reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.9 - Financial reports

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A licensed organized delivery system shall file an annual report for the segregated account established pursuant to 11:22-4.8(b)  with the Commissioner, on or before March 1 of each year, for the immediately preceding calendar year, completed as prescribed by the National Association of Insurance Commissioners (NAIC) Health Annual Statement Instructions, and completed on a statutory accounting principles basis, in accordance with the NAIC Accounting Practices and Procedures Manual, effective January 1, 2001, incorporated herein by reference, as amended and supplemented (NAIC, 2301 McGee Street, Kansas City, MO 64108). The annual report shall be submitted using the NAIC health blank in effect at the time of the calendar year reported. Annual statements shall be accompanied by a fee in the amount of $ 100.00.
(b) A licensed organized delivery system shall submit, no later than June 1, audited annual financial reports for the immediately preceding calendar year for the segregated account established pursuant to 11:22-4.8(b), and shall also file a report with respect to all of its operations, completed on a generally accepted accounting principles basis, certified by an independent certified public accountant, in accordance with N.J.A.C. 11:2-26. In addition, a statement by a qualified actuary setting forth the actuary's opinion as to the adequacy of reserves shall be filed with the annual report filed pursuant to (a) above, which shall satisfy the requirements set forth in N.J.A.C. 8:38-11.6(a)2.
(c) A licensed organized delivery system shall file quarterly reports for the segregated account established pursuant to 11:22-4.8(b)  with the Commissioner, no later than 45 days following the close of each of the first three calendar quarters (that is, May 15, August 15, and November 15, respectively), completed as prescribed by the NAIC Health Annual Statement Instructions, and completed on a statutory accounting principles basis, in accordance with the NAIC Accounting Practices and Procedures Manual, effective January 1, 2001, incorporated herein by reference, as amended and supplemented. The quarterly report shall be submitted using the NAIC health blank in effect at the time of the quarter submitted.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.10 - Treatment as domestic insurer

Current through Register Vol. 56, No. 14, July 15, 2024
Regardless of the state in which it is incorporated, pursuant to 17:48H-16 and 26 a licensed organized delivery system shall be treated as a domestic insurer subject to 17:27A-1 et seq. and 17B:32-31 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.11 - Suspension or revocation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may suspend or revoke the license issued to an organized delivery system upon a finding that:
1. The licensed organized delivery system is operating in contravention of its basic organizational documents;
2. The licensed organized delivery system is unable to fulfill its obligations to the carriers with whom it contracts;
3. The net worth of the licensed organized delivery system is less than that required by this subchapter, or the licensed organized delivery system has failed to correct any deficiency in its net worth as required by the Commissioner;
4. The continued operation of the licensed organized delivery system would be hazardous to the health and welfare of the enrollees or contract holders with whom it has contracted to provide health care services or detrimental to a carrier with whom it has contracted to provide the services;
5. The licensed organized delivery system has failed to file any report required by 17:48H-1 et seq. or this subchapter;
6. The licensed organized delivery system has failed to provide the health care services for which it has been licensed or has provided health care services which are in contravention of the contract or contracts filed with the Commissioner;
7. The licensed organized delivery system is unable to maintain the standards set forth in this subchapter;
8. The licensed organized delivery system has failed to comply with the provisions of 26:2S-1 et seq.;
9. The licensed organized delivery system has otherwise failed to comply with 17:48H-1 et seq., or with other applicable law, including this subchapter; or
10. There are other reasonable grounds that warrant suspension or revocation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.12 - Plan for insolvency

Current through Register Vol. 56, No. 14, July 15, 2024
In connection with the plan for insolvency required as part of an application for licensure, a licensed organized delivery system shall maintain insurance to cover the expenses to be paid for continued benefits following a determination of insolvency, or make other arrangements acceptable to the Commissioner to ensure that benefits are continued for the period determined in the insolvency plan.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.13 - Confidentiality

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any data or information relating to the diagnosis, treatment or health of an enrollee, prospective enrollee or contract holder obtained by a licensed organized delivery system from the carrier, contract holder, enrollee, prospective enrollee or any provider shall be confidential and shall not be disclosed to any person except as provided by 17:48H-30.
(b) In addition to (a) above, the following documents shall be confidential and shall not be considered public documents pursuant to the "Right-to-Know" law, N.J.S.A. 47:1A-2:
1. Pending applications for a license;
2. In biographical affidavits, the affiant's social security number and residence address;
3. The applicant's business plan;
4. Compensation formulas and fee schedules; and
5. With respect to an examination of a licensed ODS, all information as set forth in N.J.S.A. 17:23-24f and 11:1-36.6.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.14 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Failure to comply with the provisions of this subchapter shall result in the imposition of penalties as provided in 17:48H-22, 17:48H-29, 17B:30-17, 17:27A-1 et seq., 26:2S-1 et seq., 17B:30-23 et seq. and 17B:30-26 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter establishes minimum standards for health benefit plans, prescription drug plans and dental plans.
(b) This subchapter applies to all insurance companies, health service corporations, medical service corporations, hospital service corporations, dental service corporations, dental plan organizations, prepaid prescription service organizations and health maintenance organizations that deliver or issue for delivery health benefit plans, prescription drug plans or dental plans in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.3 - Network deductible

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A network deductible is permitted in a contract issued by a health maintenance organization that provides out-of-network benefits only for emergency and urgent care, in a POS contract issued by a health maintenance organization or health service corporation, and in an SCA policy providing hospital and medical coverage issued by an insurance company, provided that:
1. Effective with contracts or policies effective on or after January 1, 2019, health carriers shall use an individual network out-of-pocket limit that is no greater than the maximum annual limitation on cost sharing provided under 45 CFR 156-130 and a family network out-of-pocket limit that is no greater than two times the individual network out-of-pocket limit, unless the Commissioner issues an Order within 45 days of the issuance of final Federal rules governing benefits and payment parameters to freeze the out-of-pocket limit at the prior policy year maximum;
2. The individual network per covered person annual deductible is no greater than $ 2,500, except as stated in (a)3 and 4 below;
3. For a network-based bronze contract or policy available in the individual health coverage or small employer health benefits markets, meaning a plan with a 60 percent actuarial value, the network per covered person annual deductible shall not exceed $ 3,000;
4. For a contract or policy to be offered as a catastrophic contract or policy in the individual health coverage market, the per covered person annual deductible shall equal the greatest permissible maximum out-of-pocket as defined in 45 CFR 156.130(a)(2), except the deductible shall be waived for three physician visits per calendar year and shall not apply to preventive health services;
5. The individual network deductible is not applied to preventive care;
6. The contract contains a family network deductible no greater than two times the individual network deductible; and
7. The network deductible shall not be applied to services or supplies provided by capitated providers.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.4 - Network coinsurance

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Network coinsurance is permitted in a contract issued by a health maintenance organization that provides out-of-network benefits only for emergency and urgent care, in a POS contract issued by a health maintenance organization or health service corporation, and in an SCA policy providing hospital and medical coverage issued by an insurance company, provided that:
1. The contract or policy complies with the requirements set forth in N.J.A. C. 11:22-5.3(a)1;
i. If a carrier offers a contract with an individual network out-of-pocket limit in excess of $ 3,000, it shall also offer a contract with an individual network out-of-pocket limit of $ 2,500 or less.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.5 - Network copayment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Network copayments in health benefit plans and stand-alone prescription drug plans may not exceed the following amounts:
1. Preventive services, $ 30.00;
2. Primary care provider office visit, $ 50.00;
3. Specialist physician office visit, $ 75.00;
4. Emergency room visit, $ 100.00;
5. Outpatient surgery, $ 500.00;
6. Inpatient admission, $ 500.00 per day up to a maximum of $ 2,500 per admission;
7. Magnetic resonance imaging, computerized axial tomography and positron emission tomography, $ 100.00;
8. Generic drug, $ 25.00 per 30-day supply;
9. Preferred drug, $ 50.00 per 30-day supply;
10. Non-preferred drug, $ 75.00 per 30-day supply; and
11. For any other services and supplies, the copayment is to be determined so that the carrier insures 50 percent or more of the aggregate risk for the service or supply to which the copayment is applied.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.6 - Out-of-pocket limits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following shall apply to individual network, family network and individual out-of-network out-of-pocket limits:
1. Carriers shall track the accumulation of copayment, deductible and coinsurance payments to identify when the out-of-pocket limit has been satisfied, and shall not require covered persons to report payment of copayments, coinsurance or deductible for inclusion in the out-of-pocket limit;
2. All amounts paid as copayment, coinsurance and deductible shall count toward the out-of-pocket limit, and shall not be excluded because of the nature of the service rendered, the illness or condition being treated, or for any other reason, except carriers may, provided the terms of the health benefit plan so state, elect to exclude from the out-of-pocket limit the cost sharing associated with prescription drug coverage, whether provided as part of the health benefit plan or as a rider; and
3. When the out-of-pocket limit has been reached, the covered person, or the covered members of the family in the case of a family network out-of-pocket limit, shall have no further obligation to pay any amounts as copayment, coinsurance or deductible for services and supplies provided by providers for the remainder of the calendar, contract or policy year, except for prescription drugs if, under the terms of the applicable plan, prescription drugs do not accumulate toward the out-of-pocket limit.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.8 - Network and out-of-network coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) POS contracts issued by health maintenance organizations and health service corporations, and SCA policies issued by insurance companies, shall provide coverage for covered services and supplies regardless of whether rendered by a network or an out-of-network provider, with the following exceptions:
1. The following services and supplies may be covered only when provided by a network provider, and are not required to be covered when provided by an out-of-network provider:
i. Health club membership;
ii. Prescription drugs, other than insulin and oral agents for controlling blood sugar as mandated by 17:48-6n, 17:48A-7l, 17:48E-35.1 1, 17B:26-2.1l, 17B:27-46.1m and 26:2J-4.1 1, and medications to treat infertility as mandated by 17:48-6x, 17:48A-7w, 17:48E-35.2 2, 17B:27-46.1x and 26:2J-4.2 3;
iii. Dental services and supplies, other than services and supplies for injury to sound natural teeth, bony impacted teeth and as required by P.L. 1999, c. 49;
iv. Routine eye care and appliances;
v. Routine foot care;
vi. Routine hearing care and appliances;
vii. Smoking cessation programs; and
viii. Travel companion benefits.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.9 - Prescription drug benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Health benefit plans and stand-alone prescription drug plans that provide benefits for prescription drugs listed on a formulary may provide higher benefits for formulary drugs than for nonformulary drugs, provided:
1. The benefit for all tiers of formulary and nonformulary drug coverage shall result in a cost to the covered person of no more than 50 percent of the plan's contracted cost of the drug, after application of any deductibles, for prescription drugs provided by network providers. For prescription drugs provided by out-of-network providers, coinsurance shall not exceed 50 percent.
2. If a health benefit plan has a separate deductible for prescription drugs, or a stand-alone prescription drug plan has a deductible, such deductible shall not exceed $ 250.00 per calendar year for all tiers of formulary drugs and $ 250.00 per year for all tiers of nonformulary drugs; and
3. If a health benefit plan or a stand-alone prescription drug plan has a benefit maximum for prescription drugs, the maximum shall be the same for formulary and nonformulary drugs.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.9A - Benefits for termination of pregnancy

Current through Register Vol. 56, No. 14, July 15, 2024
A health benefit plan or stand-alone prescription drug plan must provide prescription drug benefits for the termination of pregnancy consistent with N.J.S.A. 26:2S-39 and N.J.A.C. 11:22-5.9.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.10 - Dental benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following standards apply to health benefit plans and stand-alone dental plans that provide benefits for dental services only when rendered by network providers, and plans that provide benefits for dental services rendered by both network and out-of-network providers:
1. The in-network benefit provided by the carrier shall result in average cost sharing, through coinsurance or copayments, of no more than 75 percent of the carrier's contracted cost of that service or for the cost of a class of similar services.
i. An aggregate deductible for all services and any dollar benefit maximums may be disregarded in determining the cost-sharing, but a per service deductible shall be considered a copayment.
ii. A scheduled in-network benefit shall be considered a benefit with a copayment equal to the difference between the contracted rate and the scheduled benefit.
iii. A carrier shall not use the cost of periodic examinations in determining the average cost sharing requirement.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS › Section 11:22-5.11 - Effect on previously-approved forms

Current through Register Vol. 56, No. 14, July 15, 2024
Any form that was previously filed with and approved by the Commissioner, but does not meet the requirements of this subchapter, shall be deemed withdrawn as of September 8, 2010 and may not be made available for new issue or for renewal on or after that date.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 6 - EXCLUSIONS AND PREAUTHORIZATION REQUIREMENTS › Section 11:22-6.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter specifies standards for war and other exclusions and preauthorization requirements in health benefit plans.
(b) This chapter applies to any insurance company, health service corporation, medical service corporation, hospital service corporation and health maintenance organization that issues health benefit plans in New Jersey.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 6 - EXCLUSIONS AND PREAUTHORIZATION REQUIREMENTS › Section 11:22-6.3 - War exclusions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall permit war risk exclusions in health benefit plans only if they consist of military exclusions, noncombatant exclusions and/or civilian exclusions. Military, noncombatant and civilian exclusions shall be no more restrictive than the following:
1. Military exclusions may exclude treatment of illness or injury suffered:
i. As a result of war or an act of war, if the illness or injury occurs while the covered person is serving in the military, naval or air forces of any country, combination of countries or international organization; and
ii. As a result of the special hazards incident to service in the military, naval or air forces of any country, combination of countries or international organization, if the illness or injury occurs while the covered person is serving in such forces and is outside the home area.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 6 - EXCLUSIONS AND PREAUTHORIZATION REQUIREMENTS › Section 11:22-6.4 - Requirements for preauthorization provisions

Current through Register Vol. 56, No. 14, July 15, 2024
Preauthorization provisions may be included in health benefit plans only upon compliance with the requirements of 11:4-42.8, except for 11:4-42.8(a)5.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 6 - EXCLUSIONS AND PREAUTHORIZATION REQUIREMENTS › Section 11:22-6.5 - Effect on previously filed forms

Current through Register Vol. 56, No. 14, July 15, 2024
Forms filed before February 17, 2004 with noncomplying war exclusions and/or preauthorization provisions shall be administered in accordance with the standards of 11:22-6.3 and 6.4 and shall be deemed withdrawn as of January 1, 2005.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 7 - CARRIER/PROVIDER JOINT NEGOTIATION AGREEMENTS › Section 11:22-7.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to implement 52:17B-196 et seq., which provides for joint negotiations regarding non fee-related matters, fees and fee-related matters by physicians and dentists with carriers. This subchapter establishes standards and procedures for carriers to report to the Department certain information concerning the number of a carrier's covered lives and the impact of provider negotiations conducted pursuant to 52:17B-196 et seq.
(b) This subchapter shall apply to all insurance companies, health service corporations, hospital service corporations, medical service corporations and health maintenance organizations authorized to issue health benefits plans in this State. This subchapter shall also apply to all dental service corporations and dental plan organizations authorized to issue dental plans in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 7 - CARRIER/PROVIDER JOINT NEGOTIATION AGREEMENTS › Section 11:22-7.2 - 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:
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State, and a dental service corporation or dental plan organization authorized to issue dental plans in this State.
"Covered lives" means covered persons for purposes of required reporting of the number of such persons.
"Covered person" means a person on whose behalf a carrier, which offers a health benefits or dental plan, is obligated to pay benefits or provide services pursuant to that plan.
"Covered service" means a health care or dental service or supply provided to a covered person under a health benefits or dental plan for which the carrier is obligated to pay benefits or provide services subject to contractual provisions such as deductible, coinsurance and copayment.
"Department" means the New Jersey Department of Banking and Insurance.
"Dental plan" means a benefits plan that pays or provides dental expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier.
"Health benefits plan" means a plan that pays or provides hospital, medical or dental expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier. For purposes of this subchapter, health benefits plan shall not include the following plans, policies, or contracts: Medicare supplement coverage and Medicare risk contracts; accident only, specified disease or other limited benefits; credit; disability; long-term care; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement coverage; coverage arising out of a workers' compensation or similar law; automobile medical payment insurance; personal injury protection insurance issued pursuant to P.L. 1972, c.70 (39:6A-1 et seq.); dental or vision care coverage only; or hospital expense or confinement indemnity coverage only.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 7 - CARRIER/PROVIDER JOINT NEGOTIATION AGREEMENTS › Section 11:22-7.3 - Quarterly and annual reports

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier shall report to the Department quarterly the number of covered persons enrolled in a dental plan or health benefits plan during that quarter in a format set forth in this subchapter as Appendix A, incorporated herein by reference. Instructions for completing this report are included in Appendix A. Due dates for the reports are as follows: May 15 for the first quarter, August 15 for the second quarter, November 15 for the third quarter, and March 1 for the fourth quarter.
(b) Every carrier shall report to the Department annually the impact of provider negotiations conducted pursuant to 52:17B-196 et seq. in a format set forth in this subchapter as Appendix B, incorporated herein by reference. Instructions for completing this report are included in Appendix B. The due date for this report shall be March 1.
(c) The reports described in (a) and (b) above shall be submitted to the Department by the due dates referenced in those subsections to:
New Jersey Department of Banking and Insurance
Life & Health Actuarial Bureau
Provider Negotiation Reports
20 West State Street
PO Box 325
Trenton NJ 08625-0325
(d) An original and one copy of each report described in subsections (a) and (b) above shall be submitted in hard copy. An electronic version of the quarterly enrollment report shall be provided on one of the following media:
1. CD-ROM; or
2. Floppy diskette.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 8 - HEALTH INSURANCE IDENTIFICATION CARDS › Section 11:22-8.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish standards and criteria regarding information contained on health insurance identification cards issued by carriers authorized to issue health benefit plans in this State.
(b) This subchapter shall apply to all insurance companies, health service corporations, hospital service corporations, medical service corporations and health maintenance organizations authorized to issue health benefit plans in this State and to all third party administrators licensed or registered in this State. The subchapter shall not apply to Medicaid and NJ FamilyCare coverage.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 8 - HEALTH INSURANCE IDENTIFICATION CARDS › Section 11:22-8.3 - Requirement to issue identification cards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each carrier or third party administrator shall issue, or cause to be issued, an identification card to the primary insured covered by a health benefit plan. Additional cards may be issued to other persons included under the primary insured's coverage. The carrier or third party administrator may contract with an administrator, agent, contractor or other vendor to issue the cards; however, the carrier or other provider shall remain responsible for the proper issuance of the cards and for their compliance with this subchapter.
(b) The following information shall appear on all health benefit plan identification cards:
1. The name of the carrier issuing the health benefit plan or the name of the third party administrator administering the health benefit plan;
2. An indication of whether the plan is insured or self funded;
3. The insured's name;
4. The insured's identification number, the contract number and the policy or group number, if applicable;
5. The name of the primary care provider for each covered person where selection of a primary care provider is required;
6. A phone number or electronic address for authorization and admission certifications, if required; and
7. In-network cost sharing information, including amounts applicable to primary care provider visits, specialist visits, emergency room visits and hospital stays.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 8 - HEALTH INSURANCE IDENTIFICATION CARDS › Section 11:22-8.4 - Time limits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Beginning on the operative date of this subchapter, health insurance identification cards shall be provided according to the following schedule:
1. A carrier or third party administrator shall provide each primary insured a new identification card within 30 days of a health benefit plan becoming effective.
2. A card shall be issued to the primary insured within 30 days of the date that the primary insured initially becomes eligible for coverage under an existing health benefit plan (for example, new employee).
3. A new card shall be issued to the primary insured no later than 30 days after a change in any information required to be included on the card pursuant to 11:22-8.3.
4. Noncomplying cards shall be replaced with complying cards upon plan renewals.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 8 - HEALTH INSURANCE IDENTIFICATION CARDS › Section 11:22-8.5 - Informational filing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier or third party administrator issuing a card pursuant to this subchapter shall make an informational filing of the form of the card with the Department. The filing shall contain the form of the card with all required information specific to the fictitious insured. All variants of the form shall be identified.
(b) Informational filings shall be submitted to the Department at the following address:
New Jersey Department of Banking and Insurance
Attention: Life and Health Division
Health Benefit Card Filings
20 West State Street
PO Box 325
Trenton, NJ 08625-0325
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 9 - MATERNITY INSTALLMENT PAYMENTS › Section 11:22-9.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to implement P.L. 2009, c. 113 by establishing a process whereby, if requested by such a provider, a health insurance carrier shall reimburse a New Jersey licensed obstetrical provider in installments for maternity services rendered by the provider during the term of a covered person's pregnancy.
(b) This subchapter shall apply to all health benefits plans that provide benefits for maternity services and that are delivered, issued, executed or renewed in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 9 - MATERNITY INSTALLMENT PAYMENTS › Section 11:22-9.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the meanings as set forth below unless the context clearly indicates otherwise:
"CPT" means the American Medical Association's Current Procedural Terminology (CPT) maintained by the American Medical Association (AMA). CPT is a code set that accurately describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
"Health benefits plan" means an individual or group contract which pays hospital and medical expense benefits or provides hospital and medical services, and is delivered or issued for delivery in this State by or through a carrier.
"Health insurance carrier" or "carrier" means an insurance company, medical service corporation, health service corporation and health maintenance organization authorized to issue health benefits plans in this State.
"Maternity services" means prenatal care (office visits and screening tests), labor and delivery services (including hospitalization) and postpartum/postnatal care (routine hospital and outpatient visits following delivery).
"Obstetrical provider" or "provider" means an obstetrician/gynecologist licensed by the State Board of Medical Examiners or a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 9 - MATERNITY INSTALLMENT PAYMENTS › Section 11:22-9.3 - General requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Obstetrical providers may elect to be reimbursed for maternity services rendered to a covered person on either a global basis (one payment for all services rendered during the term of a covered person's pregnancy for antepartum care, delivery and postpartum care) or on an installment basis (more than one payment for services rendered during the term of a covered person's pregnancy).
(b) Carriers shall permit providers to elect at least annually whether to be reimbursed for maternity services on a global or an installment basis. Such election shall be made in writing and take effect with respect to pregnancies beginning on or after 30 days following receipt of notice by the carrier. Written notice of the provider's election may be effectuated via mail, fax, e-mail or web-based provider portal.
(c) Providers shall be permitted to opt out of their initial election to be reimbursed in installments at any time within the first year following that election and annually thereafter for any given provider taxpayer identification number. Carriers may require that the election change be in writing. Carriers shall not defer application of the change more than 30 days following receipt of the election change.
(d) Any such election as described in (b) or (c) above shall be made with respect to all providers billing under the same provider identification number unless otherwise agreed to by the provider and the carrier.
(e) In the absence of an installment election, carriers shall reimburse providers billing for services rendered on a global basis based on billings actually received, subject to the carrier's reasonable requests for medical records and other documentation necessary to establish the appropriate payment.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 9 - MATERNITY INSTALLMENT PAYMENTS › Section 11:22-9.4 - Global reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For providers electing to be reimbursed for maternity services on a global basis, carriers shall accept billings under the CPT codes most current to the date of billing for services as published by the AMA for global routine maternity care. The global routine maternity care CPT codes as of July 5, 2011 are the following:
1. 59400--Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care;
2. 59510--Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care;
3. 59610--Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery; and
4. 59618--Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 9 - MATERNITY INSTALLMENT PAYMENTS › Section 11:22-9.5 - Installment reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For providers electing to be reimbursed for maternity services on an installment basis, carriers shall remit at least three equal installment payments during the term of the covered person's pregnancy as follows:
1. Following the 12th week of pregnancy;
2. Following the 28th week of pregnancy; and
3. Following delivery.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 1 - GENERAL PROVISIONS › Section 11:23-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter sets forth the licensing and registration requirements of third party administrators of health benefits plans and the certification requirement of third party billing services in accordance with the provisions of 17B:27B-1 et seq.
(b) This chapter applies to all persons who act as, offer to act as, or hold themselves out to be, a third party administrator of health benefits plans or third party billing service in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 2 - LICENSE OR REGISTRATION REQUIREMENTS FOR THIRD-PARTY ADMINISTRATORS › Section 11:23-2.1 - License or registration required

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No person shall act as, offer to act as, or hold himself or herself out to be, a third party administrator in this State unless licensed or registered by the Commissioner as set forth in 11:23-2.2.
(b) Every third party administrator that is either not licensed in New Jersey as an insurer or an organized delivery system and is not an affiliate or subsidiary of an insurer licensed in New Jersey, or an affiliate or a subsidiary of a New Jersey licensed insurer and only processes or pays claims on behalf of benefits payers other than insurers shall be licensed by the Commissioner pursuant to the provisions of the Act.
(c) Every third party administrator that is a subsidiary or affiliate of an insurer licensed in New Jersey and processes claims on behalf of both that insurer and benefits payers other than that insurer shall be required to register with the Commissioner pursuant to the provisions of the Act.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 2 - LICENSE OR REGISTRATION REQUIREMENTS FOR THIRD-PARTY ADMINISTRATORS › Section 11:23-2.3 - Standards for approval of applications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may issue a license to an applicant or approve an application for registration as a third party administrator if he or she finds that the applicant meets the following standards:
1. All of the materials required by the Act, this chapter or by the Commissioner have been filed;
2. The persons responsible for conducting the applicant's affairs are competent, trustworthy and possess good reputations, and have appropriate experience, training and education;
3. The applicant has demonstrated the ability to assure that its services will be performed in a manner which will ensure the efficient operation of its business, including appropriate financial controls;
4. The standard contract forms to be used by the applicant are acceptable;
5. The applicant has adequate financial arrangements with the benefits payers for which it will perform its services and adequate arrangements for complying with the provisions of 17B:30-23 et seq. and N.J.A.C. 11:22-1 and 3, if applicable;
6. The compensation arrangements made between the applicant and benefits payers do not result in the assumption of financial risk by the applicant;
7. The name used by the applicant to do business in this State does not so closely resemble the name of an insurer authorized to do business in this State or otherwise include such descriptive language as to be likely to mislead the public with respect to the nature of its business operations; and
8. The applicant meets all requirements of the Act and these rules and demonstrate the ability to continue to meet all those requirements.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 2 - LICENSE OR REGISTRATION REQUIREMENTS FOR THIRD-PARTY ADMINISTRATORS › Section 11:23-2.4 - Procedures for review of applications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The time period for the Department's review of an application shall commence the day the application is received.
(b) The Department shall advise the applicant if the application is incomplete not later than 60 days after receipt of the application.
(c) The application shall be deemed to be complete and approved if the applicant is not notified that the application is incomplete or disapproved within 60 days of the receipt of the application. If approval is deemed, the applicant shall notify the Department in writing of its intent to rely on a deemed approval prior to commencing operations.
(d) Notice to the applicant that the application has been found to be incomplete shall specify the missing item(s) or information.
(e) Any resubmission of the application after the deficiency has been cured shall be considered initial receipt.
(f) The Department may disapprove an incomplete application.
(g) Prior to approving an application, the Department may request that an applicant provide, in writing, any additional information that the Department deems necessary to consider the application. Failure by an applicant to provide the requested information to the Department within 45 days from the date of the Departments written request shall result in an application being deemed withdrawn without further notice.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 2 - LICENSE OR REGISTRATION REQUIREMENTS FOR THIRD-PARTY ADMINISTRATORS › Section 11:23-2.5 - Denial of application

Current through Register Vol. 56, No. 14, July 15, 2024
The Commissioner may deny an application for licensure or registration as a third party administrator if he or she finds that any of the standards established by the Act or these rules have not been met or for any other reasonable grounds. If the application for licensure or registration is denied, the Commissioner shall notify the applicant in writing by certified mail, return receipt requested, setting forth his or her reasons for denial. The applicant may request a hearing by notice to the Commissioner no later than the 30th day following receipt of the notice of denial.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 2 - LICENSE OR REGISTRATION REQUIREMENTS FOR THIRD-PARTY ADMINISTRATORS › Section 11:23-2.6 - Organizational examinations

Current through Register Vol. 56, No. 14, July 15, 2024
In addition to the application review, an organizational investigation or examination may be performed before or after an applicant is licensed or registered as a third party administrator. Such investigation or examination shall consist of a general survey of the third party administrators corporate records, including charter, bylaws and minute books; verification of net worth; verification of principal place of business; determination of assets and liabilities; and a review of such other factors as the Commissioner deems necessary. The materials related to such an investigation or examination shall be confidential as set forth in 17B:27B-7.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.1 - Third party administrator agreement with benefits payer

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A third party administrator shall not conduct any business with a benefits payer in the absence of a written agreement between the administrator and the benefits payer. This subsection shall not apply to a third party administrator registered in accordance with 11:23-2.1(c)  with respect to services performed for an insurer.
(b) The agreement shall be retained as part of the official records of the administrator for the duration of the agreement and for five years thereafter.
(c) The provisions of the agreement shall include, but shall not be limited to:
1. All services, including services other than processing and payment of claims, to be provided by the administrator and the manner in which the administrator is to be compensated;
2. The responsibilities of the benefits payer to the administrator with respect to claims to be paid by the administrator on behalf of the benefits payer, including:
i. The provision of enrollment and eligibility information;
ii. Arrangement for a preliminary or escrowed deposit of funds by the benefits payer, if any;
iii. The method used for the transmittal of funds from the benefits payer to the administrator;
iv. Notification by the benefits payer of modifications in the benefits payer's benefits plan;
v. Provisions setting forth the respective liability of the administrator and benefits payer for payment of ineligible claims;
vi. Liability for claim payments that are overdue; and
vii. Provisions regarding the procurement of reinsurance or stop-loss insurance;
3. The responsibilities of the administrator to the benefits payer, including:
i. The maintenance of appropriate back-up systems against the loss of records;
ii. Establishment and maintenance of appropriate financial controls;
iii. Provisions regarding the benefits payer's rights with respect to the conducting of claims audits by an outside auditor;
iv. The maintenance of appropriate insurance coverage, which shall include general liability insurance, valuable papers insurance and errors and omissions coverage and such other coverage as is appropriate to the form of organization and nature of the business of the third party administrator;
v. Appropriate access by the benefits payer to the administrator's records;
vi. Procedures for making available the claims experience and other claims-related information to the benefits payer at its request, including, but not limited to, monthly reports; and
vii. Preparation or provision of data required for prompt-pay reports and payment of any penalties payable under the contract; and
4. Specific performance standards, evaluation criteria and monetary amounts of penalties payable under the contract.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.2 - Access to certain information by the Commissioner

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner shall have access to all books and records of a third party administrator for the purposes of examination, audit and inspection, the reasonable expense of which shall be paid to the Department by the third party administrator. Any trade secrets, proprietary information, information which if disclosed would give an advantage to competitors or bidders and the identities and addresses of enrollees contained in the books and records shall be kept confidential, except that the Commissioner may use the information in any proceeding instituted against the administrator or benefits payer.
(b) The benefits payer shall own the records generated by the administrator pertaining to the benefits payer, except that the administrator shall retain the right to continuing access to such books and records to permit the administrator to fulfill all of its contractual obligations to the benefits payer and its obligations to the Department.
(c) In the event that an agreement between an administrator and a benefits payer is canceled, the administrator may, with the written agreement of the benefits payer, transfer all records to a new administrator instead of retaining them for five years.