reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.3 - Adjudication of claims; compensation

Current through Register Vol. 56, No. 14, July 15, 2024
If a third party administrator adjudicates claims under a health benefits plan, the commissions, fees or charges that the benefits payer pays the administrator shall not be based solely on the number or amount of claims denied or adjusted downward by the administrator. This provision shall not prohibit an administrator from receiving performance-based compensation if that compensation is not predicated on denial or downward adjustment of claims or coverage.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.4 - Fiduciary capacity of third party administrator; fidelity bond to be maintained

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A third party administrator shall be deemed to act in a fiduciary capacity on behalf of the benefits payer in the receipt and transmittal of the funds of a benefits payer, and shall have all responsibility attendant to a fiduciary as established by law.
(b) An administrator shall maintain in force a fidelity bond in its own name on its directors, officers, partners and employees.
(c) The minimum amount of the fidelity bond shall be the greater of $ 100,000 or one percent of the total amounts received from benefits payers in the previous calendar year for the purpose of paying claims on behalf of benefits payers.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.5 - Funds to be maintained in separate accounts

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All funds remitted to an administrator by a benefits payer licensed or authorized to do business in this State shall be held by the third party administrator in a separate account maintained in the name of the benefits payer, or in a separate account maintained jointly in the names of the benefits payer and the administrator.
(b) If funds have been collected by the administrator from a provider or enrollee on behalf of a benefits payer, they shall be promptly deposited into a separate account maintained in the name of the benefits payer or an account maintained jointly in the names of the benefits payer and the administrator, or remitted to the benefits payer, as provided in the contract. Funds shall not be commingled with any other funds of the administrator or other clients of the administrator. Copies of all records pertaining to the collection of funds shall be made available to the benefits payer as provided in the contract.
(c) If an account is jointly held by the administrator and the benefits payer, it shall be maintained in a State or Federally chartered insured depository institution, and the administrator shall provide the benefits payer with a monthly accounting of all transactions in that account.
(d) A benefits payer shall have the responsibility to make available to the administrator funds necessary to enable the administrator to pay claims in a timely manner, as provided in the contract. An administrator shall not be liable to any party for the failure of the benefits payer to make funds available to pay claims.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.6 - Prompt delivery of certain information

Current through Register Vol. 56, No. 14, July 15, 2024
Any policies, certificates, booklets, termination notices or other written communications delivered by the benefits payer to the third party administrator for delivery to enrollees shall be delivered by the administrator promptly, in accordance with the instructions of the benefits payer and the terms of their contract.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.7 - Notification of material change

Current through Register Vol. 56, No. 14, July 15, 2024
A third party administrator shall immediately notify the Commissioner in writing of any material change in its ownership, control, or other fact or circumstance affecting its qualifications for a licensure or registration, as applicable, including, but not limited to, a change in name, new or revised standard contracts, or any other information required by this subchapter to be supplied with an initial license application. The notification shall be provided to the Commissioner at:
New Jersey Department of Banking and Insurance
Office of Solvency Regulation
PO Box 325
Trenton, NJ 08625-0325
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.8 - Annual report

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A third party administrator shall file with the Commissioner on or before June 1 of each year an annual report for the preceding calendar year that shall consist of an audited and an unaudited part. The unaudited part shall contain the complete names and addresses of all benefits payers with which the administrator had a contract in effect during the preceding calendar year, and the status of all contracts in effect in the previous year.
(b) The audited part of the annual report for the preceding calendar year shall be prepared on a generally accepted accounting principles (GAAP) basis. If the financial affairs of the third party administrators parent company are audited by an independent certified public accountant, but those of the third party administrator are not, then a copy of the most recent audited financial statement of the third party administrators parent company, audited by an independent certified public accountant, shall be submitted.
(c) The filing fee for the annual report shall be $ 100.00.
(d) One signed copy of each part of the annual report shall be submitted to:
New Jersey Department of Banking and Insurance
Office of Solvency Regulation
PO Box 325
Trenton, NJ 08625-0325
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 3 - THIRD PARTY ADMINISTRATORS › Section 11:23-3.9 - Services provided to self-funded multiple employer welfare arrangements

Current through Register Vol. 56, No. 14, July 15, 2024
No third party administrator shall contract with or on behalf of a self-funded multiple employer welfare arrangement (MEWA) which is not duly registered with the Department pursuant to 17B:27C-1 et seq. It shall be the responsibility of the third party administrator to verify that a MEWA is so registered. The third party administrator shall be diligent in monitoring the status of the MEWA and shall report any change in status as a material change pursuant to 11:23-3.7.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 4 - SUSPENSION OR REVOCATION OF LICENSE OR REGISTRATION › Section 11:23-4.1 - Suspension or revocation of license; grounds and penalties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may suspend or revoke a license or registration issued pursuant to the Act if he or she finds that the third party administrator:
1. Is in an unsound financial condition;
2. Is using methods or practices in the conduct of its business that render its further transaction of business in this State hazardous or injurious to the benefits payers with which it has contracted or the public;
3. Has failed to pay any judgment rendered against it in this State within 60 days after the judgment has become final;
4. Has violated any lawful rule or order of the Commissioner or any provision of State law;
5. Has refused to be examined or to produce its accounts, records and files for examination, or if any of its officers have refused to supply information with respect to its affairs, or has refused to perform any other legal obligation as to an examination, when required by the Commissioner;
6. Has, without just cause, refused or failed to pay proper claims or perform services arising under its contracts;
7. At any time fails to meet any requirement, on the basis of which issuance of the initial license could have been refused had that failure then existed and been known to the Commissioner;
8. Has been convicted of, or has entered a plea of guilty or nolo contendere to a felony or crime of the first, second or third degree in this State, without regard to whether adjudication was withheld;
9. Has had a credential as a third party administrator suspended, revoked or non-renewed for cause in another state;
10. Has willfully reimbursed enrollees for benefits not eligible under the benefits payer's benefits plan;
11. Has provided false or inaccurate information in the certification provided with an initial application for licensure or registration pursuant to 11:23-2.2(a)  or in any other submission to the Department; or
12. Has contracted with or on behalf of a self-funded multiple employer welfare arrangement (MEWA) which is not registered pursuant to 17B:27C-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 4 - SUSPENSION OR REVOCATION OF LICENSE OR REGISTRATION › Section 11:23-4.2 - Temporary suspension of license or registration; grounds and penalties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may, without advance notice or hearing, enter an order temporarily suspending the license or registration of a third party administrator if he or she finds that one or more of the following circumstances exist:
1. The administrator is insolvent or impaired;
2. A proceeding for receivership, conservatorship, rehabilitation or other delinquency proceeding regarding the administrator has been commenced in another state; or
3. The financial condition or business practices of the administrator otherwise pose an imminent threat to the public health, safety or welfare of the residents of this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 4 - SUSPENSION OR REVOCATION OF LICENSE OR REGISTRATION › Section 11:23-4.3 - Civil penalties

Current through Register Vol. 56, No. 14, July 15, 2024
The Commissioner may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $ 250.00 nor more than $ 5,000 for each day that a third party administrator is in violation of the Act. A penalty imposed by the Commissioner pursuant to this section may be in lieu of, or in addition to, suspension or revocation of a license or registration pursuant to the Act. A penalty may be recovered in a summary proceeding pursuant to the "Penalty Enforcement Law of 1999," P.L. 1999, c. 274 (2A:58-10 et seq.).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.1 - Acting as, or holding oneself out as, a third party billing service; certification 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 billing service in this State unless certified by the Commissioner in accordance with the Act.
(b) All third party billing services shall obtain certification prior to operating in this State.
(c) Except for those who apply for a temporary initial certification by August 2, 2005, all third party billing services shall obtain certification prior to operating in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.3 - Information to be provided to Commissioner

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to the information otherwise required by the Act, these rules, or based upon the unique facts of particular cases, by the Commissioner, a third party billing service shall file with the Commissioner:
1. A description of the applicant's proposed method of marketing its services;
2. A statement setting forth the manner in which the applicant is to be compensated;
3. A description of the quality assurance procedures established by the applicant; and
4. A description of the procedures for prompt submissions of claims to a benefits payer other than an automobile insurer pursuant to the provisions of 17B:30-23 and N.J.A.C. 11:22-3.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.4 - Approval of certification application; standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may approve an application for certification as a third party billing service if he or she finds that the applicant meets the standards established by the Act, including, but not limited to, the following:
1. All of the information required by the Act, these rules or by the Commissioner has 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 ensure that its services will be performed in a manner which will result in the efficient operation of its business, including, if the applicant accepts payments from benefits payers on behalf of its clients, appropriate financial controls;
4. The standard contract forms to be used by the applicant are acceptable; and
5. The applicant has adequate arrangements for complying with the provisions of 17B:30-23 et seq. and N.J.A.C. 11:22-3.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.5 - Denial of application for certification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may deny an application for certification as a third party billing service 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.
(b) If the application for certification is denied, the Commissioner shall notify the applicant in writing by certified mail, return receipt requested, setting forth the reasons for the denial.
(c) 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 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.6 - Written agreement between third party billing service and client

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A third party billing service shall not conduct any business with a client in the absence of a written agreement between the billing service and the client. The agreement shall be retained as part of the official records of the third party billing service for the duration of the agreement.
(b) The agreement shall include:
1. The services to be provided by the third party billing service on behalf of the client;
2. Financial arrangements to be used if the third party billing service accepts monies from benefits payers on behalf of a client;
3. Provisions setting forth the respective liability of the client and the third party billing service for the accuracy and eligibility of submitted claims, and for the prompt submission of claims to a benefits payer other than an automobile insurer pursuant to the provisions of 17B:30-23 and N.J.A.C. 11:22-3; and
4. The responsibilities of the third party billing service to the client with respect to the maintenance of appropriate back-up systems against the loss of records, and the maintenance of appropriate insurance coverage by the third party billing service against the risk of loss.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.7 - Fiduciary duty of third party billing service; maintenance of separate accounts

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A third party billing service that accepts monies from benefits payers on behalf of a client shall be deemed to act in a fiduciary capacity on behalf of the client in the receipt and transmittal of funds and shall have all responsibility attendant to a fiduciary as established by law.
(b) Monies transmitted by benefits payers or on behalf of clients shall be kept in a separate account maintained in the name of the client or jointly in the names of the client and the third party billing service, and shall not be commingled with any other funds of the third party billing service or other clients of the third party billing service.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.8 - Notification of material change in ownership or control of, or in other previously supplied information related to the billing service

Current through Register Vol. 56, No. 14, July 15, 2024
A third party billing service shall immediately notify the Commissioner of any material change in its ownership, control, or other fact or circumstance affecting its continuing qualification for Certification.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.9 - Suspension or revocation of certification; grounds

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may suspend or revoke a certification issued pursuant to the Act if he or she finds that the third party billing service:
1. Is using methods or practices in the conduct of its business that render its further transaction of business in this State hazardous or injurious to its clients or to the public;
2. Has failed to pay any judgment rendered against it within 60 days after the judgment has become final;
3. Has violated any lawful rule or order of the Commissioner or any provision of the laws of this State;
4. Has, without just cause, refused or failed to perform services arising under its contracts with clients;
5. Has been convicted of, or has entered a plea of guilty or nolo contendere to a felony or crime of the first, second or third degree in this State, without regard to whether adjudication was withheld; or
6. Has had its credential as a third party billing service suspended, revoked or non-renewed for cause in another State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 5 - THIRD-PARTY BILLING SERVICES › Section 11:23-5.10 - Civil penalties

Current through Register Vol. 56, No. 14, July 15, 2024
The Commissioner may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $ 250.00 nor more than $ 5,000 for each day that a third party billing service is in violation of the Act. A penalty imposed by the Commissioner pursuant to this section may be in lieu of, or in addition to, suspension or revocation of a certification pursuant to the Act. A penalty may be recovered in a summary proceeding pursuant to the "Penalty Enforcement Law of 1999," P.L. 1999, c. 274 (2A:58-10 et seq.).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 1 - SCOPE AND DEFINITIONS › Section 11:24-1.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The rules in this chapter were developed by the Commissioner of Health and Senior Services in collaboration with the Commissioner of Banking and Insurance and govern the establishment and operation of health maintenance organizations in New Jersey pursuant to the authority set forth in 26:2J-1 et seq. These rules are only applicable to managed care plans that constitute a health maintenance organization as defined herein and in 26:2J-1 et seq.
(b) The provisions of these rules shall apply, except where in conflict with:
1. Any individual contract issued by a health maintenance organization (HMO) to the extent that the contract is formulated in accordance with the provisions of the New Jersey Individual Health Coverage Program established pursuant to 17B:27A-1 et seq.; or
2. Any contract issued to a small employer by a HMO to the extent that the contract is formulated in accordance with the provisions of the New Jersey Small Employer Health Coverage Program established pursuant to 17B:27A-17 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.1 - Certificate of need and licensing

Current through Register Vol. 56, No. 14, July 15, 2024
Any health maintenance organization (HMO) which proposes the establishment and/or operation of a health care facility or any change in or expansion of a health care facility, or the institution of new health care services as defined in the Health Care Facilities Planning Act ( 26:2H-1 et seq.) shall comply with all pertinent provisions of the Act, as amended and N.J.A.C. 8:33, Certificate of Need application and Renewal process, and all applicable health planning and licensing rules and regulations.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.2 - Application for a new or amended certificate of authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any person, organization , or corporation desiring to establish and/or operate an HMO shall apply to the Commissioner for a certificate of authority, pursuant to N.J.S.A. 26:2J-1 et seq. Applications for a certificate of authority may be obtained from:
New Jersey Department of Banking and Insurance
Valuations Bureau
Office of Solvency Regulation 20 West State Street
PO Box 325
Trenton, NJ 08625-0325
http://www.state.nj.us/dobi/division insurance/managedcare/mcapps.htm#hmo
1. Two copies of the entire application shall be submitted to the Department at the above address; and
2. If the applicant proposes to be a Medicaid program participant, one copy of the application shall be submitted to:
New Jersey Department of Human Services
Office of Managed Health Care
Division of Medical Assistance and Health Services
PO Box 712
Trenton, NJ 08625-0712
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.3 - Issuance of a certificate of authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A certificate of authority to establish and operate an HMO to service commercial enrollees shall be issued upon approval of the Commissioner.
(b) A certificate of authority to establish and operate an HMO to service both Medicaid and commercial enrollees shall not be approved for purposes of serving Medicaid enrollees until such time that the Commissioner has received and considered the recommendation of the Department of Human Services, Division of Medical Assistance and Health Services on the applicant's compliance with the State and Federal requirements of a contract between the applicant and the Department of Human Services.
(c) Issuance of a certificate of authority shall be granted upon demonstration of compliance, to the satisfaction of the Commissioner, with these rules and the requirements in 26:2J-1 et seq.
(d) Prior to issuance of a certificate of authority, a preoperational audit shall be conducted by the Departments of Banking and Insurance and/or Human Services to evaluate the HMO's ability to perform essential functions including, but not limited to, claims processing, utilization management and quality assurance protocols, adequacy of accounting and information systems, operational and financial controls, and network adequacy. The applicant shall bear all reasonable costs associated with conducting the preoperational audit, including, but not limited to, outside consultant and subcontractor fees.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.4 - Comprehensive assessment reviews

Current through Register Vol. 56, No. 14, July 15, 2024
(a) After issuance of a certificate of authority, the HMO shall undergo a comprehensive assessment review by the Department on a triennial basis.
(b) The comprehensive assessment review conducted by the Department may include an on-site review and shall be based upon the Department's review of the following:
1. A filing of information by the HMO of any substantial change to operations identified in 11:24-2.7 not previously filed with the Department. This filing shall not require the submission of any documents previously filed with the Department, if such documents have remained valid and unchanged since their original filing;
2. The results of the HMO's external quality audit, as required at 11:24-7.2;
3. A statement from the HMO attesting that it or any affiliate certified or licensed as an HMO or health insuror has been in substantial compliance with all applicable state and Federal rules and/or regulations for the last 12 months in any other state in which it has been approved to do business; and
4. All network adequacy, utilization management, continuous quality improvement, performance and outcome measurements or other data or information provided for in this chapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.5 - Denial of a certificate of authority

Current through Register Vol. 56, No. 14, July 15, 2024
Subject to the provisions of 26:2J-22, an application for a certificate of authority or amendment thereto may be denied if the Commissioner finds noncompliance with these rules or any provision of 26:2J-1 et seq., or otherwise finds the HMO or other affiliated entity operating as an HMO or regulated health insurance business to be in violation of any other applicable New Jersey, other State or Federal law where these violations have resulted in an enforcement action, and the applicant owned, operated, or managed in whole or in part, the HMO which was the subject of the action during the 12 month period preceding the filing of the application.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.6 - Amendment to an approved certificate of authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a) After issuance of a certificate of authority, any HMO which proposes to expand or reduce its service area, change the operational model of its health care delivery system, subcontract its complaint and appeal process, quality improvement, utilization management functions, credentialing, marketing, claims processing, or network management, engage in a transaction that results in any person having ownership of 10 percent or greater control of the HMO, or initiate a contract with Medicaid and/or Medicare shall be subject to the approval of the Commissioner for an amendment to the HMO's certificate of authority. Actions that shall require an amendment include, but are not limited to:
1. A change in the operational model of the health care delivery system, including, but not limited to:
i. A group model converting to or adding an individual practice association (IPA); or
ii. An IPA model converting to or adding a group model, including establishment of the initial health center in any service area.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.7 - Notice of changes in HMO operations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Following issuance of a certificate of authority, the HMO shall notify the Department, in writing, of any substantial change to items identified at 11:24-2.2(c)1  through 24, at least 30 days prior to the date when such change is expected to occur. The Department shall deem such change approved within 30 days from the date of receipt of notice of the change unless the Department notifies the HMO otherwise. Substantial changes include, but are not limited to:
1. Any change or reduction in the provider network that adversely impacts network adequacy requirements identified at N.J.A.C. 11:24-6;
2. The subcontracting of any major functions not specified at 11:24-2.6(a)  to another entity;
3. The nonrenewal of a hospital provider's contract which shall be reported in accord with 11:24-3.5(b); and
4. The establishment of a new group health center in a county or service area that has previously received certificate of authority approval for initiation of group health center services in that area.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.8 - Approval of a point of service (POS) plan

Current through Register Vol. 56, No. 14, July 15, 2024
In addition to the requirements set forth in 11:24-2.7, any HMO proposing to enter into an arrangement for the provision of out-of-network covered services to members shall also comply with the requirements delineated in N.J.A.C. 11:24-14.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.9 - Changes in ownership interests

Current through Register Vol. 56, No. 14, July 15, 2024
Any change of control of the HMO shall be subject to review and approval by the Commissioner pursuant to the New Jersey Insurance Holding Company Systems Act, 17:27A-1 et seq., and implementing rules, including N.J.A.C. 11:1-35.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.10 - Surrender of a certificate of authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as the Holding Company Systems Act, 17:27A-1 et seq. and rules promulgated pursuant thereto may apply and require otherwise, in the event that an HMO voluntarily ceases operation, it shall provide at least 90 business days advance notice to all members, employers, providers and the Department. The notice shall identify the storage location of medical records, where applicable, and procedures for obtaining copies of such records.
(b) Every HMO intending to surrender a certificate of authority shall provide a plan at least 90 business days in advance of the surrender to the Department to assure continuity of coverage and medical care and assistance to members, as necessary, in accordance with 11:24-12.2.
(c) Except as the Holding Company Systems Act, 17:27A-1 et seq. and rules promulgated pursuant thereto may apply and require otherwise, when the surrender is due to an acquisition or merger, the certificate of authority shall remain active and obligations of the surrendering HMO shall remain in effect until the termination notices and requirements of the IHC and SEH programs are met and all liabilities of the HMO surrendering its certificate of authority are assumed by the surviving entity, or are otherwise extinguished.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.11 - Registered agent

Current through Register Vol. 56, No. 14, July 15, 2024
Each HMO shall maintain an office in New Jersey and provide the Department with the name and address of its registered agent or else a power of attorney duly executed by such applicant, if not domiciled in this State, appointing the Commissioner and his or her successors in office, and duly authorized designees, as the true and lawful attorney of such applicant in and for this State upon whom all lawful process in any legal action or proceeding against the HMO on a cause of action arising in this State may be served. The HMO shall assure in writing that it submits to New Jersey jurisdiction for all New Jersey laws and regulations and that it shall submit to inspections by Department staff at any out of state site.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.12 - Examinations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department may conduct an examination of the HMO annually, but in no case less than once every three years, concerning the quality of health care services and other affairs of the HMO, including providers with whom such organization has contracts, agreements, or other arrangements. This examination may include, but not be limited to, the review of documents, patient records, information required in 11:24-3.6, and conferences with providers and members. The HMO shall be assessed an amount authorized at 26:2J-18, as may be amended, to offset the expenses of examination under this section. The fee shall be remitted within 90 days following the date of the assessment.
(b) The Department shall incorporate the annual examination process as described above into the comprehensive assessment review process.
(c) The Department may conduct special examinations at any time to ascertain whether the HMO is in compliance with this chapter and all applicable State and Federal statutes and regulations. A report of this examination shall be provided to the HMO within 30 business days of completion of the special examination. Any violations resulting from this examination shall be identified and responded to in accordance with 11:24-2.1 3.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.13 - Violations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A violation may be cited by the Commissioner or his or her designee upon determination that the HMO does not comply with the rules in this chapter and 26:2J-1 et seq.
(b) At the conclusion of an examination, or within 30 business days thereafter, the Department shall provide the HMO with a written summary of violations of this chapter and any factual findings used as a basis to determine that a violation has occurred.
(c) The Department may require that the HMO submit a written plan of correction specifying how each violation that has been cited will be corrected along with the time frames for completion of each corrective action. A single plan of correction may address all events associated with a given violation. The plan of correction, where required, shall be submitted by the HMO within 20 business days of receipt of the notice of violations, or sooner, if the Commissioner determines that the violations jeopardize the safety of enrollees. The plan of correction shall be reviewed by the Department and shall be approved where the plan demonstrates to the satisfaction of the Department that compliance will be achieved within a reasonable time period. If the plan is not approved, the Department may request that an amended plan of correction be submitted within five business days.
(d) The summary of violations and the written plan of correction shall not be released as public information until such time that the Department has received the plan of correction or, in the event no plan of correction is submitted, 20 business days of receipt of the summary of violations by the HMO, whichever is sooner. Unless otherwise documented, the Department will presume receipt of the summary of violations by the HMO by the third business day if sent by regular mail.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.14 - Enforcement remedies available

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may impose the following enforcement remedies against an HMO for violations of regulations in this chapter or other statutory requirements:
1. A monetary penalty may be imposed for each violation in an amount determined by the Commissioner, which shall be in amounts as authorized by 26:2J-24 (not less than $ 250.00 and not greater than $ 10,000 for each day that the carrier is in violation, based on the severity of the violation, as determined by the Commissioner on a case-by-case basis), as amended from time to time. The Department shall provide the HMO with reasonable notice in writing of the intent to levy the penalty, and a reasonable time, as determined by the Commissioner, within which to correct the violation. Any such penalty may be recovered in a summary proceeding pursuant to the Penalty Enforcement Law (N.J.S.A. 2A:58 et seq.);
2. Suspension of a certificate of authority pursuant to 26:2J-19, which may include the suspension of marketing and enrollment;
3. Revocation of a certificate of authority pursuant to 26:2J-19;
4. An order to cease and desist pursuant to 26:2J-24;
5. Institution of a proceeding to obtain injunctive relief pursuant to 26:2J-24;
6. Other remedies for violations of statutes, as provided by State or federal law.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS › Section 11:24-2.15 - Hearings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to 26:2J-22, if the Commissioner proposes to suspend, revoke, or deny a certificate of authority, or issues a cease and desist order, the Commissioner shall notify the HMO in writing, specifically stating the grounds for such denial, suspension, revocation, or order and fixing a time of at least 20 days thereafter for a hearing on the matter.
(b) If the Commissioner levies a civil penalty, the HMO has a right to request a hearing on the matter, which must be filed within 20 days of receipt of the notice.
(c) The hearing will be conducted through the Office of Administrative Law in accordance with the Administrative Procedures Act, 52:14B-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
(d) After such hearing or upon failure of the HMO to request a hearing, the Commissioner shall make a final determination based on written findings and make such findings available to the HMO.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.1 - Compliance with laws and rules

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall comply with the provisions of the New Jersey Health Maintenance Organizations Act, 26:2J-1 et seq.
(b) The HMO shall comply with applicable Federal, state, and local laws, rules and regulations.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.2 - Nondiscriminatory enrollment practices

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as provided in 11:24-3.4(a), an HMO shall not refuse to renew the coverage of a member covered under a contract for basic health care services, or alter the terms of, or cancel, an existing contract solely on the basis of the following:
1. The health of the member;
2. The age of the member;
3. The sex of the member;
4. The frequency of the member's use of the health care services of the HMO;
5. The filing of a complaint or appeal by the member as permitted by these rules; or
6. Other reasons prohibited by the Trade Practices Act, N.J.S.A. 17B-30-1 et seq., or the New Jersey Law Against Discrimination, N.J.S.A. 10:5-1.1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.3 - Open enrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) After an HMO has been in operation for 24 months, it shall have an annual open enrollment period for its group contracts for basic health care services of at least one month during which it accepts members up to the limits of its capacity, as determined by the HMO, in the order in which they apply for membership. Such requirement for annual open enrollment is not applicable to contracts executed pursuant to 17B:27A-18 and 19.
(b) Notwithstanding (a) above, HMOs providing or arranging for basic health care services on a group contract basis may limit the open enrollment to all members of the group or groups covered by such contracts.
(c) The HMO shall notify its subscribers in writing, both at the time of enrollment and through a notice in the promotional material which it distributes to prospective members, that, unless the member moves his or her place of residence outside of the HMO's designated service area, a person's choice of health benefits plan generally will determine his or her coverage until the next annual open enrollment period, regardless of the continued availability of a particular health care provider who contracts with the HMO.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.4 - Member contract termination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A member shall not have his or her membership in an HMO cancelled except for the following reasons:
1. Failure to pay the premiums and other applicable charges for such coverage, including copayment coinsurance and deductibles;
2. Failure to abide by the rules and/or policies and procedures of the HMO;
3. Fraud or material misrepresentation affecting coverage, including misuse of a member identification card; or
4. The group of which the individual is a member is not renewed in accordance with the HMO's underwriting guidelines or is cancelled for failure to pay premiums.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.5 - Provider contract termination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall establish a policy governing termination of health care professionals and other providers. The policy shall include at least:
1. Standards by which the HMO will provide notice to the provider of termination of his or her participation in the time and manner specified in the provider's contract.
i. In instances in which the contract is terminated prior to the contract's renewal date, the HMO shall provide health care professionals with at least 90-days written notice of the termination, specifying the health care professional's right to a hearing before a panel appointed by the HMO.
(1) The HMO shall provide in writing the reasons for the termination, if requested by the health care professional, within no more than 15 days of receipt of the request if the reason is not otherwise stated in the written notice of termination.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.6 - Hearings for provider terminations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A health care professional shall have the right to request in writing a hearing within 10 business days following the date of receipt of notice of termination of the health care professional occurring prior to the date of termination from an HMO's network stated in the provider agreement.
1. A contract shall be deemed to have terminated, creating the right to a hearing, whenever a contract terminates on any date other than a designated renewal or anniversary date of the contract, except that no such right shall exist with respect to terminations described at 11:24-3.5(a)1  ii.
2. If no renewal or anniversary date is specified in the contract, then the renewal or anniversary date shall be deemed to be the month and day in each calendar year on which the contract was originally signed by both parties, or become effective, whichever date is latest.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.7 - Complaint and appeal system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every HMO shall establish and maintain a system to provide for the presentation and resolution of complaints brought by members or by providers acting on behalf of a member and with the member's consent, regarding any aspect of the HMO's health care services, including, but not limited to, complaints regarding quality of care, choice and accessibility of providers, network adequacy and adverse benefit determinations. All such general complaint systems must, at a minimum, incorporate to the satisfaction of the Commissioner, the following components:
1. Written notification to all members and providers of the telephone numbers and business addresses of the HMO employees responsible for complaint resolution;
2. A system to record and document the status of all complaints, which shall be maintained for at least three years;
3. Availability of an HMO member services representative to assist members, as requested, with complaint procedures;
4. Establishment of a specified response time for complaints, not to exceed 30 days from receipt thereof by the HMO or, if applicable, the time frames specified in N.J.A.C. 11:24-8;
5. A process describing how complaints are processed and resolved;
6. Procedures for follow-up action including the methods to inform the complainant of resolution;
7. Procedures for notifying the continuous quality improvement program of all valid complaints related to quality of care; and
8. A mechanism for notifying members and providers in writing that they may contact the Department, in the case of Medicaid enrollees, the Division of Medical Assistance and Health Care Services within the Department of Human Services, or, in the case of Medicare beneficiaries, the Health Care Financing Administration within the United States Department of Health and Human Services, if dissatisfied with the resolution reached through the HMO's internal complaint system.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter 3 - GENERAL REQUIREMENTS › Section 11:24-3.8 - Submission of documents and data

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HMO shall submit all membership, utilization, financial, and descriptive plan information to the Department as requested. This shall include, but is not limited to:
1. A quarterly report on forms prescribed by the Department and specified at 11:24-11.6(d). This report shall be submitted within 45 days after the end of each quarter; and
2. An annual report, a current directory of providers, and a record of all member and provider complaints, inclusive of all malpractice actions, on forms prescribed by the Department, as specified at 11:24-11.6. These reports shall be submitted by March 1 of the following year. The record of member and provider complaints referred to above shall include at least the following:
i. The total number of complaints and utilization management appeals filed within the last year, categorized by cause and disposition;
ii. The average length of time for resolution of each complaint and utilization management appeal by cause or category; and
iii. The number, amount and disposition of malpractice claims settled or adjudicated during the year in which the HMO was a named party to the suit.