the PA and the supervising physician, which must be submitted to and approved by the Board of Medicine. PAs can prescribe medications, including controlled substances, within their scope of practice and under the authority of their supervising physician. For Medical Assistants (MAs), particularly in medspas or wellness clinics, their scope of practice is limited to delegated tasks that do not require independent medical judgment. MAs generally cannot perform invasive procedures, administer injectables (like Botox or fillers), or provide medical advice. Their role is typically administrative or involves assisting licensed practitioners with patient care tasks that are explicitly delegated and performed under direct supervision. RSA 329:21-a addresses delegation of medical acts. Any delegation must be appropriate for the MA's training and competence and must be performed under the supervision of a licensed physician, APRN, or PA. For procedures like IV therapy, a licensed professional (RN, APRN, PA, MD) must perform or directly supervise the administration. Unlicensed personnel cannot independently initiate or manage IV infusions. Companies must ensure strict adherence to these scope of practice rules to avoid unauthorized practice of medicine or nursing, which carries significant legal and professional penalties.

Navigating New Hampshire's Corporate Practice of Medicine (CPOM) doctrine is paramount when structuring healthcare businesses. Given the prohibition on non-licensed entities practicing medicine, the Professional Corporation (PC) - Management Services Organization (MSO) model is the predominant compliant structure. A PC, formed under RSA 294-A, must be owned by licensed professionals (e.g., physicians for a medical practice, dentists for a dental practice). This PC employs the licensed providers and directly provides clinical services. The MSO, a separate general business corporation, provides all non-clinical, administrative, and management services to the PC. These services typically include billing, scheduling, marketing, IT, human resources for non-clinical staff, and facility management. The MSO is owned by the investors or entrepreneurs who wish to participate in the healthcare business without violating CPOM. Fee-splitting rules are critical here. RSA 329:17, V explicitly prohibits physicians from sharing fees with unlicensed individuals or entities for patient referrals or services. Therefore, the MSO's compensation must be structured as a fixed fee or a fair market value percentage of the PC's gross revenue (not net profit), or a combination thereof, for the legitimate management services provided. The compensation cannot be directly tied to the volume or value of patient referrals or specific clinical services in a way that constitutes illegal fee-splitting. The Management Services Agreement (MSA) between the MSO and the PC is the foundational document. It must clearly delineate the services provided by the MSO, the compensation structure, the term, and critically, explicitly state that the PC retains sole control over all clinical decision-making, patient care, and employment of clinical staff. The MSO cannot interfere with the physician-patient relationship or dictate medical protocols. Professional corporation requirements under RSA 294-A mandate that the corporate name include words like 'Professional Association' or 'P.A.' and that all shareholders, directors, and officers who render professional services be licensed in the state. For structuring ownership for compliance, non-physician investors can own the MSO, but not the PC. The PC must be owned by one or more licensed physicians. This separation ensures that the clinical entity remains under the control of licensed professionals, while the MSO handles the business aspects. This model is applicable across medspas, dental practices, IV therapy clinics, and telehealth entities. Careful legal counsel is essential to draft these agreements and ensure strict adherence to state and federal regulations, including anti-kickback statutes and Stark Law if applicable.

New Hampshire has continued to evolve its healthcare regulatory landscape, with several key developments and ongoing legislative efforts relevant to telehealth and healthcare operations. Recent legislative actions have largely focused on solidifying and expanding telehealth access. Following the COVID-19 Public Health Emergency, New Hampshire made permanent many of the telehealth flexibilities. HB 1625 (2022), for instance, codified and expanded upon existing telehealth statutes, ensuring continued coverage parity and broad modality acceptance. This bill reinforced the ability to establish a provider-patient relationship via telehealth without a prior in-person visit, a significant win for telehealth providers. There are ongoing discussions, though no specific bills have passed as of late 2024, regarding further refinements to telehealth interstate licensure, potentially exploring compacts beyond the Interstate Medical Licensure Compact (IMLC). New Hampshire is a member of the Interstate Medical Licensure Compact (IMLC), allowing eligible physicians to obtain expedited licensure in participating states. This is a crucial development for telehealth companies seeking to expand physician networks efficiently. The state is also part of the Nurse Licensure Compact (NLC), facilitating multi-state practice for registered nurses and APRNs. Board actions or enforcement cases by the New Hampshire Board of Medicine and Board of Pharmacy consistently reinforce the importance of proper prescribing practices, particularly for controlled substances. There's an emphasis on robust patient evaluations, thorough documentation, and strict adherence to PDMP requirements. While no landmark CPOM enforcement cases have been widely publicized recently, the boards maintain a vigilant stance on unauthorized practice and illegal fee-splitting, prompting continued caution in business structuring. Pending legislation for 2025-2026 may include further clarification on remote supervision for certain allied health professionals, and potential adjustments to the scope of practice for specific provider types, though these are typically incremental changes. Companies should monitor the legislative calendar for bills related to data privacy, cybersecurity in healthcare, and any new mandates for health equity in telehealth delivery. The overall trend indicates a supportive environment for telehealth, balanced with a strong commitment to patient safety and professional oversight.

Entering the New Hampshire healthcare market requires a methodical approach to ensure compliance from the outset. Here's actionable guidance: 1. Entity Formation & CPOM Compliance: Immediately engage legal counsel experienced in NH healthcare law to structure your business. If you are not a licensed professional, plan for an MSO-PC model. Establish your Professional Corporation (PC) under RSA 294-A with licensed professional ownership, and a separate Management Services Organization (MSO) for administrative functions. Draft a robust Management Services Agreement (MSA) that clearly defines roles, responsibilities, and fair market value compensation, ensuring no clinical control by the MSO and no illegal fee-splitting. 2. Licensure: All healthcare professionals providing services to NH patients must be licensed in New Hampshire. For physicians, leverage the Interstate Medical Licensure Compact (IMLC) if eligible. For nurses, the Nurse Licensure Compact (NLC) facilitates multi-state licensure. Begin the licensing process early, as it can take several months. 3. Telehealth Protocol Development: Develop comprehensive telehealth policies and procedures that align with RSA 318-E:1-10. This includes protocols for establishing the provider-patient relationship, informed consent, patient identity verification, emergency protocols, and data security (HIPAA compliance). Ensure your technology stack is secure and appropriate for the modalities used. 4. Prescribing Compliance: Implement strict protocols for prescribing, especially for controlled substances. Mandate PDMP checks as per RSA 318-B:35 for opioids and benzodiazepines. Train providers on federal DEA requirements for controlled substance prescribing via telehealth, anticipating the reinstatement of in-person requirements for initial prescriptions. 5. Scope of Practice Adherence: Clearly define the roles and responsibilities of all clinical staff (MDs, APRNs, PAs, MAs) based on their specific NH scope of practice. For PAs, ensure a board-approved practice agreement is in place. For MAs, strictly limit tasks to delegated, non-clinical support under direct supervision. Common pitfalls to avoid include: assuming out-of-state licensure is sufficient, failing to establish a compliant MSO-PC structure, inadequate informed consent for telehealth, and non-compliance with controlled substance prescribing rules. Timeline expectations: Expect 3-6 months for professional licensure, 1-2 months for entity formation and agreement drafting, and ongoing time for policy development and staff training. Proactive compliance is key to sustainable operations in New Hampshire.