Current through Register Vol. 56, No. 18, September 16, 2024
(a) Any person
desiring to establish, operate or administer a dental plan organization shall
apply to the Commissioner for a certificate of authority. An application for a
certificate of authority as a dental plan organization is available on the
Department's website at
www.state.nj.us/dobi/division_insurance/managedcare/dpo_app.pdf
or can be obtained from:
New Jersey Department of Banking and Insurance
Valuation Bureau
Life and Health Division
20 West State Street
PO Box 325
Trenton, NJ 08625-0325
Phone: 609-292-5427
(b) Following the issuance of a Certificate
of Authority, the DPO shall notify the Department in writing 60 days prior to
any significant modification of information submitted with the application, or
subsequently submitted, and shall include the document being modified and an
explanation of the modification. Examples of modifications which are considered
significant include, but are not limited to:
1. Changes in the DPO's organizational
structure;
2. New officers,
partners or members of the DPO's board of directors, board of trustees,
executive committee or other governing board or committee;
3. Changes in the group or individual
contract form issued by the DPO;
4.
Adjustments to financial statements;
5. A change in ownership; and
6. Changes to provider agreements.
(c) No DPO shall use a specialist
pool unless it is filed with the Department for approval. The specialist pool
filing shall be deemed approved upon the expiration of 30 days after it is
filed unless disapproved in writing by the Commissioner within that time. All
specialist pools shall comply with the following requirements:
1. A specialist pool may exist only when the
specialists contract with the DPO to serve as participating dentists, but are
not employees of the DPO;
2. The
procedures for which specialists are responsible, and which are not provided by
primary dentists, shall be identified in the contract between the specialist
and the DPO. The contract shall be included in the request for approval
submitted to the Department;
3. The
specialist shall be paid on a contractual fee schedule basis. The contractual
fee schedule shall be included in the specialist contract filed pursuant to
11:10-1.5, and in the request for
approval filed with the Commissioner;
4. The schedule of charges filed pursuant to
11:10-1.1 2 shall identify, by
plan, the proportion of the charges attributable to the specialist services,
and shall be included in the request for approval filed with the
Commissioner;
5. After addition of
the charges and deductions for payments to specialists, any excess in the
specialist pool shall be paid on an annual basis to the primary dentists and
shall not be retained by the DPO. The method by which payment of the excess is
to be made to the dentists shall be included with the request for approval
filed with the Commissioner. Any changes in the methodology shall be filed with
the Commissioner before its use;
6.
The DPO shall be responsible for all payments for services provided by
specialists. Payments shall be made from the specialist pool until all funds
are depleted, and thereafter payments shall be made from the DPO's general
funds; and
7. In conjunction with
the filing of the annual report required by
11:10-1.7, each DPO having an
approved specialist pool shall submit a separate financial accounting of the
specialist pool for the preceding calendar year. The report shall set forth, by
plan, the contributions to the pool, the payments made to specialists from the
pool and the resulting excess or deficit. If an excess exists, the report shall
indicate when the distribution of the excess will be made and whether the
method of distribution remains unchanged from that originally filed with the
Department.
(d) A DPO
shall file for approval with the Department an alternative payment methodology
prior to use. The alternative payment methodology shall be deemed approved 30
days after filing unless disapproved in writing by the Commissioner within that
timeframe. All alternative payment methodologies shall include the following:
1. A clear explanation of the methodology and
numerical examples illustrating how the methodology will operate; and
2. An explanation of the appropriateness of
the payment methodology to recruit new dentists, retain contracted dentists in
underserved areas and/or eliminate disincentives for contracted dentists to
render quality dental care to covered persons of the DPO.
(e) Three copies of a request for approval of
a specialist pool or alternative payment methodology shall be submitted to the
Department at the following address:
Chief Actuary
Office of Life and Health
New Jersey Department of Banking and Insurance
20 West State Street
PO Box 325
Trenton, NJ 08625-0325
(f) Every DPO shall report to the
Commissioner the name and address of, and the amount of any fee paid to, a
finder within 30 days of the use or employment of the finder.
(g) A DPO that has not had its certificate of
authority suspended or revoked shall automatically renew each year while in
compliance with this subchapter.
