New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.2 - 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.
"Affiliate" means a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the organized delivery system.
"Capitation" means a fixed per member, per month, payment or percentage of premium payment for which the provider assumes the risk for the cost of contracted services without regard to the type, value or frequency of the services provided.
"Carrier" means an insurer authorized to transact the business of health insurance as defined at 17B:17-4, a hospital service corporation authorized to transact business in accordance with 17:48-1 et seq., a medical service corporation authorized to transact business in accordance with 17:48A-1 et seq., a health service corporation authorized to transact business in accordance with 17:48E-1 et seq. or a health maintenance organization authorized to transact business pursuant to 26:2J-1 et seq.
"Certified organized delivery system" means an organized delivery system that is compensated on a basis which does not entail the assumption of more than de minimis financial risk by the organized delivery system and that is certified by the Department in accordance with 17:48H-1 et seq.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Comprehensive health care services" means the basic benefits provided under a health benefits plan, including medical and surgical services provided by licensed health care providers who may include, but are not limited to, family physicians, internists, cardiologists, psychiatrists, rheumatologists, dermatologists, orthopedists, obstetricians, gynecologists, neurologists, endocrinologists, radiologists, nephrologists, emergency services physicians, ophthalmologists, pediatricians, pathologists, general surgeons, osteopathic physicians, physical therapists and chiropractors. Basic benefits may also include inpatient or outpatient services rendered at a licensed hospital, covered services performed at an ambulatory surgical facility and ambulance services.
"Consumer Price Index" means the medical component of the Consumer Price Index for all Urban Consumers, as reported by the United States Department of Labor, shown as the average index for New York-Northern New Jersey-Long Island region and the Philadelphia-Wilmington-Trenton-region combined as published by the Commissioner in the New Jersey Register.
"Department" means the New Jersey Department of Banking and Insurance.
"Financial risk" means exposure to financial loss that is attributable to the liability of an organized delivery system for the payment of claims or other losses arising from covered benefits for treatment or health care services other than those performed directly by the person or organized delivery system liable for payment, including a loss sharing arrangement. A payment method wherein a provider accepts reimbursement in the form of a capitation payment for which it undertakes to provide health care services on a prepayment basis shall not per se be considered financial risk. A financial risk shall exist if, under an agreement between the organized delivery system and the carrier, the financial obligations of the organized delivery system for payment of benefits or for providing treatment or health care services does or potentially may exceed any payments that may be received from the carrier. Financial obligation shall include the attendant administrative costs related to providing the treatment or services.
"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier. Health benefits plan includes, but is not limited to, Medicare supplement coverage and risk contracts to the extent not otherwise prohibited by Federal law. For the purposes of this subchapter, health benefits plan shall not include the following plans, policies or contracts: accident only, credit, disability, long-term care, CHAMPUS supplement coverage, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to 39:6A-1 et seq. or hospital confinement indemnity coverage.
"Licensed organized delivery system" means an organized delivery system that is compensated on a basis which entails the assumption of financial risk by the organized delivery system and that is or should be licensed in accordance with 17:48H-1 et seq. and this subchapter.
"Limited health care services" means a health service or benefit which a carrier has elected to subcontract for as a separate service, which may include, but shall not be limited to, substance abuse services, vision care services, mental health services, podiatric care services, chiropractic services or rehabilitation services. Limited health care services shall not include pharmaceutical services, case management services or employee assistance plan services.
"NAIC" means the National Association of Insurance Commissioners.
"Organized delivery system" or "system" means an organization with defined governance that:
1. Is organized for the purpose of and has the capability of contracting with a carrier, directly or indirectly, to provide, or arrange to provide, under its own management substantially all or a substantial portion of the comprehensive health care services or benefits under the carrier's benefits plan on behalf of the carrier, which may or may not include the payment of hospital and ancillary benefits; or
2. Is organized for the purpose of acting on behalf of a carrier, directly or indirectly, to provide, or arrange to provide, limited health care services that the carrier elects to subcontract for as a separate category of benefits and services apart from its delivery of benefits under its comprehensive benefits plan, which limited services are provided on a separate contractual basis and under different terms and conditions than those governing the delivery of benefits and services under the carrier's comprehensive benefits plan. This shall include any agreement to subcontract any separate health care service or benefit, unless expressly excluded herein. An organized delivery system shall not include:
i. An entity otherwise authorized or licensed in this State to provide comprehensive or limited health care services on a prepayment or other basis in connection with a health benefits plan or a carrier;
ii. An entity regulated under 18A:64G-1 et seq.; and
iii. Any professional corporation, professional association; or independent practice association, to the extent such entity's shareholders are comprised solely of providers, and the entity performs no duties or services beyond those for which its shareholders are otherwise licensed in this State.
"Provider" means a physician, health care professional, health care facility, or any other person who is licensed or otherwise authorized to provide health care services or other benefits in the state or jurisdiction in which they are furnished.
"Reserve liabilities" means an amount sufficient to provide for:
1. All claims incurred, whether reported or unreported, which are unpaid and for which the system is or may become liable, including the expense of adjustment or settlement of those claims;
2. Continuing health care services for which a consideration has been received, or a consideration is due but unpaid; and
3. Continuing health care services under the contract to persons who, on the date of termination of the contract, are confined in an inpatient facility until discharge from the facility.