New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.3 - 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.
"Alternative payment" means a type of payment to a DPO contracted dentist based upon a payment methodology approved by the Department.
"Capitation" means a method of compensation by a DPO to its contracted dentists for dental services and supplies provided to covered persons of the DPO on the basis of a fixed periodic payment per covered person or enrollee.
"Commissioner" means the Commissioner of the Department of Banking and Insurance.
"Consultant" means a person who holds himself out as an advisor or renders advice on the organization, financing, administration or operation of a dental plan to any employer, union, trust fund or dental plan organization.
"Covered person" means any person eligible to receive covered benefits or services and supplies under the terms of the dental plan.
"Dental plan" means any contractual arrangement for dental services and supplies to covered persons where contracted dentists are compensated by means of capitation, salary or a method authorized, submitted to and approved by the Commissioner.
"Department" means the Department of Banking and Insurance.
"Dental plan organization" or "DPO" means any person who undertakes to provide directly or to arrange for or administer one or more dental plans providing dental services and supplies.
"Emergency" means procedures to evaluate and stabilize dental conditions of recent onset and severity accompanied by excessive bleeding, severe pain, or acute infections that would lead a prudent layperson possessing an average knowledge of dentistry to believe that immediate care is needed.
"Enrollee" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the dental plan, or in the case of an individual contract, the person in whose name the contract is issued.
"Evidence of coverage" means any certificate, agreement, or contract issued to an enrollee, setting out the dental services and supplies to which the enrollee and his or her dependents are entitled.
"Fee-for-service" is a reimbursement arrangement in which the amount reimbursed for dental services is paid either to an enrollee or to a provider of services and the amount is determined on the basis of the dental procedure performed and/or the amount charged by the dentist for the procedure. An example of a fee-for-service plan is one covering or indemnifying the services provided by dentists on the basis of a schedule of fees or percentage reimbursement of the fee charged, under which the dentist does not share in the "volume of service" risk assumed by the DPO.
"Finder" means a person who brings together a dental plan organization with an employer, union or trust fund for the purpose of establishing a contractual relationship to provide dental services, or facilities or equipment related to the operation of the dental plan or dental plan organization.
"National Association of Insurance Commissioners" or "NAIC" means the National Association of Insurance Commissioners, its affiliates, subsidiaries, any agency or committee thereof, or any successor organization.
"One full-time equivalent dentist" means one dentist working full time or an aggregation of hours spent by more than one dentist on DPO covered person so as to equal a 40-hour week. A full-time general practitioner can serve a group of at least 1,500 covered persons. This number could vary by specialty and service performed; for example, an orthodontist may serve a smaller number of patients than a general practitioner.
"Primary dentist" means a dentist who is not a specialist.
"Specialist" means a dentist whose training and expertise are in a specific area of dentistry. Recognized clinical specialists in dentistry include, but are not limited to, endodontists, oral and maxillofacial surgeons, oral pathologists, orthodontists, periodontists and prosthodontists.
"Specialist pool" means a portion of the premium that is set aside to cover the cost of specialist services not provided by the primary care dentist and not paid on a capitation basis.
"Supplemental dental plan" means an arrangement in which a dentist or group of dentists agrees to relieve patients of paying any patient charges or copayments associated with dental insurance or other dental coverage for a predetermined fee. Supplemental dental plan also means an arrangement which covers less than 50 percent of a covered person's dental expenses regardless of whether the enrollee has other coverage.