New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 6 - EXCLUSIONS AND PREAUTHORIZATION REQUIREMENTS › Section 11:22-6.2 - 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.
"Act of war" means any act peculiar to military, naval or air operations in time of war.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefit plans in this State.
"Covered person" means a person on whose behalf a carrier is obligated to pay benefits or provide services pursuant to the health benefits plan.
"Health benefits plan" means any hospital and medical expense insurance policy or certificate; health, hospital, or medical service corporation contract or certificate; or health maintenance organization subscriber contract or certificate delivered or issued for delivery in this State by any carrier. For purposes of this subchapter, "health benefits plan" shall not include one or more, or any combination of, the following: coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefit plans shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in Federal regulations. Health benefit plans shall not include hospital confinement indemnity coverage if: the benefits are provided under a separate policy, certificate or contract of insurance; there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor; and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. Health benefits plan shall not include the following if it is offered as a separate policy, certificate or contract of insurance: Medicare supplemental health insurance as defined under section 1882(g)(1) of the Federal Social Security Act ( 42 U.S.C. §
										1395ss(g)(1) ); and coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code ( 10 U.S.C. §§
										1071 et seq.); and similar supplemental coverage provided to coverage under a group health plan.
"Home area" means the 50 states of the United States of America, the District of Columbia and Canada.
"Preauthorization" means the process by which carriers determine the medical necessity and/or medical appropriateness of otherwise covered treatments and procedures prior to the rendering of such treatments and procedures including, but not limited to, preadmission review, pretreatment review, utilization and case management.
"War" includes, but is not limited to, declared war, and armed aggression by one or more countries resisted on orders of any other country, combination of countries or international organization.