New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Appendix - APPENDIX › Exhibit C

Current through Register Vol. 56, No. 14, July 15, 2024
EXPLANATION OF BRACKETS
Plans A/50 through D
(Appendix Exhibit A)
All text which is enclosed in brackets [] is variable. Enclosure in Brackets does not give Carriers liberty to deviate from the standard text which is enclosed in brackets, except as expressly stated in the policy form text or in this Explanation of Brackets. In many instances, variable text is text which a carrier elects to either include or exclude. When the forms are prepared as issue documents, no brackets should appear, since the forms, as issued, should specify all the elections the Carrier has made. Such text may generally be categorized in the following ways.
a Some areas of variability are self-explanatory. Examples include: [Carrier], [Policyholder], and [ABC]
b Some areas of variability are noted with brief italicized explanations within the text. Examples include: use of high deductible health plan text and specialist copay.
c Some areas of variability are intended to allow for flexibility in terms of a carrier's administrative practices.
d Some areas of variability are subject to ranges and parameters specified in statute and/or regulation
e Some areas of variability are determined by the election made by a Carrier.
f Some areas of variability are determined by the delivery system (i.e., indemnity or PPO, POS or EPO)
g Some areas of variability apply to the limited circumstance of plans to be issued in the Marketplace created under the Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the Health Care and Education Reconciliation Act, Public Law 111-152 (Marketplace).
Note:
Due to the complexity of issuing plans through or in conjunction with an approved Selective Contracting Arrangement, commonly known as PPO, POS and EPO plans, explicit guidance is set forth in item 21 below.
Areas of variability, which may require clarification and explanation as to use, are explained below. The order of the list is generally consistent with the order of appearance in the policy forms.
1. The Health Care Quality Act requires carriers to specify the legal name, trade name, e-mail and fax numbers. Carriers may include this information on a separate page, immediately following the face page, as illustrated in the standard forms. Alternatively, carriers may include this information directly on the face page.
2. Although the schedule pages specify the plan letter in the upper right corner this identification is intended solely to identify which plan letter the page illustrates. Carriers need not specify the plan letter on the schedule pages of plans being issued.
3. Deductible, and Co-Payments, as offered by the carrier, may be elected by the Policyholder, subject to the availability specified in regulation.
4. There are sample PPO, POS and EPO schedule pages. There are corresponding provisions in the benefit provisions.
5. The sample schedule pages illustrate a variety of cost sharing features with combinations of copayments, deductibles and coinsurance. Designs illustrated on one sample page may be included in other schedule pages. For example, some of the sample pages illustrate specific cost sharing applied to pediatric dental and vision benefits. Similar text may be included in other schedule pages. In addition, coinsurance percentages necessary to achieve a cost sharing reduction through the marketplace may be used even in such percentages are not illustrated on the same schedules.
6. One of the schedule pages illustrates a tiered network design. Carriers should adapt the schedule page to illustrate the services for which a tiered network design is applicable. Additional variable text addressing a tiered network is included in the PPO, POS and EPO descriptions and other coverage sections of the policy.
7. The definition of Eligible Person and the Who is Eligible provision contain bracketed text addressing PPACA's requirement that the person must be a U.S. citizen, national or lawfully present in the United States to be covered under a policy offered in the Marketplace. Such variable text applies in the limited circumstance of plans issued in the Marketplace. Such bracketed text must not be included in plans otherwise issued in New Jersey.
8. The list of services and supplies for which pre-approval is required includes some new items, included in brackets: specified therapies, therapeutic manipulation, and prescription drugs. The benefit provisions for these services and supplies also includes text in brackets concerning pre-approval. Carriers that elect to require pre-approval for these services and supplies must include them on the list on the schedule page in addition to using the pre-approval text in the benefit provision. The provision may include information regarding the website.
9. The definition of an Approved Cancer Clinical Trial and the corresponding benefit provision should be included only by those carriers that wish to make such coverage available and want to specify such coverage in the policy form.
10. The definition of Reasonable and Customary should only include a reference to the negotiated fee schedule if the Carrier is offering the plan using a PPO, POS or EPO delivery system.
11. The definitions section includes definitions that would be included if a carrier offers a mail order pharmacy program
12. The text describing provider compensation in the PPO, POS and EPO section contains a number of bracketed words and phrases. Include the words and phases that describe the arrangement carrier has with network providers.
13. The continuation of care text must be included in all plans that use networks.
14. The Deductible Credit provision includes variable text regarding cost sharing reduction that would be included for policies issued on the Marketplace. Such variable text must not be included in plans otherwise issued in New Jersey.
15. The treatment of hemophilia provision includes variable text that would only be included in network-based plans.
16. The prescription drugs provision includes variable text that would be included by carriers that require pre-approval for specified drugs.
17. The therapy services provision includes variable text that would be included by carriers that require pre-approval for certain therapy services.
18. The Dental Benefits text is enclosed in brackets. For policies sold on the Marketplace the Dental Benefits provision may be excluded if the Marketplace offers a standalone dental plan with a pediatric dental essential health benefit. Such bracketed text must be included in plans otherwise issued in New Jersey unless a carrier is reasonably assured that an individual has obtained such pediatric dental coverage through a marketplace-certified stand-alone dental plan. Dental benefits may be limited to services provided by a network provider.
19. The method a Carrier chooses to make the optional cancer treatment benefits available will determine which transplant benefit text the Carrier would include. For Carriers electing to include the optional cancer treatment benefits as part of the standard forms, the list of services for which Pre-Approval is required, as it appears in the Schedule of Benefits, must be modified to omit the item for autologous bone marrow transplant and associated dose intensive chemotherapy.
20. The Centers of Excellence Features provisions may be omitted. If included in the policy, the text must conform to the text of the standard form.
21. Carriers that issue plans through or in conjunction with an approved Selective Contracting Arrangement must consider the following when creating the plan documents:
a. The policy and certificate documents contain "SAMPLE" schedule page text. The dollar amounts for the deductibles and copayments are purely illustrative. Refer to 11:20-3.1(d)  for direction as to which amounts may be substituted for those in the example. For plans that utilize a copay feature, the copays replace the cash deductible for the particular service, and benefits following the copay must be paid at 100%. The dollar amounts for the copays must be consistent with those that an HMO carrier may use. [($ 15, $ 30, $ 40 or $ 50)]
b. Include the specific page of text describing the PPO, POS or EPO mechanism, with specification of the name of the network or provider organization.
22. The Notice of Loss provision of the Claims Provisions may be omitted at the option of the Carrier.
23. The Payment of Claims provision of the Claims Provisions should include the second or third sentence of the last paragraph, as appropriate.