New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
For the purposes of this subchapter, the words and terms set forth below shall have the following meanings, unless the context clearly indicates otherwise.
"Carrier" means an insurance company authorized to transact the business of insurance in this State and doing a health insurance business in accordance with 17B:17-1 et seq., a hospital service corporation authorized to do business pursuant to 17:48-1 et seq., a medical service corporation authorized to do business pursuant to 17:48A-1 et seq., a health service corporation authorized to do business pursuant to 17:48E-1 et seq., or a health maintenance organization authorized to do business pursuant to 26:2J-1 et seq.
"Covered person" means the natural person on whose behalf a carrier is obligated to pay benefits or provide health care services pursuant to the health benefits plan.
"Department" means the New Jersey Department of Banking and Insurance.
"Designation" or "designated" means that a health care provider has been approved by the Department to contract with carriers for the purposes of rendering service for the home treatment of bleeding episodes associated with hemophilia.
"Health benefits plan" means a policy or contract for the payment of benefits for hospital and medical expenses or the provision of hospital and medical services, that is delivered or issued for delivery in this State by a carrier. The term "health benefits plan" specifically includes:
1. Medicare supplement coverage and risk contracts for the provision of health care services covered by Medicare to the extent that State regulation of such contracts or policies is not otherwise preempted by Federal law; and
2. Any other policy or contract not otherwise specifically excluded by statute or this definition.
The term "health benefits plan" specifically excludes:
1. Accident only policies;
2. Credit health policies;
3. Disability income policies;
4. Long-term care policies;
5. TRICARE/CHAMPUS coverage, and supplements thereto;
6. Hospital confinement indemnity coverage;
7. Coverage arising out of a workers' compensation law or similar such law;
8. Automobile medical payment insurance or personal injury protection insurance issued pursuant to 39:6A-1 et seq.; and
9. Coverage for medical expenses contained in a liability insurance policy.
"Health care provider" means a person licensed to deliver one or more health care services pursuant to Title 45 or Title 26 of the New Jersey Statutes, or a health care service firm as that term is defined at 13:45B-13.2.
"Managed care plan" means a health benefits plan that integrates the financing and delivery of appropriate health care services to covered persons by agreement with participating health care providers, who are selected to participate on the basis of explicit standards, to furnish a comprehensive set of health care services and financial incentives for covered persons to use the participating health care providers and procedures set forth in the plan.
"Person" means both legal and natural person except as otherwise specified.
"State-recognized outpatient regional hemophilia care center" means a health care facility participating in the Federally funded hemophilia treatment center network, as determined by the United States Department of Health and Human Services, that is located within New Jersey's geographic borders, without regard to the hemophilia treatment center's Federally designated region.