reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-6.1 - Managed care plan to pay full contractual rate to out-of-network provider, direct payments, certain circumstances.

26:2S-6.1 Managed care plan to pay full contractual rate to out-of-network provider, direct payments, certain circumstances.
2. a. With respect to a carrier which offers a managed care plan that provides for both in-network and out-of-network benefits, in the event that:
(1) a covered person is admitted by an out-of-network health care provider to an in-network health care facility for covered, medically necessary health care services; or
(2) the covered person receives covered, medically necessary health care services from an out-of-network health care provider while the covered person is a patient at an in-network health care facility and was admitted to the health care facility by an in-network provider, the carrier shall reimburse the health care facility for the services provided by the facility at the carrier's full contracted rate without any penalty for the patient's selection of an out-of-network provider, in accordance with the in-network policies and in-network copayment, coinsurance or deductible requirements of the managed care plan.
b. The provisions of subsection a. of this section shall apply only if the covered person complies with the preauthorization or review requirements of the health benefits plan regarding the determination of medical necessity to access in-network inpatient benefits, as set forth in writing pursuant to section 5 of P.L.1997, c.192 (C.26:2S-5).
c. With respect to a carrier which offers a managed care plan that provides for both in-network and out-of-network benefits, in the event that the covered person assigns, through an assignment of benefits, his right to receive reimbursement for medically necessary health care services to an out-of-network health care provider, the carrier shall remit payment for the reimbursement directly to the health care provider in the form of a check payable to the health care provider, or in the alternative, to the health care provider and the covered person as joint payees, with a signature line for each of the payees. Payment shall be made in accordance with the provisions of this section and P.L.1999, c.154 (C.17B:30-23 et al.). Any payment made only to the covered person rather than the health care provider under these circumstances shall be considered unpaid, and unless remitted to the health care provider within the time frames established by P.L.1999, c.154 (C.17B:30-23 et al.), shall be considered overdue and subject to an interest charge as provided in that act.
L.2001, c.367, s.2; amended 2009, c.209.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-6.2 - Waiver of health insurance copayments for certain active duty military and their families.

26:2S-6.2 Waiver of health insurance copayments for certain active duty military and their families.
1. a. Notwithstanding any other law or contract provision to the contrary, if a covered person is a member of the military serving on active duty, or a family member of the covered person on active duty, who is also a covered person under the health benefits plan, a primary care physician or an advanced practice nurse may waive that covered person's copayment that would otherwise be collected as payment for treatment by the primary care physician or the advanced practice nurse for a covered service pursuant to a participating provider contract between the primary care physician or the advanced practice nurse and a carrier providing a health benefits plan.
b. For the purposes of this section, "carrier" shall include, in addition to an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, the State Health Benefits Commission and the School Employees' Health Benefits Commission.
L.2019, c.111, s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-7 - Review of application for participation

26:2S-7 Review of application for participation
7. Each application for participation by a licensed health care professional that is submitted to a carrier which offers a managed care plan shall be reviewed by a committee of the carrier that includes appropriate representation of health care professionals with knowledge in the applicant's scope of professional practice.
L.1997,c.192,s.7.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-7.1 - Universal application for credentialing physicians for a carrier's provider network.

26:2S-7.1 Universal application for credentialing physicians for a carrier's provider network.
1. The Commissioner of Banking and Insurance, in consultation with the New Jersey Association of Health Plans, the Health Insurance Association of America, the Medical Society of New Jersey, the New Jersey Hospital Association, and such other representatives of managed care plans as the commissioner deems appropriate, shall adopt by regulation, a universal physician application for participation form for use by carriers which offer managed care plans for the purpose of credentialing physicians who seek to participate in a carrier's provider network and for the purpose of credentialing physicians who are employed by hospitals or other health care facilities which seek to participate in a carrier's provider network.
The commissioner, in consultation with the New Jersey Association of Health Plans, the Health Insurance Association of America, the Medical Society of New Jersey, the New Jersey Hospital Association and such other representatives of managed care plans as the commissioner deems appropriate, shall also adopt by regulation a form for renewal of credentialing, which shall be an abbreviated version of the universal application form. The renewal form shall be designed to enable a physician to indicate changes in the information provided in the application form.
The commissioner shall revise the universal application and renewal forms, as necessary, to conform with industry-wide, national standards for credentialing.
In developing the forms, the commissioner shall consult with the Commissioner of Human Services to ensure that the credentialing requirements for participation in the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), and the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.) are adequately reflected on the application and renewal forms.
L.2001, c.88, s.1; amended 2012, c.17, s.295.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-7.2 - Acceptance of application by carriers

26:2S-7.2. Acceptance of application by carriers
2. Within 180 days of the adoption of the forms by regulation pursuant to this act, a carrier which offers a managed care plan shall accept the universal physician application for participation form and renewal form adopted pursuant to this act for the purpose of credentialing physicians who seek to participate in the carrier's provider network and for the purpose of credentialing physicians who are employed by hospitals or other health care facilities which seek to participate in the carrier's provider network.
Nothing in this section shall be construed to prevent a carrier from requesting additional information from an applicant that is not provided for in the universal application or renewal form, as applicable, if the requested information does not duplicate any information included in the applicable form.
L.2001,c.88,s.2.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-7.3 - Rules, regulations.

26:2S-7.3 Rules, regulations.
3. The Commissioner of Banking and Insurance shall adopt regulations within 180 days of the date of enactment of this act, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to carry out the purposes of this act.
L.2001, c.88, s.3; amended 2012, c.17, s.296.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-8 - Establishment of policy governing removal of health care providers

26:2S-8 Establishment of policy governing removal of health care providers
8. A carrier which offers a managed care plan shall establish a policy governing removal of health care providers from the provider network which includes the following:
a. The carrier shall inform a participating health care provider of the carrier's removal policy at the time the carrier contracts with the health care provider to participate in the provider network, and at each renewal thereof.
b. If a licensed health care professional's participation will be terminated prior to the date of the termination of the contract, the carrier shall provide the health care professional with 90 days' written notice of the termination and notice of a right to a hearing. If requested by the health care professional, the carrier shall provide the reasons for the termination in writing, and shall hold a hearing within 30 days of the date of the request. The hearing shall be conducted by a panel appointed by the carrier, which panel shall be comprised of a minimum of three persons, at least one of whom is a clinical peer in the same discipline and the same or similar specialty as the health care professional being reviewed. The panel shall make a decision that: (1) the health care professional shall be terminated, or (2) the health care professional shall be reinstated or provisionally reinstated, subject to conditions set forth by the panel. The panel's determination shall be in writing and shall be made in a timely manner. Participation in this process shall not be deemed to be an abrogation of the health care professional's legal rights.
The notice required and opportunity for a hearing pursuant to this subsection shall not apply in those cases when the contract expires and is not renewed, the termination is for breach of contract, in the opinion of the medical director, the health care professional represents an imminent danger to an individual patient or the public health, safety or welfare, or there is a determination of fraud.
c. If the carrier finds that a health care professional represents an imminent danger to an individual patient or to the public health, safety or welfare, the medical director shall promptly notify the appropriate professional State licensing board. Notification to the State Board of Medical Examiners shall be subject to the provisions of section 5 of P.L.1989, c.300 (C.45:9-19.5).
L.1997,c.192,s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-9 - Contract terms concerning appropriate medical care

26:2S-9 Contract terms concerning appropriate medical care
9. The contract between a participating health care provider and a carrier which offers a managed care plan:
a. Shall state that the health care provider shall not be penalized or the contract terminated by the carrier because the health care provider acts as an advocate for the patient in seeking appropriate, medically necessary health care services;
b. Shall not provide financial incentives to the health care provider for withholding covered health care services that are medically necessary as determined in accordance with section 6 of this act, except that nothing in this subsection shall be construed to limit the use of capitated payment arrangements between a carrier and a health care provider; and
c. Shall protect the ability of a health care provider to communicate openly with a patient about all appropriate diagnostic testing and treatment options.
L.1997,c.192,s.9.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-9.2 - Written fee schedule information furnished to health care providers, proprietary information.

26:2S-9.2 Written fee schedule information furnished to health care providers, proprietary information.
1. a. A carrier which offers a managed care plan that negotiates with a health care provider to become a participating provider, who is reimbursed per procedure under the plan, shall, upon request, furnish the health care provider with a written fee schedule, or in an electronic format if agreed upon by both parties, showing the fees for the 20 most common evaluation and management codes and the 20 most common office-based or hospital-based in-network services for the health care provider's specialty or sub-specialty, to be provided by the health care provider under the plan pursuant to the proposed or existing contract between the carrier and health care provider. If the carrier negotiates with the health care provider to become a participating provider under more than one managed care plan offered by the carrier, the carrier shall provide the applicable fee schedule for each plan. If the carrier negotiates a fee schedule with the health care provider that is specific to that health care provider, the carrier shall provide only the applicable fee schedule for that health care provider. If the rate that the health care provider will be paid is a percentage of another rate, it shall be sufficient for the carrier to provide that formula to the health care provider. The carrier shall furnish the fee schedule pursuant to this subsection within 15 days of the request of the provider.
The fee schedule provided to the health care provider by the carrier is proprietary and shall be confidential. Unauthorized distribution of the fee schedule may result in the health care provider's termination from the network in accordance with the provisions of N.J.A.C. 8:38-1.1 et seq.
b. The carrier shall reimburse the health care provider in accordance with the fee schedule provided to the health care provider pursuant to the contract. The carrier may revise the fee schedule upon providing the health care provider with written notice of the change and, upon request, a copy of the revised fee schedule.
c. Nothing in this section shall be construed to limit the ability of a carrier to make payments under a managed care plan based on its claims payment policies.
L.2005,c.286,s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-9.3 - Violations, penalty.

26:2S-9.3 Violations, penalty.
2. A carrier which violates any provision of this act shall be liable to a penalty of not more than $1,000 for each violation. Each failure to timely respond to a health care provider's request for a fee schedule shall be considered a separate violation. The penalty shall be collected by the Commissioner of Banking and Insurance in the name of the State in a summary proceeding in accordance with the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.).
L.2005,c.286,s.2.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10 - Offer of point-of-service plan, terms

26:2S-10 Offer of point-of-service plan, terms
10. a. A carrier which offers a managed care plan shall offer a point-of-service plan to every contract holder which would allow a covered person to receive covered services from out-of-network health care providers without having to obtain a referral or prior authorization from the carrier. The point-of-service plan may require that a subscriber pay a higher deductible or copayment and higher premium for the plan, pursuant to limits established by the department, in consultation with the Department of Banking and Insurance, by regulation.
b. A carrier shall provide each subscriber in a plan whose contract holder elects the point-of-service plan, with the opportunity, at the time of enrollment and during the annual open enrollment period, to enroll in the point-of-service plan option. The carrier shall provide written notice of the point-of-service plan to each subscriber in a plan whose contract holder elects the point-of-service plan and shall include in that notice a detailed explanation of the financial costs to be incurred by a subscriber who selects that plan.
c. The requirements of this section shall not apply to a carrier contract which offers a managed care plan that provides health care services to Medicaid recipients pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or a federally qualified, nonprofit health maintenance organization.
d. A carrier which offers a managed care plan utilizing a selective contracting arrangement approved in accordance with N.J.A.C.11:4-37.1 et seq. that provides benefits for out-of-network providers shall be deemed to be in compliance with this section.
e. A health maintenance organization affiliated with an insurance company authorized to issue health benefits plans in this State that offers point-of-service benefits exclusively through a point-of-service plan provided by the affiliated insurance company using a selective contracting arrangement approved in accordance with N.J.A.C.11:4-37.1 et seq., shall be deemed to be in compliance with this section if the point-of-service plan is offered pursuant to the requirements of subsections a. and b. of this section.
L.1997,c.192,s.10.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10.1 - Home treatment for bleeding episodes associated with hemophilia, required coverage.

26:2S-10.1 Home treatment for bleeding episodes associated with hemophilia, required coverage.
1. A carrier which offers a managed care plan that provides benefits or health care services, as applicable, for the home treatment of bleeding episodes associated with hemophilia, including the purchase of blood products and blood infusion equipment, shall comply with the provisions of this section.
a. For the purpose of providing home treatment services for bleeding episodes associated with hemophilia, the carrier shall be required to contract with, and exclusively use, providers that comply with standards adopted by regulation of the Department of Banking and Insurance in consultation with the Hemophilia Association of New Jersey. At a minimum, the standards shall require that each provider:
(1) provide services pursuant to a prescription from the covered person's attending physician and not make any substitutions of blood products without prior approval of the attending physician;
(2) provide all brands of clotting factor products in low, medium and high-assay range levels to execute treatment regimens as prescribed by a covered person's attending physician, and all needed ancillary supplies for the treatment or prevention of bleeding episodes, including, but not limited to, needles, syringes, and cold compression packs;
(3) have the ability to deliver prescribed blood products, medications, and nursing services within three hours after receipt of a prescription for an emergent situation, and maintain 24-hour on-call service to accommodate this requirement;
(4) demonstrate experience with and knowledge of bleeding disorders and the management thereof;
(5) demonstrate the ability for appropriate and necessary record keeping and documentation, including the ability to expedite product recall or notification systems and the ability to assist covered persons in obtaining third party reimbursement;
(6) provide for proper removal and disposal of hazardous waste pursuant to State and federal law;
(7) provide covered persons with a written copy of the agency's policy regarding discontinuation of services related to loss of health benefits plan coverage or inability to pay; and
(8) provide covered persons, upon request, with information about the expected costs for medications and services provided by the agency that are not otherwise covered by the covered person's health benefits plan.
b. The Department of Banking and Insurance shall compile a list of providers who meet the minimum standards established pursuant to this section and shall make the list available to carriers and covered persons, upon request.
c. As used in this section: "blood product" includes, but is not limited to, Factor VIII, Factor IX and cryoprecipitate; and "blood infusion equipment" includes, but is not limited to, syringes and needles.
L.2000, c.121, s.1; amended 2012, c.17, s.297.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10.2 - Clinical laboratory services at outpatient regional hemophilia care center, required coverage

26:2S-10.2. Clinical laboratory services at outpatient regional hemophilia care center, required coverage
2. A carrier which offers a managed care plan shall provide payment for services to the clinical laboratory at a hospital with a State-designated outpatient regional hemophilia care center regardless of whether the hospital's clinical laboratory is a participating provider in the managed care plan, if the covered person's attending physician determines that use of the hospital's clinical laboratory is necessary because:
a. the results of laboratory tests are medically necessary immediately or sooner than the normal return time for the carrier's participating clinical laboratory; or
b. accurate test results need to be determined by closely supervised procedures in venipuncture and laboratory techniques in controlled environments that cannot be achieved by the carrier's participating clinical laboratory.
The carrier shall pay the hospital's clinical laboratory for the laboratory services at the same rate it would pay a participating clinical laboratory for comparable services.
The carrier shall retain the right to review all services provided pursuant to this section for medical necessity.
L.2000,c.121,s.2.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10.3 - Regulations by department.

26:2S-10.3 Regulations by department.
11. The Department of Banking and Insurance, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt regulations to carry out the provisions of sections 1 and 2 of this act.
L.2000, c.121, s.11; amended 2012, c.17, s.298.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10.4 - Optometrist not required to participate in certain plans.

26:2S-10.4 Optometrist not required to participate in certain plans.
1. a. A carrier shall not require an optometrist to participate in a vision care plan as a condition for entering into a contract with that carrier for the provision of medically necessary physician services within the scope of practice of an optometrist.
b. Nothing in this section shall be construed to prevent a carrier from entering into a contract with a vision care plan.
L.2017, c.264, s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10.5 - Contract between carrier and vision care provider, fees permissible.

26:2S-10.5 Contract between carrier and vision care provider, fees permissible.
2. a. No contract between a carrier or a vision care plan and a vision care provider may seek to or require that a vision care provider provide services or materials at a fee limited or set by the carrier or vision care plan unless the services or materials are reimbursed as covered services or covered materials under the contract.
b. A vision care provider shall not charge more for services and materials that are noncovered services or noncovered materials to an enrollee of a vision care plan or carrier than the provider's usual and customary rate for those services and materials.
L.2017, c.264, s.2.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10.6 - Vision care provider, choice of sources, providers.

26:2S-10.6 Vision care provider, choice of sources, providers.
3. No contract between a carrier or vision care plan and a vision care provider shall restrict or limit, either directly or indirectly, the vision care provider's choice of sources and suppliers of services or materials or use of optical labs provided by the vision care provider to an enrollee.
L.2017, c.264, s.3.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10.7 - Definitions relative to optometrists, vision care plans.

26:2S-10.7 Definitions relative to optometrists, vision care plans.
4. As used in this act:
"Contractual discount" means a reduction from a vision care provider's usual and customary rate for covered services and materials required under a participating provider agreement.
"Covered materials" means materials for which reimbursement from the carrier or vision care plan is provided to a vision care provider by a covered person's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual limitations of deductibles, copayments, or coinsurance.
"Covered services" means services for which reimbursement from the carrier or vision care plan is provided to a vision care provider by an enrollee's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual limitations of deductibles, copayments, or coinsurance.
"Materials" means ophthalmic devices including but not limited to lenses, devices containing lenses, ophthalmic frames and other lens mounting apparatus, prisms, lens treatments and coatings contact lenses, and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa.
"Services" means the professional work performed by a vision care provider.
"Vision care plan" means an entity that creates, promotes, sells, provides, advertises or administers, an integrated or stand-alone vision benefit plan, or a vision care insurance policy or contract which provides vision or medically necessary benefits to an enrollee pertaining to the provision of covered services or covered materials.
"Vision care provider" means a licensed doctor of optometry practicing under the authority of R.S.45:12-1 et seq. or a licensed medical or osteopathic doctor practicing under the authority of R.S.45:9-1 et seq. that has also completed a residency in ophthalmology.
L.2017, c.264, s.4.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-10.9 - Regulations for benefits carrier relative to prescription drug benefits.

26:2S-10.9 Regulations for benefits carrier relative to prescription drug benefits.
3. a. A carrier that provides benefits for prescription drugs shall not require a covered person to make a payment at the point of sale for any amount for a deductible, coinsurance payment, or a copayment for a prescription drug benefit in an amount that exceeds the amount the covered person would pay for the prescription drug if the covered person purchased the prescription drug without using a health benefits plan.
b. A carrier shall not prohibit a network pharmacy from disclosing, and shall not apply a penalty or any other type of disincentive to a network pharmacy that discloses, to a covered person lower cost prescription drug options, including those that are available to the covered person if the covered person purchases the prescription drug without using health insurance coverage.
c. Any provision of a contract that conflicts with the provisions of subsection b. of this section shall be void and unenforceable.
d. A violation of this section shall be an unlawful practice and a violation of P.L.1960, c.39 (C.56:8-1 et seq.), and shall also be subject to any enforcement action that the Commissioner of Banking and Insurance is authorized to take pursuant to section 5 of P.L.2015, c.179 (C.17B:27F-5) .
L.2019, c.257, s.3.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-13 - Immunity from civil liability for participants in Independent Health Care Appeals Program

26:2S-13 Immunity from civil liability for participants in Independent Health Care Appeals Program
13. a. An employee of the department who participates in the Independent Health Care Appeals Program shall not be liable in any action for damages to any person for any action taken within the scope of his function in the Independent Health Care Appeals Program. The Attorney General shall defend the person in any civil suit and the State shall provide indemnification for any damages awarded.
b. The carrier that is the subject of a review shall not be liable in any action for damages to any person for any action taken to implement a recommendation of the independent utilization review organization pursuant to this act.
L.1997,c.192,s.13.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-14 - Report to Legislature, Governor

26:2S-14 Report to Legislature, Governor
14. The commissioner shall report every six months to the Senate and General Assembly standing reference committees on health and insurance and to the Governor on the status of the Independent Health Care Appeals Program. The report shall include a summary of the number of reviews conducted and medical specialties affected, a summary of the findings and recommendations made by the independent utilization review organization, any actions taken by the commissioner against a carrier pursuant to subsection d. of section 12 of this act and any other information and recommendations deemed appropriate by the commissioner.
L.1997,c.192,s.14.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-14.1 - General hospital to provide information concerning the Independent Health Care Appeals Program.

26:2S-14.1 General hospital to provide information concerning the Independent Health Care Appeals Program.
1. A general hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall be required, as prescribed by regulation of the Commissioner of Health, to:
(1) post, in a conspicuous place in each of its waiting rooms for members of the general public, a notice, as prescribed pursuant to section 3 of P.L.2011, c.190 (C.26:2S-14.2), which provides information about the operation of, and how to apply for, the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11); and
(2) ensure that appropriate hospital staff, including direct patient care providers, staff that are concerned with billing for hospital services or provide financial counseling to patients, and staff otherwise engaged in providing patient advocacy or patient relations services, are made aware of the program and are able to provide information to patients and their family members, or other persons on the patient's behalf, about how to contact the program.
L.2011, c.190, s.1; amended 2012, c.17, s.299.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-14.2 - Size, content, format of notice.

26:2S-14.2 Size, content, format of notice.
3. The Commissioner of Banking and Insurance, in consultation with the Commissioner of Health and the State Board of Medical Examiners, shall prescribe the size, content, and format of the notice about the Independent Health Care Appeals Program to be posted in general hospitals pursuant to section 1 of P.L.2011, c.190 (C.26:2S-14.1) and in physicians' medical offices pursuant to section 2 of P.L.2011, c.190 (C.45:9-22.26), and shall make the notice available to general hospitals and physicians, and to members of the general public, by posting it on the Internet website of the Department of Banking and Insurance.
L.2011, c.190, s.3; amended 2012, c.17, s.300.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-14.3 - Rules, regulations.

26:2S-14.3 Rules, regulations.
4. The Commissioner of Health and the State Board of Medical Examiners, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and in consultation with each other and the Commissioner of Banking and Insurance, shall adopt rules and regulations to effectuate the purposes of this act.
L.2011, c.190, s.4; amended 2012, c.17, s.301.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-15 - Compliance with department reporting requirements

26:2S-15 Compliance with department reporting requirements
15. a. A carrier which offers a managed care plan shall comply with department reporting requirements with respect to quality outcomes measures of health care services and independent consumer satisfaction surveys.
b. The department shall make available to members of the general public, upon request, the results of the independent consumer satisfaction survey and the analysis of quality outcomes measures of health care services provided by managed care plans in the State, prepared by the department.
L.1997,c.192,s.15.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-15.1 - Annual report to carrier by managed behavioral health care organization.

26:2S-15.1 Annual report to carrier by managed behavioral health care organization.
4. a. A carrier that owns, wholly or in part, or contracts with a managed behavioral health care organization shall require the managed behavioral health care organization to provide the carrier and the commissioner with an annual report, no later than March 15th of each year and covering the preceding calendar year, which includes the following information:
(1) the payments made by the managed behavioral health care organization to health care providers for the provision of behavioral health care services to covered persons during the preceding calendar year, which shall be separately identified in the report from the other information that is required to be included pursuant to this subsection;
(2) the total expenses incurred by the managed behavioral health care organization for quality assurance and utilization management activities and treatment plan reviews, whether administrative or clinical in nature, during the preceding calendar year, which shall be separately identified in the report;
(3) the total expenses incurred by the managed behavioral health care organization for other administrative functions, including, but not limited to, accounting and financial reporting, billing and collection, data processing, debt or debt service, legal services, promotion and marketing, or provider credentialing, during the preceding calendar year, which shall each be separately identified in the report; and
(4) the amount of any premiums or other fees received by the managed behavioral health care organization during the preceding calendar year.
b. A carrier shall make available to a subscriber or other covered person, upon request, a copy of the report that is required pursuant to subsection a. of this section. The carrier may charge a fee, in an amount to be established by the commissioner, for furnishing a copy of the report or form to a subscriber or other covered person, which shall reasonably reflect the cost of preparation and the actual cost of postage and handling.
L.2005,c.172,s.4.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-16 - Violations, penalties

26:2S-16 Violations, penalties
16. a. A carrier that violates any provision of this act shall be liable to a civil penalty of not less than $250 and not greater than $10,000 for each day that the carrier is in violation of the act if reasonable notice in writing is given of the intent to levy the penalty and, at the discretion of the commissioner, the carrier has 30 days, or such additional time as the commissioner shall determine to be reasonable, to remedy the condition which gave rise to the violation, and fails to do so within the time allowed. The penalty shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with "the penalty enforcement law," N.J.S.2A:58-1 et seq.
b. (1) The commissioner or the Commissioner of Banking and Insurance may issue an order directing a carrier or a representative of a carrier to cease and desist from engaging in any act or practice in violation of the provisions of this act.
(2) Within 20 days after service of the order of cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this act have occurred. The hearing shall be conducted pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and judicial review shall be available as provided therein.
c. In the case of any violation of the provisions of this act, if the commissioner elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued pursuant to subsection b. of this section, the commissioner may institute a proceeding to obtain injunctive relief in accordance with the applicable Court Rules.
L.1997,c.192,s.16.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-17 - Recommendations for legislative action

26:2S-17 Recommendations for legislative action
17. The commissioner and the Commissioner of Banking and Insurance shall develop recommendations for legislative action to address the issue of regulating health care or managed care entities that seek to contract directly with employers or other purchasers on a risk-assuming basis. The recommendations shall identify the type of health care or managed care entities and the scope of activities of these entities that should be subject to regulation by the State. In preparing the recommendations, the commissioners shall consider the current State statutory and regulatory requirements for health maintenance organizations and insurance companies issuing health benefits plans in the State, as well as federal legislation and laws and court rulings to determine how these health care and managed care entities that assume risk should be regulated.
The commissioners shall report their recommendations to the Senate and General Assembly standing reference committees on health and insurance and to the Governor within one year of the effective date of this act.
L.1997,c.192,s.17.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-18 - Enforcement; rules, regulations

26:2S-18 Enforcement; rules, regulations
19. The commissioner shall enforce the provisions of this act.
Within six months of the effective date of this act, in consultation with the Commissioner of Banking and Insurance, the commissioner shall adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to carry out the purposes of this act. The regulations shall establish consumer protection and quality standards governing carriers which offer a managed care plan or use a utilization management system that are consistent with the standards governing health maintenance organizations in the State.
The regulations shall include standards for: a quality management program; provider participation in a network; adequacy of the provider network with respect to the scope and type of health care benefits provided by the carrier, the geographic service area covered by the provider network and access to medical specialists, when appropriate; utilization management as required in this act; a covered person complaint system; a patient appeals system as required in this act; the establishment of consumer rights of covered persons; carrier disclosure as required in this act; and outcomes and data reporting requirements as required in this act.
L.1997,c.192,s.19.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-18.1 - Publication of annual financial statements.

26:2S-18.1 Publication of annual financial statements.
5. The Department of Banking and Insurance shall, for each carrier in the State, publish on the department's website the annual financial statement, in the format adopted by the National Association of Insurance Commissioners (NAIC) and in use at the time the statement is due, within 30 days of the receipt of that statement.
L.2017, c.100, s.5.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-19 - Findings, declarations relative to Managed Health Care Consumer Assistance Program

26:2S-19. Findings, declarations relative to Managed Health Care Consumer Assistance Program
1. The Legislature finds and declares that:
a. Managed health care, regardless of the form it takes, is now a major vehicle for the delivery of health care in this nation; and the rapid transition to managed health care has left consumers confused and concerned about how it affects them and how to navigate the managed health care system;
b. Despite the clear promises of reduced costs, quality service and comprehensive care made by managed care plans, many consumers are uncertain about how to obtain appropriate care and inhibited in their efforts to do so. They often lack necessary information about the benefits and referral requirements of specific plans and have no access to resources which might assist them to obtain quality care on a timely basis;
c. Consumers need help understanding their rights and responsibilities and how to access care and assert their rights in a complex managed care environment; and
d. It is, therefore, in the public interest to establish a program to provide consumers with the information and assistance they need to access the high-quality, cost-effective health care available from managed care plans and to promote the rights and interests of managed care consumers.
L.2001,c.14,s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-20 - Definitions relative to Managed Health Care Consumer Assistance Program.

26:2S-20 Definitions relative to Managed Health Care Consumer Assistance Program.
2. As used in this act:
"Carrier" means a carrier as defined in section 2 of P.L.1997, c.192 (C.26:2S-2).
"Commissioner" means the Commissioner of Banking and Insurance.
"Department" means the Department of Banking and Insurance.
"Managed care plan" means a managed care plan as defined in section 2 of P.L.1997, c.192 (C.26:2S-2).
"Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).
"Medicare" means the federal Medicare program established pursuant to the federal Social Security Act, Pub.L.89-97 (42 U.S.C. s.1395 et seq.).
"NJ FamilyCare" means the FamilyCare Health Coverage Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.).
"Program" means the Managed Health Care Consumer Assistance Program established pursuant to this act.
L.2001, c.14, s.2; amended 2012, c.17, s.302.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-22 - Report to Governor, Legislature

26:2S-22. Report to Governor, Legislature
4. The commissioner shall report to the Governor and the Legislature, no later than 18 months after the effective date of this act and annually thereafter, on the data collected by the program, the activities of the program and its effectiveness in meeting its objectives, including an evaluation of consumer problems, concerns and complaints, and shall accompany that report with any recommendations that the commissioner deems appropriate.
L.2001,c.14,s.4.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-23 - Immunity from liability

26:2S-23. Immunity from liability
5. An employee, volunteer, board member or other representative of an organization selected by the commissioner pursuant to section 3 of this act shall be immune from liability for any action taken in the good faith performance of their official duties in connection with the program.
L.2001,c.14,s.5.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-24 - Appropriations; fees, use

26:2S-24. Appropriations; fees, use
6. a. There is appropriated $500,000 to the department from the General Fund to provide funding for the program, except that funds may be appropriated, in lieu of part or all of the amount appropriated from the General Fund, from the monies made available to the State from tobacco companies under the nationwide settlement of the respective actions by state governments against those companies.
b. (1) The program may charge fees for the provision of materials to the public consistent with P.L.1963, c.73 (C.47:1A-1 et seq.). The commissioner may establish a separate fee schedule for training and education services that may be provided by the program to for-profit organizations, and for the distribution to nongovernmental entities of statistical information that may be developed by the program.
(2) Revenues received by the department pursuant to paragraph (1) of this subsection shall be deposited into a special nonlapsing fund which the commissioner shall create in the department for the purpose of providing funding for the program, and these revenues and the interest earned therefrom shall be utilized to fund the program in addition to the amount appropriated pursuant to subsection b. of this section.
L.2001,c.14,s.6.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-25 - Rules, regulations.

26:2S-25 Rules, regulations.
8. The Commissioner of Banking and Insurance, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations to effectuate the purposes of this act.
L.2001, c.14, s.8; amended 2012, c.17, s.304.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-26 - Definitions relative to certain dental benefit plans.

26:2S-26 Definitions relative to certain dental benefit plans.
1. As used in this act:
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, dental service corporation, dental plan organization, or health maintenance organization, authorized to issue dental plans in this State.
"Covered person" means a person on whose behalf a carrier offering a dental plan is obligated to pay benefits for or provide dental services pursuant to the plan.
"Covered service" means a dental care service for which a reimbursement is available under a covered person's dental plan, or for which a reimbursement would be available but for the application of contractual limitations including, but not limited to, deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation, or services not reimbursable due to the dentist's failure to comply with a provision of the dentist's participating provider agreement or the dental plan.
"Dental plan" means a benefits plan which pays or provides dental expense benefits for covered services and is delivered or issued for delivery in this State by or through a carrier either on a stand-alone basis or as part of other coverage including, but not limited to, health benefits coverage.
L.2014, c.70, s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-27 - Covered services.

26:2S-27 Covered services.
2. Notwithstanding section 22 of P.L.1993, c.162 (C.17B:27A-54) or any other law or regulation to the contrary, a contract between a carrier and a dentist to provide covered services shall not require, directly or indirectly, that a dentist provide services to a covered person at a fee set by, or at a fee subject to the approval of, the carrier unless the dental services are a covered service under the person's dental plan.
L.2014, c.70, s.2.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2S-28 - Rules, regulations.

26:2S-28 Rules, regulations.
3. The Commissioner of Banking and Insurance shall promulgate rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to effectuate the purposes of this act.
L.2014, c.70, s.3.