reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 11 - FINANCIAL STANDARDS AND REPORTING › Section 11:24-11.6 - Financial reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every HMO shall submit, no later than March 1, an annual report for the immediately preceding calendar year, completed as prescribed by the NAIC Annual Statement Instructions for Health Maintenance Organizations, and completed on a SAP basis, in accordance with the NAIC Accounting Practices and Procedures Manual, effective January 1, 2001, incorporated herein by reference, as amended and supplemented (NAIC, 2301 McGee Street, Kansas City, MO 64108).
1. HMOs shall submit the annual report for calendar year 1996 (reported in March 1997) and thereafter using the current format established for any year by the National Association of Insurance Commissioners for HMOs, more commonly referred to as the "NAIC blank" for HMOs, the forms of which are available for purchase through several independent insurance service companies throughout the United States.
2. Every HMO shall submit with the annual report a certification of and an opinion by a member of the American Academy of Actuaries or an active fellow of the Society of Actuaries that the reserves required by 11:24-11.3 and included on the HMO's SAP annual report are sufficient.
i. The actuarial certification shall identify the specific methodology used to determine the reserves, and shall specify whether and how the methodology has changed since the last report.
ii. The workpapers prepared by the actuary in support of the certification shall be made available to the Department of Banking and Insurance upon request.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 11 - FINANCIAL STANDARDS AND REPORTING › Section 11:24-11.7 - Reporting of compensation arrangements with health care providers involving incentive or disincentive programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In conjunction with the submission of the New Jersey--Specific Annual Supplement made in accordance with 11:24-11.6(c), every HMO shall submit aggregate reports on compensation arrangements between the HMO and providers under contract with the HMO (directly or through a secondary contractor) using the edition of HEDIS Table XIX (Primary Care Physician Payment Arrangement), Table XX (Specialist Payment Arrangement), and Table XXI (Mental Health Provider Payment Arrangement) for Medicaid in effect at the time of submission. Such tables are available from the National Commission on Quality Assurance, 1350 New York Avenue, Suite 700, Washington, DC 20005.
1. An HMO operating multiple lines of business (Medicaid, Medicare, and commercial, including any administrative service only business unless the health care providers have contracted with the self-funded arrangement) shall submit information separately for Medicaid, Medicare and commercial business if the HMO has different compensation arrangements for these lines of business.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 11 - FINANCIAL STANDARDS AND REPORTING › Section 11:24-11.8 - Rating

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior to issuing or amending any contracts for coverage, an HMO shall submit a certification, including an actuarial opinion certified by a member of the American Academy of Actuaries or an active fellow of the Society of Actuaries, for filing with the Commissioner demonstrating that the rates to be used by the HMO are not excessive, inadequate or unfairly discriminatory (except as (a)1 below applies), specifying the rating methodology the HMO shall use.
1. Except as (a)2 below may apply, the Commissioner shall find that a filing that uses one of the three following rating methodologies produces rates that are not unfairly discriminatory without further actuarial certification or demonstration:
i. Community rating that does not consider the age, gender, geography, occupation or health status of any specific member covered under a contract form when determining premiums of that specific member;
ii. Community rating by class that does not take into consideration the health status of any specific member covered under a contract form when determining premiums for that specific member; or
iii. Prospective experience rating by group that does not take into consideration the health status of a covered member of a specific (employment-based) group when determining premiums for that specific member, but which does segregate the group's health history and claims experience from other groups covered under the same contract form for purposes of establishing premiums for the group on a prospective basis.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 12 - REHABILITATION, CONSERVATION AND LIQUIDATION › Section 11:24-12.1 - Rehabilitation, conservation and liquidation generally

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An HMO shall cease new enrollment, except for addition of family members of current members, upon receipt of notice of the filing of a petition by the Commissioner for an order authorizing rehabilitation of the HMO pursuant to 17B:32-31 et seq., Life and Health Insurers Rehabilitation and Liquidation Act, if enrollment has not ceased prior to that date, until such time as the petition may be denied.
(b) Participating health care providers, whether or not subject to a total or partial hold harmless provision of their participation contract with the HMO, and nonparticipating health care providers incurring expenses for rendering services to the HMO's members that are covered within the terms of the HMO's contract with the member shall have class 3 claims against the HMO as specified in N.J.S.A 17B:32-71 (which follow the class 3 claims of members or subscribers and their beneficiaries), and shall not bill or otherwise pursue any legal action against a member of an HMO against whom an order or rehabilitation of liquidation has been issued.
(c) Neither the reformation of member or provider contracts, restructuring of liabilities, or transfer of all or a portion of the HMO's business to another HMO that may occur in the course of the rehabilitation or liquidation of an HMO shall alter the applicability of (a) or (b) above unless the Commissioner or a court of competent jurisdiction specifically orders that (a) or (b) or both be altered so as to facilitate the reformation, restructuring or transfer of business.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 12 - REHABILITATION, CONSERVATION AND LIQUIDATION › Section 11:24-12.2 - Alternate methodology for assuring continuation of services to HMO members

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may order carriers and other HMOs to offer the members of an insolvent HMO an opportunity to become insured or to enroll with the carriers and other HMOs, during no less than a 30-day open enrollment period to be determined by the Commissioner, except as (b) below may apply.
1. If more than a single choice was offered to the members of a group during the group's last regular enrollment period, the Commissioner's order shall be limited to those carriers and HMOs that participated in the enrollment process with the insolvent HMO during the group's last regular enrollment period, except that if the Commissioner determines that the other HMOs and/or managed care plans of the carriers that participated with the insolvent HMO lack sufficient capacity to assure that health care services shall be available and accessible to the group's members, then the Commissioner may order all HMOs operating within the same service areas as the insolvent HMO to enroll an equitable portion of the insolvent HMO's members, as determined by the Commissioner.
i. Carriers and HMOs that participated with the insolvent HMO at the group's last regular enrollment period shall offer the members of the insolvent HMO the same coverage at the same rates that the carriers and HMOs offered to the group's members at the group's last regular enrollment period, which shall be effective until the group's regular renewal period.
ii. HMOs that did not participate with the insolvent HMO at the group's last regular enrollment period shall offer the members of the insolvent HMO coverage that is most similar to the coverage the members have with the insolvent HMO, as determined by the Commissioner, at the successor HMO's then-current rates for the coverage offered.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 13 - LICENSING OF REPRESENTATIVES AND ADVERTISING › Section 11:24-13.1 - General applicability of producer licensing requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as (e) below or 11:24-13.2 may apply, no HMO shall employ, directly or indirectly, any person to solicit, negotiate or bind contracts for the delivery to subscribers or members of health care services through an HMO, or to communicate with subscribers or members concerning the terms and conditions of such a contract, or to establish or administer office management practices affecting subscribers or members, or to process claims, or to transmit funds between subscribers or members, producers, premium finance companies, insurance companies or the HMO unless such person is licensed as an insurance producer in New Jersey in accordance with N.J.A.C. 11:17, Producer Licensing, and the HMO has complied with the specific requirements of 11:17-2.9.
1. An HMO shall contract only with an insurance producer who has completed the educational requirements prescribed at N.J.A.C. 11:17-3 and is licensed as an insurance producer with a health authority.
2. Those persons whose duties are clerical in nature shall not be required to be a licensed producer. Clerical duties are those administrative tasks accomplished in the office and under the supervision of the HMO or a licensed producer that are necessary to produce the contract for health services in accordance with the HMO's or producer's normal procedures and systems, including but not limited to, those functions incorporated under the definition of clerical duties at 11:17A-1.2.
3. Those persons who are in the employ of the HMO whose income from his or her employ with the HMO is not dependent, in whole or in part, upon commission shall not be required to be licensed as a producer unless such person's duties with the HMO include soliciting, negotiating or binding contracts with subscribers or members.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 13 - LICENSING OF REPRESENTATIVES AND ADVERTISING › Section 11:24-13.2 - Medicaid marketing representatives

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Notwithstanding 11:24-13.1, an HMO under contract with the Division of Medical Assistance and Health Services of the New Jersey Department of Human Services to enroll Medicaid recipients shall register its marketing representatives employed solely for the purpose of enrolling Medicaid recipients in accordance with 11:17-2.1 1 as Medicaid marketing representatives, unless such person is an insurance producer and is appointed by the HMO as its agent pursuant to 11:24-13.1.
(b) An HMO shall register each Medicaid marketing representative with the Department in accordance with 11:17-2.1 1 prior to the representative commencing any marketing activities. Any HMO already enrolling Medicaid recipients using persons who are not licensed insurance producers as required pursuant to 11:24-13.1 on July 1, 1997 shall register such persons as Medicaid marketing representatives (if the HMO does not otherwise intend to comply with 11:24-13.1 with respect to its Medicaid business) by September 29, 1997 and shall otherwise comply with this chapter. Registrations shall be sent to the following:
Attn: License Processing
New Jersey Department of Banking and Insurance
20 West State Street
PO Box 327
Trenton, NJ 08625-0327
(c) Every HMO that uses or intends to use Medicaid marketing representatives shall submit to the Departments of Human Services and Banking and Insurance, at the addresses specified at 11:24-11.6(i) and (j), a pre-registration training program for Medicaid marketing representatives.
1. The materials submitted shall include the form the HMO shall issue to Medicaid marketing representatives evidencing satisfactory completion by the Medicaid marketing representative of the HMO's pre-registration training program.
2. An HMO enrolling Medicaid recipients with persons not registered as either insurance producers or as Medicaid marketing representatives on the effective date of this subchapter shall submit a pre-registration training program no later than September 29, 1997.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 13 - LICENSING OF REPRESENTATIVES AND ADVERTISING › Section 11:24-13.3 - Advertising and marketing

Current through Register Vol. 56, No. 14, July 15, 2024
Except to the extent that HMOs shall be specifically exempted by reference by a provision of an applicable statute or rule, HMOs, producers and Medicaid marketing representatives shall comply with statutes and rules regulating the marketing, advertising, solicitation and sale of health insurance, and enforcement thereof by the Commissioner, including, but not limited to, N.J.A.C. 11:2-11 and 11:4-17.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 13 - LICENSING OF REPRESENTATIVES AND ADVERTISING › Section 11:24-13.4 - Disclosure of provider compensation arrangements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HMOs shall make the following disclosure statements, as applicable, in all applications for enrollment and member handbooks:
1. Every HMO shall make the following disclosure:
"[Different] providers in our network have agreed to be paid [in different ways by us. Your provider may be paid] [each time s/he treats you ("fee for service")][, or may be paid] [a set fee each month for each member whether or not the member actually receives services ("capitation")][, or may receive] [a salary]."
2. The HMO shall add the following statement if the HMO contracts directly or indirectly with providers to participate in financial incentive arrangements (for example, this includes financial incentive arrangements between an intermediate entity and a physician or physician group):
"These payment methods may include financial incentive agreements to pay some providers more ("bonuses") or less ("withholds") based on many factors: member satisfaction, quality of care, and control of costs and use of services among them."
3. Each HMO shall make the following statement:
"If you desire additional information about how our primary care physicians or any other provider in our network are compensated, please call us (or carrier name) at (telephone number) or write (address)."
4. Every HMO shall make the following statement:
"The laws of the State of New Jersey, at 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make referrals to other health care providers in which s/he has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care provider or facility when making a referral to that health care provider or facility. If you want more information about this, contact your physician, chiropractor or podiatrist. If you believe that you are not receiving the information to which you are entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (973) 504-6200 OR (800) 242-5846."
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 13 - LICENSING OF REPRESENTATIVES AND ADVERTISING › Section 11:24-13.5 - Trade and claims practices and coordination of benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HMOs shall be subject to all of the provisions of the Trade Practice Act, 17B:30-1 et seq., any amendments thereto, and all rules promulgated thereunder, except to the extent that HMOs have been specifically excluded by reference from a provision of the applicable statutes or rules.
(b) HMOs that elect to coordinate their benefits with those of other benefits or coverages available to members may do so subject to compliance with N.J.A.C. 11:4-28, Coordination of Benefits. HMOs that do not comply with N.J.A.C. 11:4-28 shall provide primary coverage to all members.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 13 - LICENSING OF REPRESENTATIVES AND ADVERTISING › Section 11:24-13.6 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Every producer or Medicaid marketing representative found to be in violation of this subchapter shall be subject to penalties and fines (per contract) in accordance with N.J.A.C. 11:17D, including suspension or revocation, in whole or in part, of his or her producer license or registration privilege pursuant to N.J.S.A. 17:22A-17.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION › Section 11:24-14.1 - Purpose, scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to set forth the standards by which HMOs shall offer and deliver a contract for a point of service product in New Jersey.
(b) This subchapter applies to all HMOs authorized to transact business in this State for the purposes of providing health care services in accordance with 26:2J-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION › Section 11:24-14.2 - Requirement to offer a point of services contract

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An HMO shall offer a point of service product in this State that allows a member to receive covered services from an out-of-network health care professional without obtaining a referral or prior authorization from the HMO, except if:
1. Its only members are Medicaid recipients;
2. It is a Federally-qualified, nonprofit HMO; or
3. The HMO is affiliated with an insurance company or health service corporation that offers a contract or policy for delivery in this State in conjunction with a selective contracting arrangement approved in accordance with N.J.A.C. 11:4-37, Selective Contracting Arrangements, and that policy or contract allows a covered person to receive services covered under the policy or contract or receive payment of benefits therefor from providers not in the insurance company's or health service corporation's network of participating providers without obtaining a referral or prior authorization from the insurance company or health service corporation.
i. In addition to (a)3 above, the insurance company or health service corporation shall provide subscribers under a group health plan in which the contractholder offers one of the insurance company's or health service corporation's contracts or policies provided in conjunction with a selective contracting arrangement an opportunity to elect coverage under the contract(s) or policy(ies) provided in conjunction with a selective contracting arrangement on at least an annual basis following a written notice to the subscribers setting forth the details of the contract(s) and policy(ies) provided in conjunction with the selective contracting arrangement.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION › Section 11:24-14.3 - General standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as set forth in (b) below, an HMO shall not enter into any arrangement for the provision of out-of-network covered services to any subscriber or member that is not in compliance with this subchapter.
(b) An HMO providing out-of-network covered services under an arrangement approved by the Department on or before April 15, 1996 shall bring the arrangement and any contracts issued under that arrangement into compliance with this subchapter beginning on the first 12 month anniversary date of each of the subscriber contracts occurring on or after October 12, 1996.
(c) An HMO shall not offer or provide any POS contract to groups of 50 or more until the form of that contract, along with applicable evidence of coverage forms, has been filed and approved or deemed approved, by the Department; an HMO shall not offer or provide a POS contract by rider, amendment or endorsement of any HMO contract.
1. If not disapproved within 60 days of the date of receipt by the Department, the form shall be deemed filed, if not affirmatively approved prior thereto.
2. Disapproval of the form shall be in writing, and shall specify the reasons for the disapproval.
3. An HMO whose form has been disapproved shall have 60 days following the date of the initial disapproval within which to correct any deficiencies set forth in the notice of disapproval, and shall have 30 days following the date of notice of any subsequent disapproval within which to correct deficiencies. A resubmission of a form shall be deemed approved upon the expiration of 30 days following resubmission of the filing to the Department unless the Department approves or disapproves the resubmission within the 30 day period.
4. If an HMO does not respond to a notice of disapproval within the required time frame, the matter shall be considered closed by the Department; if the HMO desires further consideration of its form, it shall submit the form anew to the Department.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION › Section 11:24-14.4 - Out-of-network benefit restriction under an HMO POS contract with a reinsurance-type or group master policy arrangement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An HMO may offer a POS contract with or without a gatekeeper system for out-of-network covered services, except that any POS contract offered without a gatekeeper system for out-of-network covered services shall meet the following:
1. The deductible for the out-of-network covered services shall be no less than $ 250.00 per person per benefit period, or $ 500.00 per family per benefit period, and the coinsurance requirement shall be no less than 20 percent for the next $ 5,000 of covered charges for covered services per individual per benefit period, and no less than 20 percent for the next $ 10,000 of covered charges for covered services per family per benefit period; or
2. The deductible and coinsurance requirements are otherwise designed so that, in combination, there is a substantial disincentive to accessing out-of-network covered services, as determined satisfactory to the Commissioner, consistent with (a)1 above.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION › Section 11:24-14.5 - POS under a reinsurance-type contract arrangement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The reinsurance-type contract shall cover the entire cost of the out-of-network covered services, and shall not provide for any deductible, coinsurance, copayment, or other type of mechanism by which any portion of the out-of-network covered services become self-funded by the HMO.
1. The HMO may elect not to include benefits for emergency and out-of-area care under the reinsurance-type contract.
2. If the HMO elects to include benefits for emergency and out-of-area care under the reinsurance-type contract, the HMO and the carrier or insurer may specify a deductible or other mechanism by which the HMO shall self-fund some portion of the emergency and/or out-of-area care benefits only.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION › Section 11:24-14.6 - POS under a group health contract master policy arrangement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The master policy form, certificate form , and any other form that becomes a part of the group health contract, as applicable, shall be submitted by the carrier electronically, pursuant to N.J.A.C. 11:4-40.4.
(b) The master policy form shall comply with all applicable insurance laws in this State.
(c) The master policy form and certificate form shall clearly indicate that the contract shall be used in conjunction with an HMO service contract, wherein the group policyholder is an HMO and the insureds are a class of HMO subscribers and members.
(d) The master policy shall provide indemnity benefits for all of the out-of-network covered services, except that the HMO and carrier may elect not to insure the HMO's emergency and out-of-area care through the master policy.
(e) The POS contract and evidence of coverage shall specify all of the covered services under the POS contract, clearly indicating when services covered vary between the network and out-of-network covered services (for instance, due to differences between mandates between HMOs and carriers).
(f) The certificate to be delivered to HMO members and the evidence of coverage to be delivered to HMO members may be contained in a single document, in which instance, the document shall be submitted by the HMO to the Health Bureau of the Department, and the carrier shall include a statement in its form submission to the Health Bureau of the Department that the certificate shall be combined with the evidence of coverage and shall be submitted by the HMO in accordance with this subchapter, which statement shall be certified to by a duly authorized officer of the carrier.
(g) The informational rate filing submitted by the HMO shall specify the premium and premium rating methodology for all services covered under the POS contract, including the cost to the HMO of purchasing the master policy to provide indemnity benefits for the out-of-network covered services.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION › Section 11:24-14.7 - POS under a dual contract arrangement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No HMO shall enter into a dual contracting arrangement until both the HMO contract forms and rates thereof and the indemnity policy forms and rates thereof, as applicable, have been submitted to the Department for filing, each with unique identifying numbers for the dual contract arrangement product; neither riders, amendments nor endorsements of an HMO contract or an indemnity policy shall be filed for use as a dual contracting arrangement.
(b) An indemnity policy designed to provide benefits for out-of-network covered services in conjunction with an HMO's network-based arrangement shall be subject to the following:
1. The policy form shall specify that it shall be issued and delivered in conjunction with an HMO contract, and shall contain reciprocal language incorporating the other contract;
2. The policy form shall not be designed, nor shall it be offered, as a stand-alone policy;
3. The policy form shall require execution of the indemnity policy by the contractholder; and
4. The policy form, application, certificate and other documents that make up the contract, as well as the rating formula, shall be filed by the Department as required by 17B:27-49, 17:48-1 et seq., 17:48A-1 et seq., or 17:48E-1 et seq. and N.J.A.C. 11:4-40, as appropriate for the carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 15 - PROVIDER AGREEMENTS AND RISK TRANSFERENCE › Section 11:24-15.1 - Assumption of financial risk or risk-sharing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No person shall assume financial risk, in whole or in part, for the cost or provision of, or arrangements for, one or more health services to others unless the person is:
1. An authorized payor as defined at 11:24-1.2;
2. A provider actually performing the health services (including providing supplies) within the scope of his or her license; or
3. An employer with respect to its own employees, and dependents of those employees.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 15 - PROVIDER AGREEMENTS AND RISK TRANSFERENCE › Section 11:24-15.2 - Minimum standards for provider agreements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Both primary contractor and secondary contractor agreements shall be consistent with laws regarding confidentiality of information and with professional licensing standards, including, but not limited to, 45:14B-31 et seq., and shall comply with the standards of (b) through (e) below.
(b) All provider contracts with the HMO shall specify:
1. The term of the contract and reasons for which the contract may be terminated by one or more parties to the contract, including the procedures for notice and effectuation of such termination, and opportunities, if any to cure any deficiencies prior to termination, subject to the following:
i. Provisions regarding notice of termination shall specify that if the contract is terminated prior to the contract's termination date, the HMO shall give the provider at least 90 days prior written notice; and, that in the event of such a termination, the provider has a right to request a hearing following such notice except when termination of health care professionals is based on: nonrenewal of the contract, a determination of fraud, breach of contract by the provider, or the opinion of the HMO's medical director that the provider represents an imminent danger to a patient or the public health, safety and welfare;
ii. Provisions regarding contents of the notice of termination to be provided shall specify that the notice shall contain a statement as to the right of the provider to obtain a reason for the termination in writing from the HMO if the reason is not otherwise stated in the notice; the right of the provider to request a hearing, and any exceptions to that right; and, the procedures for exercising either right;
iii. Provisions regarding the hearing shall specify the procedures for obtaining a hearing, and shall otherwise be consistent with the standards set forth at 11:24-3.6;
iv. Provisions regarding the hearing shall include a statement that a provider's participation in the hearing process shall not be deemed to be an abrogation of the provider's legal rights; and
v. Provisions regarding the right of the provider to request from the HMO the reasons for the termination shall specify the procedure for the provider to make the request, and that the HMO's reason in response to the request shall be in writing.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 15 - PROVIDER AGREEMENTS AND RISK TRANSFERENCE › Section 11:24-15.3 - Review and approval

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The form(s) of the provider agreement(s), and any amendments thereto, shall be submitted to the Department at the address specified at 11:24-11.6(i), for prior approval by the Department.
(b) Provider agreements in effect upon May 1, 2000 shall be deemed withdrawn on May 1, 2001 if not in compliance with this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 15 - PROVIDER AGREEMENTS AND RISK TRANSFERENCE › Section 11:24-15.4 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Every person acting as a secondary contractor in violation of this subchapter shall be subject to penalty and fine by the Department under the insurance laws of this state as an unauthorized insurer in accordance with 17:51-1 et seq., or 17B:33-1 et seq., as may be appropriate.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 17 - PLAN DOCUMENTS FOR GROUP CONTRACTS › Section 11:24-17.1 - Scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter shall apply to all HMO health benefits plans that are not standard health benefits plans promulgated by the Small Employer Health Benefits Program Board of Directors and which are not otherwise subject to the Small Employer Health Benefits Program Act, 17B:27A-17 et seq., and rules promulgated thereunder, with respect to terms and conditions of contracts and certificates (evidences of coverage) issued to small employers, as that term is defined by the Small Employer Health Benefits Program Act.
(b) This subchapter shall apply to all HMO health benefits plans that are not standard health benefits plans promulgated by the Individual Health Coverage Program Board of Directors or otherwise subject to the Individual Health Coverage Program Act, 17B:27A-2 et seq., and rules promulgated thereunder with respect to terms and conditions of the contract or policy forms issued on a nongroup basis under the Individual Health Coverage Program Act.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 17 - PLAN DOCUMENTS FOR GROUP CONTRACTS › Section 11:24-17.2 - General requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall provide a written contract to the contractholder and an evidence of coverage to each subscriber, which evidence of coverage may be incorporated into the member handbook required pursuant to 11:24-9.1.
1. The contract, evidence of coverage and member handbook shall conform to the Life and Health Insurance Policy Simplification Act, 17B:17-17 et seq. as demonstrated by the submission of a readability certification with a Flesch score for each form.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 17 - PLAN DOCUMENTS FOR GROUP CONTRACTS › Section 11:24-17.3 - Terms and conditions for plan documents

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every plan document shall contain the following:
1. Information about the HMO and how to contact and obtain information from the HMO, including, but not limited to, the HMO's legal name, its trade name, and phone, fax and e-mail numbers by which consumers and members may contact the HMO, including at least one number that is a toll-free number for members;
2. The eligibility requirements for the health benefits plan;
3. A specific description of benefits and services available within the service area under the health benefits plan, including emergency services, and out-of-area benefits and services;
4. A specific description of amounts that must be paid by members upon receipt of health care services, including copayments, deductibles, and coinsurance, as applicable, and with respect to POS contracts, an explanation of the member's obligation to pay charges for out-of-network services that exceed what the HMO determines are usual, customary and reasonable;
5. A description of the grounds for termination of a member and group;
6. A description of the claims procedures for members for out-of-network services;
7. A complete description of the HMO's method for resolving member complaints or grievances, and the process for appealing a utilization management decision, including all time frames applicable to the processes for making and resolving the complaint, grievance or appeal;
8. A description of continuation of coverage for those individuals who are in a health care facility at the time of termination of the group contract;
9. A description of how coverage under the health benefits plan may be continued pursuant to applicable Federal or State law (COBRA and/or 17B:27A-27 ) in the event of both member termination and group termination;
10. A description of the extension of benefits for those members who become totally disabled; and
11. A description of the service area.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 17 - PLAN DOCUMENTS FOR GROUP CONTRACTS › Section 11:24-17.4 - Specific standards for required provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) With respect to information about the HMO, the name, address and telephone number of the HMO shall be included, with a telephone number by which members may contact the HMO without incurring toll charges.
(b) With respect to eligibility requirements, the plan documents shall state what conditions must be met in order to enroll as a subscriber or a subscriber's dependent, the limiting age for subscribers and dependents, if any, including the effects of Medicare upon continued eligibility of the subscriber or dependent for some or all of the covered services under the health benefits plan, and a clear statement regarding the coverage of newborns.
1. The statement regarding newborns shall be consistent with 11:24-3.2.
2. There shall be a provision regarding special enrollment periods for employees and dependents, consistent with the requirements of the Health Insurance Portability and Accountability Act, Pub. L. 104-191, and the laws of this State regarding group health insurance, 17B:27-54 et seq.
3. All other provisions regarding eligibility shall be consistent with Federal and State laws, including eligibility of children also eligible for Medicaid, and dependency established as a matter of court order.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 17 - PLAN DOCUMENTS FOR GROUP CONTRACTS › Section 11:24-17.5 - Standards for optional provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If an HMO intends to coordinate benefits under the health benefits plan, the plan documents shall include a statement specifying that coordination may occur, and an explanation of how coordination will be achieved.
1. Coordination of benefits shall be accomplished in accordance with N.J.A.C. 11:4-28, and the explanation of coordination of benefits shall not be inconsistent with those rules.
2. If an HMO fails to include a provision regarding coordination of benefits consistent with N.J.A.C. 11:4-28, the health benefits plan shall be primary coverage for all members.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 17 - PLAN DOCUMENTS FOR GROUP CONTRACTS › Section 11:24-17.6 - Compliance

Current through Register Vol. 56, No. 14, July 15, 2024
Forms of plan documents in effect on May 1, 2000 shall be deemed withdrawn on May 1, 2001 if not in compliance with this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 18 - DRUG FORMULARIES › Section 11:24-18.1 - Development of formulary

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A formulary provided pursuant to a health benefits plan issued by an HMO shall be developed by a pharmacy and therapeutics committee composed of health care professionals with recognized knowledge and expertise in clinically appropriate prescribing, dispensing and monitoring of outpatient drugs or drug use review, evaluation and intervention. The membership of the committee shall consist of at least two-thirds licensed and actively practicing physicians and pharmacists, and shall consist of at least one pharmacist. If the HMO contracts with a third party to develop the formulary, the HMO shall be responsible for guaranteeing that the third party complies with all requirements relating to formularies as set forth in this subchapter.
(b) All drugs in a formulary shall be approved under the Federal Food, Drug and Cosmetic Act ( 21 U.S.C. §§
										301 et seq.).
(c) A formulary shall include more than one medication used to treat each covered disease state where more than one medication is available.
(d) A medication may be excluded from a formulary only if, based on the compendia listed in 11:24-18.2(c)1, it does not have a significant clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical outcome of treatment for the specific condition for which the medication is intended over other medications included in the formulary, and there is a written explanation of the basis for the exclusion that is available to providers and covered persons upon request.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 18 - DRUG FORMULARIES › Section 11:24-18.2 - Nonformulary medications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every health benefits plan issued by an HMO that provides benefits for formulary medications shall also provide benefits for nonformulary medications. Increased benefits may apply to formulary medications provided the difference between the total benefit value of formulary medication coverage and the total benefit value of nonformulary medication coverage does not exceed 30 percent. Compliance with this requirement shall be demonstrated by submitting to the Department a completed Actuarial Justification of Benefit Differentials form (incorporated herein by reference as the Appendix to this subchapter).
(b) The HMO shall establish an approval process to enable health care providers and covered persons to obtain coverage of nonformulary medications at the same level as formulary medications where the prescribing health care provider certifies the medical necessity of the medication.
(c) A nonformulary medication shall be considered medically necessary if:
1. It is approved under the Federal Food, Drug and Cosmetic Act ( 21 U.S.C. §§
											301 et seq.); or its use is supported by one or more citations included or approved for inclusion in the American Hospital Formulary Service Drug Information or the United States Pharmacopoeia--Drug Information, or it is recommended by a clinical study or review article in a major peer reviewed professional journal; and
2. The prescribing health care provider states that all formulary medications used to treat a disease state have been ineffective in the treatment of the covered person's disease or condition, or all such medications have caused or are reasonably expected to cause adverse or harmful reactions in the covered person.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 18 - DRUG FORMULARIES › Section 11:24-18.3 - Distribution of formulary

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall publish and distribute, at least quarterly, either its current formulary or a list of nonformularies, to all network providers in electronic or paper form. Such list shall clearly indicate whether the medications included are formulary or nonformulary. Alternatively, the HMO may annually distribute new formularies or a list of nonformularies, and quarterly updates, to all network providers. Publication of a current formulary or list of nonformularies on the internet shall satisfy the requirements of this subsection.
(b) The current formulary or list of nonformulary medications shall be provided by the HMO to covered persons and contractholders upon request.
(c) The contract and evidence of coverage form shall disclose the existence of the formulary, describe the approval process to obtain coverage of nonformulary medications as formulary medications and describe the process to appeal a denial of a request for approval of a nonformulary medication, including the right to appeal to the Independent Health Care Appeals Program in the Department pursuant to 26:2S-11. The contract and evidence of coverage form shall state that a copy of the formulary will be provided by the HMO to a covered person and contractholder upon request.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 18 - DRUG FORMULARIES › Section 11:24-18.4 - Operative date

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter shall become operative on July 1, 2001.
(b) All noncomplying HMO contract forms submitted for approval pursuant to N.J.A.C. 11:4-40 shall be deemed withdrawn effective July 1, 2001.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 18 - DRUG FORMULARIES › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
Actuarial Justification of Benefit Differentials
Formulary Drug Benefit
Use
Non
Percent
Formulary
Formulary
Number of Scripts per member per year
Brand
Generic
Composite
Ingredients cost including dispensing fees
Brand
Generic
Composite
Copays/Coinsurance/Deductible/OOP
Brand copay
Generic copay
Coinsurance
Deductible
Out-of-pocket limit
(excl. ded)
Calculation
(1) Starting claim cost PMPM
-
(2) Adjustment for
brand copay
-
(3) Adjustment for
generic copay
=
(4) Adjustment claim cost
(5) Value of deductible
x
(6) Impact of 3x family
deductible
=
(7) Adjusted value
of deductible
(4)-(7)
(8) Adjusted claim cost
x
(9) Coinsurance
=
(10) Adjusted claim cost
+
(11) Impact of
out-of-pocket limit
=
(12) Adjusted claim cost
(13) Formulary discount
(12) x (1-(13).
(14) Net claim cost
(14)/(1)
(15) Benefit ratio
(15 in)-(15 oon)
(16) Benefit differential
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24A-1.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this chapter is to set forth the minimum standards which carriers, as defined at 11:24A-1.2, must meet in order to be in compliance with the requirements of the Health Care Quality Act, P.L. 1997, c. 192, enacted August 8, 1997.
(b) A carrier shall comply with each of the subchapters of this chapter as appropriate to the types of health benefits plans delivered or issued for delivery by the carrier in this State.
(c) The provisions of this chapter shall apply to any services or functions of a carrier that the carrier may subcontract to another entity just as if the carrier were performing those services or functions itself, and no carrier shall be relieved of assuring full compliance with any applicable provision because one or more functions or services are subcontracted.
(d) A carrier that complies with this chapter shall not be relieved of its obligation to comply with all applicable Federal, State and local laws, rules and regulations.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 2 - PROVISIONS APPLICABLE TO ALL CARRIERS › Section 11:24A-2.1 - Scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter shall apply to all carriers that have delivered any inforce, or are offering for delivery, health benefits plans in this State.
(b) This subchapter shall apply to all health benefits plans of a carrier that have been or will be delivered or offered for delivery in this State.