New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 28 - GROUP COORDINATION OF BENEFITS › Section 11:4-28.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:
"Allowable expense" means the charge for any health care service, supply or other item of expense for which the covered person is liable, when the health care service, supply or item of expense is covered at least in part under any of the plans involved, except where a statute requires a different definition, or as otherwise specified in this subchapter.
1. A plan's COB provision may exclude from allowable expenses items of expense arising under coverages such as dental care, vision care, prescription drug or hearing aid programs. When a plan provides benefits only for dental care, vision care, prescription drugs or hearing aids, the COB provision of the group contract may limit allowable expenses to like items of expense.
2. The difference between the cost of a private hospital room and the cost of a semi-private hospital room shall not be considered an allowable expense under the above definition unless the patient's stay in a private hospital room is medically necessary in terms of generally accepted medical practice.
3. When a plan restricts COB to specific coverage in a contract (for example, major medical or dental), the group contract shall consider only the corresponding expenses or services to which COB applies as allowable expense.
"Claim" means a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of:
1. Services (including supplies);
2. Payment for all or a portion of the expenses incurred;
3. A combination of 1 and 2 above; or
4. An indemnification.
"Claim determination period" means the period of time, which shall not be less than 12 consecutive months, over which allowable expenses are compared with total benefits payable in the absence of COB, to determine whether benefit duplication exists and how much each plan will pay or provide.
1. The claim determination period shall generally be a calendar year, but a plan may use some other period of time that fits the coverage of the plan. A person may be covered by a plan during a portion of a claim determination period if that person's coverage starts or ends during the claim determination period.
2. As each claim is submitted, each plan shall determine its liability and pay or provide benefits based upon allowable expenses incurred to that point in the claim determination period. This determination shall be subject to adjustment as later allowable expenses are incurred in the same claim determination period.
"COB" means coordination of benefits.
"Group type coverage" means coverage which is not available to the general public and which can be obtained and maintained only because of membership in, or connection with, a particular organization or group.
"HMO plan" means a plan offered by a health maintenance organization that provides covered services and supplies through a network of providers that have contracted with or are employed by the health maintenance organization, and which excludes benefits for services and supplies rendered by other than network providers except in cases of emergency or referral by the health maintenance organization.
"HMO point of service plan" or "HMO POS plan" means a plan offered by a health maintenance organization that provides covered services and supplies through a network of providers that have contracted with or are employed by the health maintenance organization, and which also pays benefits for services and supplies rendered by providers who are not in the network of the health maintenance organization.
"Hospital indemnity benefits" means those benefits not related to expenses incurred. The term does not include expense-incurred benefits, even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.
"Indemnity plan" means a hospital and/or medical expense insurance policy, hospital service corporation contract, medical service corporation contract, health service corporation contract, or dental service corporation contract.
"Plan" means coverage with which coordination is allowed. The definition of "plan" in the group contract must state the coverages which will be considered in applying the COB provision of that contract. The right to include a coverage shall be limited by 1 through 3 below.
1. Any definition that satisfies the substance of this definition at 11:4-28.2 may be used. The definition of "plan" shown in the Model COB Provision in Appendix A of this subchapter is an example of what may be used.
2. This subchapter uses the term "plan". However, a group contract may, instead, use "program" or a comparable term.
3. A "plan" may include:
i. Group insurance and group subscriber contracts;
ii. Uninsured arrangements of group or group-type coverage;
iii. Group or group-type coverage through HMOs and other prepayment, group practice and individual practice plans;
iv. Group hospital indemnity benefit amounts exceeding $ 150.00 per day; and
v. Medicare or other governmental benefits, except those benefits as provided in 4ix below. This part of the definition of "plan" may be limited to the hospital, medical and surgical benefits of the governmental program.
4. "Plan" shall not include:
i. Individual or family insurance contracts;
ii. Individual or family subscriber contracts;
iii. Individual or family coverage through Health Maintenance Organizations (HMOs);
iv. Individual or family coverage under other prepayment, group practice and individual practice plans;
v. Group or group-type coverage where the cost of coverage is paid solely by the employee, member or subscriber, except that coverage provided under a right of continuation pursuant to Federal or State law shall be considered a plan;
vi. Group hospital indemnity benefits of $ 150.00 per day or less;
vii. School accident-type coverages. This coverage provides benefits for students, headstart and day care enrollees, campers, and similar participants for accidents only, including athletic injuries, either on a 24-hour basis or on a "to and from school" basis;
viii. A State plan under Medicaid; and
ix. A plan when, by law, its benefits are in excess of those of any private insurance plan or other nongovernmental plan.
"Primary plan" means a plan whose benefits for a person's health care coverage must be determined without taking into consideration the existence of any other plan. There may be more than one primary plan. A plan shall be a "primary plan" if either 1 or 2 below exists:
1. The plan has no order of benefit determination rules, or it has rules which differ from those permitted by this subchapter;
2. All plans which cover the person use the order of benefit determination rules required by this subchapter, and under those rules the plan determines its benefits first.
"Secondary plan" means a plan which is not a primary plan. If a person is covered by more than one secondary plan, the order of benefit determination rules of this subchapter shall decide the order in which their benefits are determined in relation to each other. The benefits of each secondary plan may take into consideration the benefits of the primary plan or plans and the benefits of any other plan which, under this subchapter, has its benefits determined before those of that secondary plan.
"Selective contracting arrangement" or "SCA plan" means a plan offered by a health insurer operating pursuant to Title 17B of the New Jersey statutes using an arrangement as set forth at 17B:27A-54 for the payment of predetermined fees or reimbursement levels for covered services by the carrier to preferred providers or preferred provider organizations.
"This Plan" in a COB provision means the part of the group contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans. Any other part of the group contract providing health care benefits shall be separate from "This Plan". A group contract may apply one COB provision to certain of its benefits (such as dental benefits), coordinating only with like benefits, and may apply other separate COB provisions to coordinate other benefits.