reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.9 - Provider application for participation and the review panel

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No later than August 29, 2000, an HMO shall establish a committee to review applications submitted by licensed providers to become members of the HMO network.
1. The HMO may combine the functions of this committee with another committee, so long as when performing its application review functions, the committee meets the requirements of this section, but the HMO shall not be required to combine the functions of this review committee with the functions of any committee whose function includes credentialing standards.
2. The committee shall be composed of no less than three people.
3. At least one of the committee members reviewing a specific application shall be health care providers with knowledge in the applicant provider's scope of professional practice.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 4 - MEDICAL DIRECTOR › Section 11:24-4.1 - Designation of a medical director

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall designate a physician to serve as medical director.
(b) The medical director or his or her designee shall be designated to serve as the medical director for medical services provided to the HMO's New Jersey members. This physician shall be licensed to practice medicine in New Jersey and may also serve as the overall medical director of the HMO as required in (a) above.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 4 - MEDICAL DIRECTOR › Section 11:24-4.2 - Medical director' responsibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The medical director shall be responsible for the direction, provision, and quality of medical services provided to members, including, but not limited to:
1. Defining responsibilities and inter-relationships of professional services;
2. Coordinating, supervising and overseeing the functioning of professional services;
3. Evaluating the medical aspects of provider contracts;
4. Overseeing the continuing in-service education of professional staff;
5. Providing clinical direction and leadership to the continuous quality improvement and utilization management programs;
6. Establishing policies and procedures covering all health care services provided to members;
7. Establishing a committee that has the following responsibilities:
i. Establishing mechanisms for ensuring review of provider credentials;
ii. Delineating qualifications of participating providers;
iii. Reviewing credentials of physicians and other providers who do not meet the HMO's established credentialing standards; and
iv. Establishing a system for verification of provider's credentials, recertification, performance reviews and obtaining information about any disciplinary action against the provider available from the New Jersey Board of Medical Examiners or any other state licensing board applicable to the provider, or the Federal Clearinghouse established pursuant to the Health Care Quality Improvement Act, P.L. 99-660 ( 42 U.S.C. §
												1101 et seq.);
8. Implementing a procedure that provides participating providers an opportunity to review and comment on all applicable medical, surgical and dental protocols of the HMO applicable to the area of practice of the provider; and
9. Implementing a system through which a member may readily change his or her PCP outside of an annual open enrollment period, and is made aware of this right, which system shall be applicable to all of the HMO's contracts including its POS contracts, regardless of whether referral through the PCP is required in order to access specialty care in-network or to receive benefits out-of-network.
i. An HMO shall make the selection of a new PCP effective no later than 14 days following the date of the selection when such change is discretionary, and shall make the selection of a new provider immediately effective when change of the PCP is necessitated by termination of the PCP from the network.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5 - HEALTH CARE SERVICES › Section 11:24-5.1 - Provision of health care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall, at a minimum, provide or arrange for the provision to its members all basic comprehensive health care services and all other services enumerated in this subchapter and in 26:2J-1 et seq., as it may be amended from time to time.
1. If the HMO refers a member out of network, the service or supply shall be covered as an in-network service or supply, such that the HMO is fully responsible for payment to the provider and the member is only responsible for any applicable in-network level copay, coinsurance or deductible for the service or supply.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5 - HEALTH CARE SERVICES › Section 11:24-5.3 - Emergency and urgent care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall establish written policies and procedures governing the provision of emergency and urgent care which shall be distributed to each subscriber at the time of initial enrollment.
(b) Emergency and urgent care services shall include, but are not limited to:
1. Medical and psychiatric care, which shall be available 24 hours a day, seven days a week;
2. Coverage for trauma services at any designated Level I or II trauma center as medically necessary. Such coverage shall continue at least until, in the judgment of the attending physician, the member is medically stable, no longer requires critical care, and can be safely transferred to another facility. If the HMO requests transfer to a hospital participating in the HMO network, the transfer shall be effected in accordance with Federal regulations at 42 C.F.R. 489.20 and 489.24;
3. Coverage for out-of-service area medical care when medically necessary for urgent or emergency conditions where the member cannot reasonably access in-network services;
4. Prehospital care and hospital services regardless of location when medically necessary for injury or emergency illness; and
5. Upon a member's arrival in a hospital, coverage of a medical screening examination, as required by the Federal Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §
											1395dd, and as specified in N.J.A.C. 8:43G-12.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5 - HEALTH CARE SERVICES › Section 11:24-5.4 - Supportive services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall provide or arrange for the provision of the following supportive services:
1. Ambulance or invalid coach services, as defined at N.J.A.C. 8:40 (therein as "mobility assistance vehicle services"), when authorized by the HMO for non-emergency medical transport;
2. Health education services and diabetes self-management education in accordance with 26:2J-4.1 1, and any rules promulgated pursuant thereto, including N.J.A.C. 11:4-49;
3. Nutritional education and counseling;
4. Medical social services; and
5. Preventive health services, including voluntary family planning services, and infertility services.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5 - HEALTH CARE SERVICES › Section 11:24-5.5 - Health promotion programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In accordance with 26:2J-4.6, and rules promulgated pursuant thereto, including N.J.A.C. 11:22-2, HMOs shall provide a health promotion program.
(b) An HMO shall not be required to provide health wellness promotion program services to members in values exceeding the dollar amounts established by the Commissioner as published as a public notice periodically in the New Jersey Register.
(c) The Commissioner, in consultation with the Department of the Treasury, shall adjust the threshold amounts in (b) above annually in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which it is reported, or such other date as may be set forth in the public notice published in the New Jersey Register.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5 - HEALTH CARE SERVICES › Section 11:24-5.6 - Wilm's tumor

Current through Register Vol. 56, No. 14, July 15, 2024
In accordance with 26:2J-4.1, the HMO shall provide health care services to any member for the treatment of Wilm's tumor, including, but not limited to, autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed experimental or investigational.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5 - HEALTH CARE SERVICES › Section 11:24-5.7 - Health care services for prescribed drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HMOs which provide pharmacy services, prescription drugs or a prescription drug plan shall comply with the requirements set forth at 26:2J-4.7, as well as the requirements set forth at N.J.A.C. 11:24-18, in the event that the HMO imposes a formulary upon the pharmacy services, prescription drug coverage or prescription drug plan.
(b) In accordance with 26:2J-4.5, an HMO which provides health care services for prescribed drugs approved by the Federal Food and Drug Administration (FDA) shall also provide health care services for prescribed drugs which have not been approved by the FDA if it is recognized to be medically appropriate for the specific treatment for which the drug has been prescribed in one of the following established reference compendia:
1. The American Medical Association drug Evaluations;
2. The American Hospital Formulary Service Drug Information;
3. The United States Pharmacopeia Drug Information; or
4. A clinical study or review article in a major-peer reviewed professional journal.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5A - COVERAGE FOR TERMINATION OF PREGNANCY › Section 11:24-5A.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to implement N.J.S.A. 26:2S-39, and having concluded a study and issued a report to the Governor and Legislature demonstrating that such a rule is necessary, provide that health benefit plans delivered, issued, executed, or renewed in this State provide coverage for medical and surgical abortion consistent with this subchapter.
(b) This subchapter shall apply to all policies and contracts providing hospital or medical services or benefits that are delivered, issued, executed, or renewed in this State in the individual, small group, and large group markets and all health maintenance organization contracts issued pursuant to N.J.S.A. 26:2J-1 et seq.
(c) This subchapter shall not apply to any policy or contract which, pursuant to a contract between a carrier and the New Jersey Department of Human Services, provides benefits to persons who are eligible for medical assistance pursuant to P.L. 1968, c. 413 (N.J.S.A. 30:4D-1 et seq.); the Children's Health Care Coverage Program pursuant to P.L. 1997, c. 272 (N.J.S.A. 30:4I-1 et seq.); the FamilyCare Health Coverage Program pursuant to P.L. 2000, c. 71 (N.J.S.A. 30:4J-1 et seq.); or any other program administered by the Division of Medical Assistance and Health Services in the New Jersey Department of Human Services.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5A - COVERAGE FOR TERMINATION OF PREGNANCY › Section 11:24-5A.2 - Required benefits

Current through Register Vol. 56, No. 14, July 15, 2024
Except in the case of a religious employer that is granted an exclusion, pursuant to N.J.A.C. 11:241.2, an HMO shall provide coverage, without limit or exclusion, for medical and surgical abortion in accordance with this subchapter. The HMO may apply cost sharing, including deductible, copayment, or coinsurance, as applicable, to such services provided such cost sharing is also applied to similar services or coverages under the contract.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 5A - COVERAGE FOR TERMINATION OF PREGNANCY › Section 11:24-5A.3 - Religious employer exclusion

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A religious employer may request, and the HMO shall grant, an exclusion for medical and surgical abortion coverage if coverage conflicts with the religious employer's bona fide religious beliefs and practices. An exclusion granted pursuant to this section shall not be construed to permit an HMO to exclude coverage for care that is necessary to preserve the life or health of the member, or that is the result of an act of rape or incest.
(b) An HMO that issues a policy or contract containing a religious employer exclusion shall provide written notice of such exclusion to each prospective member or covered person. Such notice shall appear in not less than 10-point type in the certificate or evidence of coverage, the member's application or enrollment form, and all sales and marketing materials.
(c) For each request that an HMO grants to a religious employer, pursuant to this section, the HMO shall make an informational filing with the Department of Banking and Insurance (Department), including a form of the written notice provided to prospective members pursuant to (b) above. Informational filings, including information that identifies the name of the employer, if such is not stated on the written notice, shall be made by the HMO and shall be submitted to the Department at the following address:
New Jersey Department of Banking and Insurance
Attention: Life and Health Division
Religious Employer Exclusion
20 West State Street
Trenton, NJ 08625-0325
lifehealth@dobi.nj.gov
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 6 - PROVIDER NETWORK › Section 11:24-6.1 - Health care service network

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each HMO shall maintain primary, specialty, ancillary, and institutional services sufficient to meet the requirements in N.J.A.C. 11:24-5.
(b) Nothing contained in this subchapter shall preclude the New Jersey Department of Human Services, Division of Medical Assistance and Health Services from requiring higher standards for services to Medicaid recipients pursuant to a contract for services between the Division of Medical Assistance and Health Services and the HMO.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 6 - PROVIDER NETWORK › Section 11:24-6.2 - Primary, specialty and ancillary providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall maintain an adequate network of primary care providers, specialists, and other ancillary health care personnel to serve the enrolled population at all times. For certificate of authority applications to initiate operations within a service area, this adequacy shall be evaluated based on enrollment projections at the end of 12 months of operation. At a minimum, the network of providers shall include:
1. Medical and other professional staff, as follows:
i. There shall be a sufficient number of licensed primary care providers (PCPs) under contract with the HMO to provide basic comprehensive health care services;
ii. There shall be a sufficient number of licensed medical specialists available to HMO members to provide medically necessary specialty care. The HMO shall have a policy assuring access to the specialists identified in (a)1ii(1) through (13) below within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved sub-county service area:
(1) Cardiologist;
(2) Dermatologist;
(3) Endocrinologist;
(4) ENT;
(5) General surgeon;
(6) Neurologist;
(7) Obstetrician/gynecologist;
(8) Oncologist;
(9) Ophthalmologist;
(10) Orthopedist;
(11) Oral surgeon;
(12) Psychiatrist; and
(13) Urologist;
iii. For specialists not identified in (a)1ii above, the HMO shall have a policy assuring access to such specialists within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved sub-county service area;
iv. There shall be a sufficient number of other health professional staff including but not limited to licensed nurses and other professionals available to HMO members to provide basic health care services;
v. There shall be sufficient licensed optometrists associated with or available to the HMO to assure that, unless referral to an ophthalmologist is determined by the PCP to be medically required and outside the scope of practice of an optometrist, the member can choose to have vision care services provided by a licensed optometrist. The HMO shall have a policy assuring access to these providers, as set forth above in 11:24-6.2(a)1  ii.
vi. If the HMO provides pharmacy services, prescription drugs, or a prescription drug plan, no registered pharmacy or pharmacist shall be denied the right to participate as a preferred provider pursuant to the terms of 26:2J-4.7.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 7 - CONTINUOUS QUALITY IMPROVEMENT › Section 11:24-7.1 - Continuous quality improvement program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall have a system-wide continuous quality improvement program to monitor the quality and appropriateness of care and services provided to members. This program shall be under the direction of the medical director or his or her designee, who shall be a physician, and shall be based on a written plan which is reviewed at least annually and revised as necessary. The plan shall describe at least:
1. The scope and purpose of the program;
2. The organizational structure of quality improvement activities;
3. Duties and responsibilities of the medical director and/or designated physician responsible for continuous quality improvement activities;
4. Contractual arrangements, where appropriate, for delegation of quality improvement activities;
5. Confidentiality policies and procedures;
6. Specification of standards of care, criteria and procedures for the assessment of the quality of services provided and the adequacy and appropriateness of health care resources utilized;
7. A system of ongoing evaluation activities, including individual case reviews as well as pattern analysis;
8. A system of focused evaluation activities, particularly for frequently performed and/or highly specialized procedures;
9. A system of monitoring member satisfaction and network providers' response and feedback on HMO operations;
10. The procedures for conducting peer review activities which shall include providers within the same discipline and area of clinical practice; and
11. A system for evaluation of the effectiveness of the continuous quality improvement program.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 7 - CONTINUOUS QUALITY IMPROVEMENT › Section 11:24-7.2 - External quality audit

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each HMO shall submit, as part of the comprehensive assessment review process, evidence of the most recent external quality audit that has been conducted within three years of the date of the comprehensive assessment review. Such audit shall be performed by an external quality review organization (EQRO) approved by the Department.
(b) The report shall describe in detail the HMO's conformance to performance standards established by the (EQRO), other national standard-setting bodies for HMOs, and/or the rules within this chapter. The report shall also describe in detail any corrective actions proposed and/or undertaken and approved by the (EQRO). The report shall be submitted to the Department within 60 days of its receipt in final form by the HMO.
(c) The HMO shall not be required to receive "accreditation" or "certification" or other such status granted by the (EQRO). If the HMO attains "accreditation" or "certification" or other such status granted by the (EQRO) within the 12 months prior to the Department's comprehensive assessment review, the HMO shall be exempted from examination by the Department in any area in which the Commissioner determines that the (EQRO's) review demonstrated specific compliance with standards substantially equivalent to those contained in this chapter.
(d) The Commissioner may grant an HMO a deferral of the above requirement for an external quality audit for a 12-month period if it is in the initial three years of start-up operations, and it demonstrates a financial or operational hardship.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 7 - CONTINUOUS QUALITY IMPROVEMENT › Section 11:24-7.3 - Performance and outcome measures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall develop a performance and outcome measurement system for monitoring the quality of care provided to HMO members. The data collected through this system may be used by the Department to:
1. Assist HMOs and their providers in quality improvement efforts;
2. Provide the Department with information on the performance of HMOs for regulatory oversight;
3. Support efforts to inform consumers about HMO performance;
4. Promote the standardization of data reporting by HMOs and providers; and
5. Any other purpose consistent with this chapter and 26:2J-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 7 - CONTINUOUS QUALITY IMPROVEMENT › Section 11:24-7.4 - Healthcare Data Committee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall establish a Healthcare Data Committee (HeDaC) to assist the Department in developing a performance measurement and assessment system for monitoring the quality of care provided to HMO members as described in 11:24-7.3.
1. The HeDaC shall be comprised and shall perform the functions as set forth at 11:24A-4.1 3(e).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 8 - UTILIZATION MANAGEMENT › Section 11:24-8.1 - Utilization management program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall establish and implement a comprehensive utilization management program to monitor access to and appropriate utilization of health care and services. The program shall be under the direction of the medical director or his or her designee, who shall be a physician, and shall be based on a written plan that is reviewed at least annually by the HMO, and is available for review by the Department upon request. The plan shall identify at least:
1. Scope of utilization management activities;
2. Procedures to evaluate clinical necessity, access, appropriateness, and efficiency of services;
3. Mechanisms to detect underutilization and overutilization;
4. Clinical review criteria and protocols used in decision-making;
5. Mechanisms to ensure consistent application of review criteria and uniform decisions;
6. Development of outcome and process measures for evaluating the utilization management program;
7. System for providers and members to appeal utilization management determinations in accordance with the procedures set forth at 11:24-8.4 through 8.7; and
8. A mechanism to evaluate member satisfaction with the complaint and appeals systems set forth at 11:24-3.6 and at 11:24-8.4 through 8.7. Such evaluation shall be coordinated with the performance monitoring activities conducted pursuant to the continuous quality improvement program set forth in N.J.A.C. 11:24-7.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 8 - UTILIZATION MANAGEMENT › Section 11:24-8.2 - Utilization management staff availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A registered professional nurse or physician shall be immediately available by phone seven days a week, 24 hours a day, to render utilization management determinations for providers.
(b) For routine utilization-related inquiries, the HMO shall provide all members and providers with a toll free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis.
(c) All members must have immediate phone access seven days a week, 24 hours a day, to their primary care provider or his or her authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 8 - UTILIZATION MANAGEMENT › Section 11:24-8.3 - Utilization management determinations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall have written policies and procedures that address responsibilities and qualifications of staff who render determinations to authorize admissions, services, procedures or extensions of stay.
(b) All determinations to deny or limit an admission, service, procedure or extension of stay shall be rendered by a physician. The determination shall be directly communicated by the physician to the provider or, if this is not possible, the provider shall be supplied with the physician's name, telephone number, and where he or she can be reached. The physician shall be available immediately in urgent or emergency cases and on a timely basis for all other cases as required by the medical exigencies of the situation. The physician shall be under the clinical direction of the medical director responsible for medical services provided to the HMO's New Jersey members. Such determinations shall be made in accordance with clinical and medical necessity criteria developed pursuant to 11:24-8.1(b)  and the evidence of coverage.
(c) All determinations shall be made on a timely basis, as required by the exigencies of the situation.
1. An HMO shall notify a provider and/or member of a determination concerning:
i. An urgent care claim and determination by the attending provider as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the urgent care claim by the HMO;
ii. A non-urgent pre-service (that is, prior authorization) no later than 15 days after receipt of the pre-service claim by the HMO; and
iii. A determination concerning a post-service claim no later than 30 days after receipt of the post-service claim by the HMO.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 8 - UTILIZATION MANAGEMENT › Section 11:24-8.4 - Appeals of adverse benefit determinations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HMO members, and any provider acting on behalf of a member with the member's consent, may appeal any adverse benefit determination resulting in a denial, termination or other limitation of covered health care services in accordance with the provisions of 11:24-8.5 and 8.6 within 180 days of receipt of the adverse benefit determination. All members and providers shall be provided with a written explanation of the appeal process in the member handbook and upon the conclusion of each stage in the process as described in 11:24-8.5 through 8.7.
1. For HMO members covered by group health benefits plans, the appeal process shall consist of an informal internal review by the HMO (stage 1 appeal), a formal internal review by the HMO (stage 2 appeal), and a formal external review (stage 3 appeal) by an independent utilization review organization (IURO) through the Independent Health Care Appeals Program established pursuant to 26:2S-11, as further described at N.J.A.C. 11:24A-5.
2. For HMO members covered by individual health benefits plans, the appeal process shall consist of an informal internal review by the HMO (stage 1 appeal) and a formal external review (stage 3 appeal) by an independent utilization review organization (IURO) through the Independent Health Care Appeals Program established pursuant to N.J.S.A. 26:2S-11, as further described at N.J.A.C. 11:24-8.7.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 8 - UTILIZATION MANAGEMENT › Section 11:24-8.5 - Informal internal utilization management appeal process (Stage 1)

Current through Register Vol. 56, No. 14, July 15, 2024
Each HMO shall establish and maintain an informal internal appeal process (stage 1 appeal) whereby any member, or any provider acting on behalf of a member, with the member's consent, who is dissatisfied with any HMO adverse benefit determination, except where the adverse benefit determination was based on a determination of member or group ineligibility, including rescission, or the application of a contract exclusion or limitation not relating to medical necessity, shall have the opportunity to speak to and appeal that determination with the HMO medical director and/or physician designee who rendered the determination. All such stage 1 appeals shall be concluded as soon as possible in accordance with the medical exigencies of the case, which in no event shall exceed 72 hours in the case of appeals from determinations regarding urgent or emergency care, an admission, availability of care, continued stay, health care services for which the claimant received emergency services but has not been discharged from a facility and 10 calendar days in the case of all other appeals. If the appeal is not resolved to the satisfaction of the member at this level, the HMO shall provide the member and/or the provider with a written explanation of his or her right to proceed to a stage 2 appeal, including the applicable time limits, if any, for making the appeal, and to whom the appeal should be addressed.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 8 - UTILIZATION MANAGEMENT › Section 11:24-8.7 - External appeals process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any HMO member, and any provider acting on behalf of a member, with the member's consent, may appeal a final internal adverse benefit determination, except where the adverse benefit determination was based on a determination of group or member ineligibility, including rescission, or the application of a contract exclusion or limitation not relating to medical necessity, to an independent utilization review organization (IURO) in accordance with the procedures set forth below.
(b) A member and/or provider shall have a minimum of a four-month period from receipt of the final internal adverse benefit determination to file a written request with the Department for an IURO appeal. The request shall be filed on the forms automatically provided to the member in accordance with 11:24-8.6(e), and shall include both the fee specified in (c) below and a general release executed by the member for all medical records pertinent to the appeal. The request shall be mailed to the following address:
Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
PO Box 329
Trenton, New Jersey 08625-0329
(888) 393-1062
(c) The fee for filing an appeal shall be as follows:
1. Members or health care providers acting on a member's behalf shall pay a $ 25.00 filing fee, payable by check or money order to the "New Jersey Department of Banking and Insurance." The filing fee shall be refunded to the member or health care provider if the final internal adverse benefit determination is reversed by the IURO;
2. Upon a determination of financial hardship, the fee shall be waived. Financial hardship may be demonstrated by the member through evidence that one or more members of the household is receiving assistance or benefits under the Pharmaceutical Assistance to the Aged and Disabled, Medicaid, NJ FamilyCare, General Assistance, SSI or New Jersey Unemployment Assistance; and
3. Annual filing fees for any one member shall not exceed $ 75.00.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 8 - UTILIZATION MANAGEMENT › Section 11:24-8.8 - General requirements for independent utilization review organizations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall, from time to time, enter into contracts with as many independent utilization review organizations as it deems necessary to conduct the external appeals provided for under 11:24-8.7. The physician reviewers of the IUROs selected by the Department shall be experienced in managed care utilization review. The contracts shall set forth all terms which the Department deems necessary to ensure a member's right of appeal under 11:24-8.7 including, but not limited to, an assessment of separate costs to the HMO for the initial IURO review under 11:24-8.7(e)  and the full review under 11:24-8.7(g).
(b) As a part of the contract process set forth in (a) above, all IUROs shall submit to the Department and shall maintain current, a list identifying all HMOs, health insurers, health care facilities and other health care providers with whom the IURO maintains any health related business arrangements. This list shall include a brief description of the nature of any such arrangement.
(c) Upon receipt of any request for an external appeal under 11:24-8.7(d)  above, the Department shall assign that appeal to one of the approved IUROs on a random basis. The Commissioner reserves the right to deny any assignment to any IURO if, in his or her determination, such an assignment would result in a conflict of interest or would otherwise create an appearance of impropriety. In reaching such a determination, the Commissioner shall take into consideration the list required of IUROs in (a) above.
(d) An IURO must have external review accreditation from a nationally recognized private accrediting organization, such as URAC.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 8 - UTILIZATION MANAGEMENT › Section 11:24-8.9 - Notice requirement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to 26:2S-14.1 and 45:9-22.2 6 and applicable rules of the Department of Health and the Board of Medical Examiners, respectively, all general hospitals licensed pursuant to 26:2H-12 et seq. and all physicians licensed pursuant to N.J.A.C. 13:35 are required to post in all patient waiting rooms within the hospital or in the physicians medical office a notice providing information about, and how to apply for, the Independent Health Care Appeals Program (IHCAP) established pursuant to 26:2S-11. In accordance with 26:2S-14.2, the size, content, and format of the notice shall be as set forth in (b) below.
(b) The notice shall be in the format and include the content as set forth in the notice entitled "An Explanation of an Individuals Right to Appeal Health Insurance Determinations," incorporated herein by reference as the subchapter Appendix, and also posted on the Departments website at
www.dobi.nj.gov/ihcapappeals/
. If posted using multiple pages, each page of the notice shall be at least 8 1/2 x 11 inches with print in 12-point type or larger. If displayed as a one-page poster, the poster shall be of sufficient size to depict all of the required text of the notice in print of at least 12-point type.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 9 - MEMBER RIGHTS AND RESPONSIBILITIES; DISCLOSURES TO CONSUMERS › Section 11:24-9.1 - Policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall establish and implement written policies and procedures regarding the rights of members and the implementation of these rights.
(b) The HMO shall provide each member with a current copy of a member's benefit handbook, including at least:
1. A complete statement of the member's rights;
2. A description of all complaint and grievance procedures, including the address and telephone numbers of the complaint offices of the HMO and of the Department; and
3. A clear and complete summary of the evidence of coverage, including limitations, exclusions, and procedures for accessing out of network services, as required by 26:2J-8(b), and the responsibility of the subscriber to pay copayments, deductibles and coinsurance, as appropriate, in terms relevant to the type of product(s) purchased.
i. HMOs shall clearly distinguish any differences in the member's financial responsibility for accessing services within and outside of the HMO's network.
ii. HMOs shall explain the member's responsibility to pay for charges incurred that are not covered under or authorized pursuant to the policy or contract.
iii. With respect to point of service contracts, HMOs shall explain the member's responsibility to pay for charges that exceed what the HMO determines are customary and reasonable (usual and customary, or usual, customary and reasonable, as appropriate) for services that are covered under the out-of-network component of the contract.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 10 - MEDICAL RECORDS › Section 11:24-10.1 - Policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall develop and implement a policy for the transfer of medical records of members whenever the following occur:
1. Change of physician or other provider;
2. Disenrollment of member from HMO; or
3. Other circumstances where requested by members or former members;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 10 - MEDICAL RECORDS › Section 11:24-10.2 - Confidentiality of medical records

Current through Register Vol. 56, No. 14, July 15, 2024
Any data or information pertaining to the diagnosis, treatment, or health of any member or applicant obtained from the member or from any provider by any HMO shall be held in confidence. The data or information shall not be disclosed to any person, except to the extent that it may be necessary to carry out the purposes of this chapter, or upon the express consent of the member or applicant; or pursuant to state or court order for the production of evidence or the discovery thereof; or in the event of claim or litigation between such member and the HMO wherein such data or information is pertinent as otherwise provided by law. An HMO shall be entitled to claim any statutory privileges against such disclosure which the provider who furnished such information to the health organization is entitled to claim. An HMO may also release aggregate data related to the diagnosis, treatment, or health of all or groups of members or applicants where the identity of every member is kept confidential and cannot be determined by the manner in which the data is released and presented.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 10 - MEDICAL RECORDS › Section 11:24-10.3 - Maintenance of medical records

Current through Register Vol. 56, No. 14, July 15, 2024
Any medical records directly maintained by the HMO shall be organized in a uniform format across all records subject to the requirements of applicable law. The HMO shall have policies governing the contents of medical records.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 10 - MEDICAL RECORDS › Section 11:24-10.4 - Copies of medical records

Current through Register Vol. 56, No. 14, July 15, 2024
Members or their legally authorized representatives shall have a right to inspect and obtain a copy of their medical records maintained by the HMO. Charges for copies of medical records shall be based upon actual costs, not to exceed prevailing community rates for photocopying.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 10 - MEDICAL RECORDS › Section 11:24-10.5 - Medical record retention

Current through Register Vol. 56, No. 14, July 15, 2024
Medical records maintained by HMO's shall be protected against loss, destruction, or unauthorized use and retained for at least 10 years or until the member reaches age 23 years, whichever is longer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 11 - FINANCIAL STANDARDS AND REPORTING › Section 11:24-11.1 - Minimum net worth

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to obtain a certificate of authority, an HMO shall have a minimum net worth, determined on a SAP basis, of at least $ 1,500,000 in cash or cash equivalents, as adjusted annually by the CPI, together with such other guarantees and assets as the Commissioner may determine appropriate to assure the solvency of the HMO, based on its business plan, beginning on July 1, 1997.
(b) Except as (d) below applies, in order to maintain its certificate of authority, an HMO shall maintain at all times a minimum net worth, determined on a SAP basis, equal to the greater of:
1. $ 1,000,000 adjusted annually by the CPI, beginning on July 1, 1997;
2. Two percent of the annual premium revenues as reported by the HMO on its most recent annual financial statement filed with the Commissioner for the first $ 150,000,000 of premium reported and one percent of the annual premium in excess of the first $ 150,000,000 of premium reported;
3. An amount equal to the sum of three months of uncovered health care expenditures, as reported on the financial statement filed most recently with the Commissioner; or
4. An amount equal to the sum of eight percent of the annual health care expenditures (not including those expenditures paid on a capitated basis to a provider and those made on a managed hospital payment basis), as reported on the four quarterly financial statements most recently filed with the Commissioner, plus four percent of the annual hospital expenditures paid on a managed hospital payment basis, as reported in the four quarterly financial statements most recently filed with the Commissioner. If an HMO is issued an initial certificate of authority on or after July 1, 1997, its minimum net worth shall be phased in over a 48 month period, running from the date that its new certificate of authority is effective, as follows:
i. Twenty-five percent of the amount required in (b)4 above, or the greater of (b)1, 2 or 3 above, whichever is greatest, until the end of the 23rd month following the month in which its new certificate of authority was effective;
ii. Fifty percent of the amount required in (b)4 above, or the greater of (b)1, 2 or 3 above, whichever is greatest from months 24 through 35;
iii. Seventy-five percent of the amount required in (b)4 above, or the greater of (b)1, 2 or 3 above, whichever is greatest, from months 36 through 47; and
iv. One hundred percent of the amount required in (b)4 above beginning in the 48th month following the month in which its new certificate of authority was effective.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 11 - FINANCIAL STANDARDS AND REPORTING › Section 11:24-11.2 - Investments

Current through Register Vol. 56, No. 14, July 15, 2024
Except as approved by the Commissioner in accordance with N.J.S.A. 26:2J-5a(1) and (3), all investments of HMOs shall be subject to and in compliance with 17B:20-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 11 - FINANCIAL STANDARDS AND REPORTING › Section 11:24-11.3 - Reserve liabilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An HMO shall maintain at all times reserve liabilities in an amount sufficient to provide for:
1. All claims incurred, whether reported or unreported, which are unpaid and for which the HMO is or may become liable, including the expense of adjustment or settlement of those claims;
2. Continued health care services to members for which a consideration has been received, or a consideration is due but unpaid; and
3. Continued health care services under the HMO contract to members who, on the date of termination of the HMO contract, are confined in an inpatient facility until discharge from the facility.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 11 - FINANCIAL STANDARDS AND REPORTING › Section 11:24-11.4 - Minimum deposits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to obtain a certificate of authority, every HMO shall deposit with the Commissioner no less than $ 300,000, adjusted annually by the CPI beginning on July 1, 1997 in accordance with N.J.A.C. 11:2-32, Custodial Deposits.
(b) In order to maintain a certificate of authority, every HMO shall annually adjust the deposit specified in (a) above to equal 20 percent of its minimum net worth, except that such deposit shall be no less than $ 300,000 and no more than $ 1,000,000 (as the minimum and maximum amounts are adjusted by the CPI).
(c) The deposit required by (a) above, adjusted in accordance with (b) above, shall be subject to the following:
1. The deposit shall be and remain an admitted asset of the HMO for purposes of determining net worth of the HMO.
2. The Commissioner shall use the deposit for administrative costs directly attributable to the rehabilitation, conservation or liquidation of the HMO.
3. All interest and other investment income derived from the deposit made shall be paid to the HMO annually upon written request.
4. An HMO may withdraw the deposit, or any part thereof, after making a substitute deposit of cash, securities, or other instruments permissible under N.J.A.C. 11:2-32, of equal amount and value.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 11 - FINANCIAL STANDARDS AND REPORTING › Section 11:24-11.5 - Plan for continuation of services upon declaration of insolvency

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to obtain and maintain a certificate of authority, an HMO shall submit a plan to the Commissioner, which assures continuation of services and benefits to members when the HMO is declared by a court of competent jurisdiction to be insolvent and placed in rehabilitation or liquidation.
1. Such plan shall assure the continuation of services and benefits to all members for the duration of the contract period for which premiums or other consideration has been paid and for any applicable grace period.
2. Such plan shall assure the continuation of services and benefits under the HMO contract to members who, on the date of the declaration of insolvency, are confined in an inpatient facility until their discharge from the facility, or their contractual benefits are otherwise exhausted, whichever occurs first.