New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 37 - SELECTIVE CONTRACTING ARRANGEMENTS OF INSURERS › Section 11:4-37.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Allowable expense" means the usual, customary and reasonable item of expense for a covered service when the item of expense is covered at least in part by the health benefits plan.
"Carrier" means any insurance company operating pursuant to Title 17B of the New Jersey statutes and authorized to issue health benefits plans in this State.
"Certified organized delivery system" means an organized delivery system certified pursuant to 17:48H-1 et seq., and compensated on a basis that does not entail the assumption of financial risk by the organized delivery system.
"Coinsurance" means the percentage of the allowable expenses payable by the covered person.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Copayment" means a specified dollar amount a covered person must pay for specified covered services.
"Covered person" means a person on whose behalf the carrier is obligated to pay benefits pursuant to the health benefits plan.
"Covered service" means a service provided to a covered person under a health benefits plan for which a carrier is obligated to pay benefits.
"Department" means the New Jersey Department of Banking and Insurance.
"Emergency care" means covered services that are provided by any health care provider for a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse such that absence of immediate attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. With respect to a pregnant woman who is having contractions, an emergency exists when there is inadequate time to effect a safe transfer to another hospital before delivery or the transfer may pose a threat to the health or safety of the woman or the unborn child.
"Evidence of coverage" means the certificate which includes a statement of the essential benefits, limitations, exclusions and services of the health benefits plan, that is issued to the employer, policyholder or other person or association in whose name the policy or contract is issued for delivery to the covered person.
"Health benefits plan" means a policy, contract or evidence of coverage delivered or issued for delivery in this State that pays benefits and/or arranges for the provision of covered healthcare services and supplies. For purposes of this subchapter, health benefits plan shall not include accident only, Medicare supplement coverage, CHAMPUS supplement coverage, coverage for Medicare services provided pursuant to a contract with the United States government, coverage for Medicaid services pursuant to a contract with the State, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, and personal injury protection issued pursuant to 39:6A-1 et seq. For purposes of this subchapter, health benefits plan shall include dental, vision, prescription drug and other limited scope or ancillary coverages.
"Health care provider" means any physician, hospital, facility, or other person who is licensed or otherwise authorized to provide health care services or other benefits in the state or jurisdiction in which they are furnished.
"Licensed organized delivery system" means an organized delivery system licensed pursuant to 17:48H-1 et seq., and compensated on a basis which entails the assumption of financial risk by the organized delivery system.
"Network provider" means a health care provider or group of health care providers who have entered into selective contracting arrangements with a carrier, a licensed or certified organized delivery system, a health maintenance organization (HMO) or, with respect to prescription drug coverage only, a preferred provider organization (PPO).
"Organized delivery system" or "ODS" means an organization with defined governance that:
1. Is organized for the purpose of and has the capability of contracting with a carrier to provide, or arrange to provide, under its own management substantially all or a substantial portion of the comprehensive health care services or benefits under the carrier's benefits plan on behalf of the carrier, which may or may not include the payment of hospital and ancillary benefits; or
2. Is organized for the purpose of acting on behalf of a carrier to provide, or arrange to provide, limited health care services that the carrier elects to subcontract for as a separate category of benefits and services apart from its delivery of benefits under its comprehensive benefits plan, which limited services are provided on a separate contractual basis and under different terms and conditions than those governing the delivery of benefits and services under the carrier's comprehensive benefits plan.
An organized delivery system shall not include an entity otherwise authorized or licensed in this State to provide comprehensive or limited health care services on a prepayment or other basis in connection with a health benefits plan or a carrier.
"Preferred provider organization" or "PPO" means an entity other than a carrier, an HMO, a certified ODS, a licensed ODS, and a prepaid prescription drug service organization that contracts with network providers to establish selective contracting arrangements for prescription drug coverage only.
"Prepaid prescription drug service organization" means any person, corporation, partnership, or other entity which, in return for a prepayment by a contract holder, undertakes to provide or arrange for the provision of prescription services to enrollees or contract holders pursuant to 17:48F-1 et seq.
"Selective contracting arrangement" or "SCA" means an arrangement for the payment of predetermined fees or reimbursement levels for covered services by the carrier to network providers, HMOs, certified ODSs, licensed ODSs or, with respect to prescription drug coverage only, to PPOs. A SCA includes an arrangement between a carrier and an HMO under which the HMO makes its provider network available to the carrier.