reglab/statecodes huggingface dataset:
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-2.2 - HCQA Registration Form

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall complete and submit to the Department the HCQA Registration Form, available from the Department upon request, describing, if required, the carrier's internal appeal process, by which covered persons, or a provider on behalf of a covered person (with the covered person's consent), may appeal a carrier's UM decision, and the carrier's notice to covered persons of the right to appeal a carrier's final UM decision to the Independent Health Care Appeals Program. A carrier's Selective Contracting Arrangement (SCA) application filed with the Department pursuant to N.J.A.C. 11:4-37 shall meet the requirements of this section.
1. Carriers shall file the HCQA Registration Form at least 30 days prior to the date that the carrier will begin to offer any health benefits plan issued under a policy or contract form for which an HCQA Registration Form has not previously been filed.
2. Completion of the HCQA Registration Form with respect to the description of the carrier's internal appeals mechanism and its notice of a covered person's right to appeal through the Independent Health Care Appeals Program shall be consistent with the requirements of 11:24A-3.5.
3. Carriers shall file a copy of the HCQA Registration Form with the Department at the following address:
Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
PO Box 329
Trenton, NJ 08625-0329
(888) 393-1062
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-2.3 - Disclosure requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall provide to each subscriber within no more than 30 days following the effective date of coverage, and upon request thereafter, through a handbook, certificate, or other evidence of coverage designed for covered persons, information describing the following:
1. The services or benefits therefor to which a covered person is entitled under the policy or contract, including:
i. All exclusions and limitations with respect to at least physical and occupational therapy, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, radiological examinations and behavioral health services;
ii. All restrictions on accessing covered services, such as the requirement to obtain prior authorization, preadmission certification, or periodic review of ongoing treatment;
iii. A full and clear description of the carrier's policies and procedures governing the provision of emergency and urgent care services or the payment of benefits therefor, including a statement that emergency or urgent care services are not covered, if that is the case;
iv. All dollar, day, visit, or procedure limitations applicable to at least those services set forth at (a)1i above, and the method for exchanging inpatient for outpatient services or vice versa, when such exchanges are permitted under the policy or contract; and
v. The right to request to use an out-of-network provider at network level cost sharing where the network does not contain a qualified, accessible, and available provider to perform a service.
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-2.4 - Submission of disclosure statements to the Department

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall deem approved those disclosures required by this chapter that a carrier makes within a contract, policy or certificate form submitted to and filed by the Department, or otherwise deemed approved by the Department in accordance with the statutes and rules of this State.
(b) The Department shall deem approved those disclosures required by this chapter to be made by carriers for individual standard health benefits plans if the IHC Program Board of Directors (as authorized by 17B:27A-2 et seq.) has promulgated standard disclosure statements meeting the requirements of 11:24A-2.3 which are to be included within the standard health benefits plan forms or other standard materials that carriers are required to provide to all covered persons in accordance with the rules of the IHC Program at N.J.A.C. 11:20.
(c) The Department shall deem approved those disclosures required by this chapter to be made by carriers for small employer standard health benefits plans if the SEH Program Board of Directors (as authorized by 17B:27A-17 et seq.) has promulgated standard disclosure statements meeting the requirements of 11:24A-2.3 which are to be included within the standard health benefits plans and/or other standard material that carriers are required to provide to all covered persons under small employer health benefits plans in accordance with the rules of the SEH Program at N.J.A.C. 11:21.
(d) In the event the carrier uses a form for its disclosures that is not required to be submitted to the Department, or is not subject to the rules of the IHC or SEH Programs, the carrier shall submit the form to the Department, and shall include with the submission of each disclosure form a statement of the policy or contract form(s) to which the disclosure is applicable, listed by form number and market name, if any, and a certification that the disclosure meets the requirements of N.J.A.C. 11:24A-2.3.
1. A carrier may use the disclosure until such time as the Department disapproves the disclosure and provides notice of the disapproval to the carrier, with the reasons for the disapproval set forth in writing.
2. The Department may disapprove the form for failing to meet the requirements of this subchapter, or because it is deceptive, misleading, or contrary to the public policy of this State.
3. The Department may disapprove the form for failing to meet the readability requirements of 17B:17-17 et seq. (the Life and Health Insurance Policy Language Simplification Act).
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-2.5 - Other rights of covered persons

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier shall establish and implement written policies and procedures regarding the rights of covered persons and the implementation of these rights.
(b) Carriers' policies and procedures shall address at least the following:
1. The right of covered persons to receive all of the disclosures set forth at 11:24A-2.3;
2. The right of covered person to have access to services, and payment of appropriate benefits therefor, when medically necessary, including availability of care 24 hours a day, seven days a week for urgent or emergency conditions, if covered;
3. The right of covered persons to be treated with courtesy, consideration, and with respect to the covered person's dignity and need for privacy; and
4. The right of covered persons to obtain information regarding the carrier's policies and procedures concerning (b)1 through 3 above.
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-2.6 - Emergency and urgent care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If a carrier's policy or contract provides benefits for emergency or urgent care services, the carrier shall include benefits for the coverage of trauma services at any designated Level I or II trauma center as medically necessary, which shall be continued at least until, in the judgment of the attending physician, the covered person is medically stable, no longer requires critical care, and can be transferred safely to another facility.
(b) In addition to (a) above, the contract or policy shall pay for coverage of a medical screening examination provided upon a covered person's arrival in a hospital, as required to be performed by the hospital in accordance with Federal law and as specified at N.J.A.C. 8:43G-12, but only as necessary to determine whether an emergency medical condition exists.
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-2.7 - Violations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may issue an order directing a carrier to cease and desist from an act or omission that violates a provision of the rules of this chapter that are applicable to the carrier, which order shall serve as constructive written notice to the carrier of an intent to levy a penalty for the violation of the rules, notwithstanding that a specific statement to that effect is not included in the order, if the order is followed by a written notice in compliance with (b)3 below.
1. A carrier shall have the right to request a hearing on the order within 20 days following the date of service of the order on the carrier, which shall be conducted in accordance with the Administrative Procedures Act, 52:14B-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
i. When requesting a hearing, the carrier shall specify in writing all reasons for which it disputes the order to cease and desist, enclose a copy of the order and verification of the date on which the order was served.
ii. When requesting a hearing, the carrier shall notify the Department of the request, providing the information set forth in (a)1i above.
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 2A - COVERAGE FOR TERMINATION OF PREGNANCY › Section 11:24A-2A.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 regulation is necessary, provide that health benefit plans delivered, issued, executed, or renewed in this State provide coverage for termination of pregnancy, 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 as follows: all hospital service corporation contracts issued, pursuant to N.J.S.A. 17:48-1 et seq.; all medical service corporation contracts issued, pursuant to N.J.S.A. 17:48A-1 et seq.; all health service corporation contracts issued, pursuant to N.J.S.A. 17:48E-1 et seq.; and all health insurance policies issued, pursuant to N.J.S.A. 17B:26-1 et seq., 17B:27-26 et seq., 17B:27A-2 et seq., and 17B:27A-17 et seq.
(c) This subchapter shall not apply to any policy or contract that, 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 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 2A - COVERAGE FOR TERMINATION OF PREGNANCY › Section 11:24A-2A.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. 11:24A-24.3, a carrier shall provide coverage, without limit or exclusion, for medical and surgical abortion in accordance with this subchapter. A carrier 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 policy.
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 2A - COVERAGE FOR TERMINATION OF PREGNANCY › Section 11:24A-2A.3 - Religious employer exclusion

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A religious employer may request, and a carrier 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 a carrier to exclude coverage for care that is necessary to preserve the life or health of the covered person or that is the result of an act of rape or incest.
(b) A carrier that issues a policy or contract containing a religious employer exclusion shall provide written notice of such exclusion to each prospective insured or covered person. Such notice shall appear in not less than 10-point type in the certificate or evidence of coverage, the covered person's application or enrollment form, and all sales and marketing materials.
(c) For each request that a carrier grants to a religious employer, pursuant to this section, the carrier shall make an informational filing with the Department of Banking and Insurance (Department), including a form of the written notice provided to prospective insureds 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 carrier 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 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 3 - UTILIZATION MANAGEMENT › Section 11:24A-3.1 - Scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter shall apply to all carriers that incorporate UM in the administration of one or more of their health benefits plans that have been or will be delivered or offered for delivery in this State.
(b) This subchapter shall apply to all health benefits plans in which UM is performed by or on behalf of the carrier in the administration of the health benefits plan.
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 3 - UTILIZATION MANAGEMENT › Section 11:24A-3.2 - Disclosure requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to the requirements of 11:24A-2.3, carriers shall include in the disclosure statements a covered person's right to appeal to the carrier an adverse benefit determination, except where the adverse benefit determination was based on eligibility, including rescission, or on the application of a contract exclusion or limitation not relating to medical necessity, setting forth:
1. A description of the internal appeal procedure, including the address and toll-free telephone number through which the covered person may contact the carrier;
2. The amount of time for a final decision on the appeal; and
3. The process for expediting appeals in urgent or emergency situations.
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 3 - UTILIZATION MANAGEMENT › Section 11:24A-3.3 - Designation of a medical director

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The carrier shall designate a physician licensed to practice medicine in New Jersey to serve as the medical director for the carrier with respect to its contracts or policies delivered in this State to which a utilization management program applies.
(b) The medical director shall be responsible for at least the following:
1. Overseeing the continuing in-service education of professional staff;
2. Providing clinical direction and leadership to the continuous quality improvement and utilization management programs;
3. Establishing policies and procedures covering all utilization management determination criteria and protocols applicable to health care services for which benefits are payable under a carrier's health benefits plans; and
4. Establishing policies and procedures covering all health care services provided to covered persons when the carrier is authorized, and elects, to engage in the direct or indirect provision of health care services.
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 3 - UTILIZATION MANAGEMENT › Section 11:24A-3.4 - Utilization management program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier's UM program shall be under the direction of the medical director, or his or her designee (who shall be a physician licensed to practice medicine in the State of New Jersey), and shall be based on a written plan, reviewed annually by the carrier, and available for review by the Department upon request, specifying at least:
1. The scope of the carrier's UM activities;
2. The procedures to evaluate clinical necessity, access, appropriateness, and efficiency of services;
3. The mechanisms to detect underutilization and over utilization of services;
4. The clinical review criteria and protocols used in decision-making;
5. The mechanisms to ensure consistent application of review criteria and uniform decisions;
6. The development of measures for evaluating the carrier's UM program, including outcome and process measures when the carrier utilizes a gatekeeper system or practice guidelines for its managed care product(s);
7. A system for covered persons, and providers on behalf of covered persons (with the covered person's consent) to appeal UM determinations in accordance with the procedures set forth at 11:24A-3.5; and
8. A mechanism to evaluate the satisfaction of covered persons with the appeals system, which mechanism shall coordinate with the carrier's CQI program required pursuant to 11:24A-3.8.
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 3 - UTILIZATION MANAGEMENT › Section 11:24A-3.6 - Independent health care appeals process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any covered person, and any provider acting on behalf of a covered person with the covered person's consent, may appeal a final internal adverse benefit determination, except where the final internal adverse benefit determination was based on eligibility, including rescission, or the application of a contract exclusion or limitation not related to medical necessity, through the Independent Health Care Appeals Program to an independent IURO.
(b) To initiate an appeal through the Independent Health Care Appeals Program, a covered person or provider acting on behalf of a covered person with the covered person's consent shall have a minimum four-month period from the date of receipt of the carrier's 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 covered person in accordance with 11:24A-3.5(k)4, and shall include both the fee specified in (c) below and a general release executed by the covered person 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 IURO appeal shall be as follows:
1. Covered persons or health care providers acting on a covered person'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 covered person 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 covered person 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 covered person shall not exceed $ 75.00.
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 3 - UTILIZATION MANAGEMENT › Section 11:24A-3.7 - Carrier action on the IURO decisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall provide benefits (including authorization of a service or supply and payment of the claim) pursuant to the IURO's determination and comply with the IURO's determination without delay, but no later than 10 business days from receipt of the IURO's determination, regardless of whether the carrier intends to seek judicial review of the external review decision, unless there is a judicial decision stating otherwise.
1. The carrier shall provide benefits to comply with the IURO decision sooner if the medical exigencies of the case warrant a more rapid response.
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 3 - UTILIZATION MANAGEMENT › Section 11:24A-3.8 - Continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall have or employ a CQI program to monitor the quality of their UM program under the direction of the carrier's medical director.
(b) A carrier shall set forth its system for its CQI program in a plan reviewable upon request by the Department specifying the following:
1. The scope and purpose of the program;
2. The organizational structure of quality improvement activities;
3. The duties and responsibilities of the medical director (or designee);
4. Contractual arrangements, if any, for delegation of quality improvement activities;
5. Confidentiality policies and procedures;
6. Specifications of standards for the assessment of the adequacy and appropriateness of health care resources utilized;
7. A system of on-going evaluation activities;
8. A system of monitoring satisfaction of covered persons; and
9. A system for evaluation of the effectiveness of the CQI program.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.1 - Scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter shall apply to all carriers that have delivered, will deliver or offer for delivery in this State a health benefits plan that is a managed care plan.
(b) This subchapter shall apply to the health benefits plans that have been or will be delivered or offered for delivery in this State by a carrier that are managed care plans.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.2 - Disclosures to covered persons

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall provide to a covered person no later than the effective date of coverage a current directory of participating providers. Carriers shall, annually thereafter, provide written notice to covered persons that the carrier's current directory is available on its website, and provide instructions for accessing the website. Carriers' websites shall prominently display clear instructions as to how to access the directory. The notice shall also state that covered persons without internet access may obtain, upon request, a written current directory pursuant to the requirements set forth at 11:24A-4.3.
1. The directory shall include all of the medical providers and hospital providers participating in the carrier's network, and may contain other participating providers at the discretion of the carrier.
2. The directory shall distinguish participating providers by provider category or specialty and by county.
3. For participating providers who provide primary care (which may include providers other than providers practicing family or internal medicine, if so designated by the carrier), the directory also shall include:
i. The office address of the participating provider;
ii. The participating provider's hospital affiliation(s); and
iii. An indication of which participating providers have the capacity to communicate in languages other than English.
4. The directory shall include a statement providing the approximate percentage of the carrier's participating physicians that are board certified, and the date on which that percentage was last calculated.
5. If a carrier does not include all of its participating providers within its directory of medical and hospital providers, the carrier shall include a statement in its directory of medical and hospital providers setting forth the categories of other participating providers in the carrier's network, and the means by which a covered person may obtain a written list or lists of such participating providers, distinguished by category and county, free of charge.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.3 - Disclosures to consumers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall, upon request, provide a written document to consumers setting forth the information required to be disclosed pursuant to 11:24A-4.2(a) through (c).
1. The carrier shall not be required to provide the consumer with the same level of detail that is provided to subscribers in the provider directory pursuant to 11:24A-4.2(a), but the carrier shall provide at least the following information:
i. The number of medical providers categorized by specialty by county in the carrier's network;
ii. The number of hospitals categorized by county in the carrier's network;
iii. The approximate percentage of the medical providers in the carrier's network that are board certified, and the date on which the calculation of the percentage was last performed;
iv. The waiting time criteria that the carrier utilizes in its selection of providers for participation in the carrier's network, if any, including a statement that no such criteria apply in those instances in which the carrier does not consider patient waiting times for appointments for routine and urgent care in selecting participating providers;
v. A statement that consumers can check with providers directly to find out if the provider is a participating provider; and
vi. A statement that the consumer may obtain more detailed information, including a provider directory (if not already included), and the process by which consumers may obtain the information free of charge.
(1) Carriers that elect to make their lists of participating providers available through an electronic database accessible to the public shall not substitute electronic access to the information as the only means by which consumers may obtain the information free of charge.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.4 - Submission of disclosures

Current through Register Vol. 56, No. 14, July 15, 2024
Carriers shall submit the forms of the written disclosures required to be made pursuant to 11:24A-4.2 and 4.3 for filing with the Department, in accordance with 11:24A-2.4 and may use such forms until disapproved by the Department, except as 11:24A-4.2(b)  applies.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.6 - Complaint system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall establish and maintain a system for the presentation and resolution of complaints brought by covered persons regarding the carrier's contracts or policies, choice and accessibility of network providers, and network adequacy, incorporating to the satisfaction of the Department at least the following components:
1. Written notification to all covered persons and network providers of the telephone numbers and business addresses of the carrier's business unit(s) responsible for complaint resolution;
2. A system to record and document the status of all complaints, which shall be maintained for at least three years;
3. Availability of a service representative to assist covered persons with complaint procedures upon request;
4. Establishment of a specified response time for complaints, not to exceed 30 days from receipt of the complaint by the carrier.
i. Carriers may specify that the 30-day period does not run until receipt of the complaint by the carrier in writing, but shall not require that the complaint be submitted on a specific form or any similar requirement prior to the start of the 30-day period;
5. A written process describing how complaints are processed and resolved;
6. Procedures for follow-up action including the methods to inform the complainant of resolution of the complaint;
7. Procedures for notifying the CQI program of all valid complaints related to quality of care; and
8. A mechanism for notifying covered persons and providers in writing that they may contact the Department if dissatisfied with the resolution reached through the carrier's complaint system.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.7 - Provider application for participation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall establish a committee to review applications submitted by licensed providers to become members of the carrier's network.
1. The carrier 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.
2. The carrier shall not be required to combine the functions of this review committee with the functions of any committee whose function includes credentialing standards.
3. The committee shall be composed of no less than three people.
4. 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 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.8 - Termination of providers from a network

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall give a health care professional written notice at least 90-days prior to termination of the provider's contract, specifying the health care professional's right to a hearing before a panel appointed by the carrier.
1. The carrier shall set forth in writing the reasons for the termination if requested by the health care professional and the reason is not otherwise stated in the written notice of termination.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.9 - Hearings for provider terminations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A health care professional shall have the right to request a hearing in writing with respect to termination of the health care professional from a carrier's network within 10 business days following the date of the notice.
1. A contract shall be deemed to have terminated, creating the right to a hearing, whenever a contract terminates on any date other than a designated renewal or anniversary date of the contract, except that no such right shall exist with respect to terminations described at 11:24A-4.8(b).
2. If no renewal or anniversary date is specified in the contract, then the renewal or anniversary date shall be deemed to be the month and day in each calendar year on which the contract was originally signed by both parties, or became effective, whichever date is latest.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.10 - Network adequacy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall maintain an adequate network, as set forth in (b) below, of PCPs, specialists and other ancillary providers to assure that covered persons are able to access services in-network and take full advantage of the in-network benefits levels when the policy or contract specifies that there is a differential between the in-network and out-of-network benefits levels for one or more covered services, or the policy or contract is subject to a gatekeeper system.
1. The requirement that the network meet the adequacy standards of (b) below shall apply only to those services for which there is an in-network benefit, and if no in-network benefit exists for a specific service, the carrier is not required to meet the network adequacy standards with respect to the type of provider who typically renders that service.
2. Notwithstanding that a contract or policy may not be subject to a gatekeeper system, if the contract or policy requires that each covered person select or have a PCP, the carrier shall comply with (b) below with respect to the offering of that policy or contract.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.11 - Utilization management program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall comply with 11:24A-3.4.
(b) In addition to (a) above, the carrier shall comply with the following:
1. The carrier shall develop its UM criteria and protocols with involvement from its participating providers in accordance with 11:24A-4.1 4; and
2. For contracts or policies in which emergency and/or urgent care services are covered, carriers shall not require covered persons or health care providers to obtain preauthorization for such services.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.12 - Internal utilization management appeal process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall establish an internal appeal mechanism whereby a covered person or a provider acting on behalf of a covered person, with the covered person's consent, may appeal any decision to deny, reduce or terminate services or the payment of benefits therefor covered under the contract or policy, in compliance with 11:24A-3.5.
(b) In addition to the requirements set forth in (a) above, a carrier shall provide a written explanation of the appeal process to all of its network providers, and to other providers upon request, as well as at the conclusion of each stage of the appeal process.
(c) In addition to (a) and (b) above the carrier shall not establish or maintain policies, procedures or set forth anything in provider agreements that prohibit or discourage a covered person or provider from discussing or exercising the right to an appeal available under this subchapter, or the right to an external appeal through the Independent Health Care Appeals Program at 11:24A-3.6.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.13 - Continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to complying with 11:24A-3.8, carriers shall comply with the requirements of 11:24-7.1 not otherwise included in 11:24A-3.8.
(b) A carrier shall have performed and shall submit to the Department, by May 1, 2002 or entrance of the carrier into the managed care plan market, and every 36 months thereafter, documentation of its most recent external quality audit performed by an external quality audit review organization approved by the Department.
1. The carrier shall submit the documentation to the Department within 60 days of its receipt in final form by the external quality review organization.
2. The carrier shall make such documentation available to the Department upon request.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.14 - Provider input on protocols

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall develop written clinical criteria and protocols and shall base its UM determinations upon such clinical criteria and protocols.
1. The carrier shall develop its clinical criteria and protocols with the input of practicing physicians and other health care providers within the carrier's network.
2. The carrier's clinical criteria and protocols shall be based upon generally accepted medical standards.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.15 - Minimum standards for provider contracts

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 shall not be so worded that compliance with the terms of the contract would cause any health care provider to violate his or her 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) In addition to complying with N.J.A.C. 11:4-37 and 11:24C-4, all provider contracts 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 renewal date, the carrier 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 in enumerated circumstances consistent with 11:24A-4.9;
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 carrier 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 set forth the procedures for requesting a hearing, and otherwise shall be consistent with the standards set forth at 11:24A-4.9;
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 carrier the reasons for the termination shall specify the procedure for the provider to make the request, and that the carrier's reason in response to the request shall be in writing;
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.16 - Reporting of compensation arrangements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall comply with the requirements of 11:24-11.7, submitting the information in conjunction with their financial statements required to be filed annually on March 1.
1. For purposes of complying with this requirement, carriers shall submit information for all of its managed care plan business by line, separated by Medicaid (if any), Medicare (if any), Medicare supplement (if any) and non-Medicare business if the carrier has different compensation arrangements for these lines of business.
2. A carrier with an HMO affiliate shall submit its data for its HMO and non-HMO affiliates separately.
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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS › Section 11:24A-4.17 - Requirement to offer a managed care plan without a gatekeeper system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier may offer a managed care plan with a gatekeeper system, but a managed care plan with a gatekeeper system shall not be the only type of managed care plan that the carrier offers in this State, except as (b) below may apply to the carrier.
(b) A carrier that offers a managed care plan with a gatekeeper system shall be deemed to be in compliance with (a) above if:
1. The carrier also offers a selective contracting arrangement approved in accordance with N.J.A.C. 11:4-37;
2. The approved 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 carrier's network of participating providers without obtaining a referral or prior authorization from the carrier; and
3. The carrier provides subscribers under all group health plans in which the contractholder offers one of the carrier's contracts or policies provided in conjunction with an approved 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.