Current through Register Vol. 56, No. 24, December 18, 2024
EXPLANATION OF BRACKETS
Plans B through E Policy and Certificate
(Appendix Exhibits F and W for Plans B - E)
All text which is enclosed in brackets [] is variable.
Enclosure in Brackets does not give Carriers liberty to deviate from the
standard text which is enclosed in brackets, except as expressly stated. In
many instances, variable text is text which a carrier elects to either include
or exclude. When the forms are prepared as issue documents, no brackets should
appear, since the forms, as issued, should specify all the elections the
Carrier has made. Such text may generally be categorized in the following
ways.
a Some areas of variability are
self-explanatory. Examples include: [Carrier], [Policyholder], and
[ABC]
b Some areas of variability
are noted with brief explanations within the text. Examples include: use of
PPO, EPO and POS text.
c Some areas
of variability are intended to allow for flexibility in terms of a carrier's
administrative practices.
d Some
areas of variability are subject to ranges and parameters specified in statute
and/or regulation
e Some areas of
variability are determined by the election made by a Carrier.
f Some areas of variability are intended
solely to accommodate plans that only allow coverage for employees. That is, no
dependent coverage is available. In such circumstances, references to
dependents and provisions that apply to dependents, as enclosed in brackets,
may be omitted. When dependent coverage is provided under the plan, all
dependent text must be included in the plan.
g Some areas of variability are determined by
the delivery system (i.e., indemnity, PPO, POS or EPO)
h Variable text is included throughout the
forms to address the potential for coverage for domestic partners. Carriers
should include the text only if the employer elects coverage for domestic
partners on the employer application. In lieu of including the text in the body
of the form, carriers may use the Open Face Rider (Exhibit D) to include the
domestic partner text as included in the standard plans.
i Some areas of variability apply to the
limited circumstance of plans to be issued in the Small Business Health Options
Program created under the Patient Protection and Affordable Care Act,
Public Law
111-148, as amended by the Health Care and
Education Reconciliation Act,
Public Law
111-152 (SHOP).
Note: Due to the complexity of issuing plans through or in
conjunction with an approved Selective Contracting Arrangement, commonly known
as PPO or POS or EPO plans, explicit guidance is set forth in item 29
below.
Areas of variability, which may require clarification and
explanation as to use, are explained below. The order of the list is generally
consistent with the order of appearance in the policy and certificate
forms.
1. Dividend text which appears
both on the Face Page and in the General Provisions should only be included by
carriers that could pay dividends.
2. The Health Care Quality Act requires
carriers to specify the legal name, trade name, e-mail and fax numbers.
Carriers may include this information on a separate page, immediately following
the face page, as illustrated in the standard forms. Alternatively, carriers
may include this information directly on the face page.
3. Although the schedule pages specify the
plan letter in the upper right corner this identification is intended solely to
identify which plan letter the page illustrates. Carriers need not specify the
plan letter on the schedule pages of plans being issued.
4. Deductible, Co-Insurance, and Copayments
may be elected by the Employer, subject to the availability specified in
regulation.
5. There are alternate
PPO and POS schedule pages that allow carriers to use separate or common
deductible and maximum out of pocket provisions. These features may be used, at
the option of the carrier. There are corresponding provisions in the benefit
provisions.
6. One of the schedule
pages illustrates a tiered network design. Carriers should adapt the schedule
page to illustrate the services for which a tiered network design is
applicable. Additional variable text addressing a tiered network is included in
the PPO, POS and EPO descriptions and other coverage sections of the
policy.
7. The list of services and
supplies for which pre-approval is required includes two items, included in
brackets: specified therapies and prescription drugs. The benefit provisions
for these services and supplies also includes text in brackets concerning
pre-approval. Carriers that elect to require pre-approval for these services
and supplies must include them on the list on the schedule page in addition to
using the pre-approval text in the benefit provision.
8. The Reinstatement provision may be
included or omitted, at the option of the carrier. The provision includes two
options for a reinstatement fee. Carriers should include the applicable
text.
9. Percentage participation
requirements as noted in the Participation Requirements and in the Termination
of the Policy - Renewal Privilege provisions of the General Provisions may be
determined by the Carrier, provided the requirements comply with the
requirements permitted in Statute and regulation.
10. The Notice of Loss provision of the
Claims Provisions may be omitted at the option of the Carrier.
11. The Payment of Claims provision of the
Claims Provisions should include the second or third sentence of the last
paragraph, as appropriate.
12. The
definition of an Approved Cancer Clinical Trial and the corresponding benefit
provision should be included only by those carriers that wish to make such
coverage available and want to specify such coverage in the policy
form.
13. The definition of
Referral should be included in POS plans that require referrals.
14. The "Actively at Work" requirement may be
deleted. To accomplish the deletion of the actively at work requirement,
carriers must delete the definition of Actively at Work, and delete the
bracketed text in the following sections: Eligible Employees, Full-Time
Requirement, When Employee Coverage Starts, Exception to the Actively at Work
Requirement, and When Employee Coverage Ends.
15. The definition of Reasonable and
Customary should only include a reference to the negotiated fee schedule if the
Carrier is offering the plan using a Preferred Provider Option or a Point of
Service delivery system.
16. The
Waiting Period provision of the Employee Coverage Provision may be omitted or
included at the option of the Employer. If included, the period may not exceed
90 days and must satisfy the requirements of regulation. The text may address a
date certain following a waiting period, such as first of the month following
2months. If included, the carrier may include the bracketed definition of
Waiting Period in the Definitions section.
17. The date Employee and Dependent coverage
begins or ends may vary to accommodate Employer and/or Carrier administration
practices. For example, Coverage may begin as of the first of the month
following any waiting period, or coverage may end immediately or may end at the
end of the month following a termination event.
18. The text describing provider compensation
in the PPO and POS sections contains a number of bracketed words and phrases.
Include the words and phases that describe the arrangement carrier has with
network providers.
19. The
continuation of care text must be included in all plans that use
networks.
20. The treatment of
hemophilia provision includes variable text that would only be included in PPO
and POS plans.
21. The prescription
drugs provision includes variable text that would be included by carriers that
require pre-approval for specified drugs.
22. The therapy services provision includes
variable text that would be included by carriers that require pre-approval for
certain therapy services.
23. The
method a Carrier chooses to make the optional cancer treatment benefits
available will determine which transplant benefit text the Carrier would
include. For Carriers electing to include the optional cancer treatment
benefits as part of the standard forms, the list of services for which
Pre-Approval is required, as it appears in the Schedule of Benefits, must be
modified to omit the item for autologous bone marrow transplant and associated
dose intensive chemotherapy.
24.
The Utilization Review Features provisions may be omitted in their entirety, or
only one section, the Required Hospital Stay Review or the Required
Pre-Surgical Review section may be omitted. If any portion of Utilization
Review Features is to be included, the text must conform to the text of the
standard form, except that the penalty for non-compliance may be adjusted to
reflect a different percentage, or to utilize a dollar penalty.
25. The Specialty Case Management provision
may be omitted. Carriers may administratively provide for such provisions. If
included in the policy and certificate, the text must conform to the text of
the standard form.
26. The Centers
of Excellence Features provisions may be omitted. If included in the policy,
the text must conform to the text of the standard form.
27. The Dental Benefits text is enclosed in
brackets. For policies sold on the SHOP the Dental Benefits provision may be
excluded if the SHOP offers a standalone dental plan with a pediatric dental
essential health benefit. Such bracketed text must be included in plans
otherwise issued in New Jersey unless a carrier is reasonably assured that an
employer is providing such pediatric dental coverage through a SHOP-certified
stand-alone dental plan. Dental benefits may be limited to services provided by
a network provider.
28. Carriers
that issue plans through or in conjunction with an approved Selective
Contracting Arrangement must consider the following when creating the plan
documents:
a. The policy and certificate
documents contain "SAMPLE" schedule page text. The dollar amounts for the
deductibles and copayments are purely illustrative. Refer to N.J.A.C.
11:21-3(d) for direction as to which amounts may be substituted for those in
the example. For plans that utilize a copay feature, the copays replace the
cash deductible for the particular service, and benefits following the copay
must be paid at 100%. The dollar amounts for the copays must be consistent with
those that an HMO carrier may use.
b. Include the specific page of text
describing either the PPO, POS or the EPO mechanism, with specification of the
name of the network or provider organization.
In addition to the above items, Carriers must consider the
following in connection with the certificate forms:
29. The face page text may be
modified to be consistent with a carrier's methods of certificate
personalization. The certificate level data that is illustrated on the face
page of the standard forms may appear on a separate schedule, or sticker, or
may be incorporated in the body of the certificate. Carriers may also elect to
issue "no-name" certificates, which would fully describe eligibility and
effective date provisions such that the covered persons could apply the rules
to determine the terms of their coverage.
30. The term "certificate" may be replaced
with certificate booklet, certificate of insurance, employee booklet, booklet
certificate, evidence of coverage, or similar titles used to identify the
document provided to employees insured under an employer's group
plan.
31. Variable schedule data
such as deductible, and copayment amounts may be included on the schedule,
shown on the face page, sticker or separate schedule.
32. The Payment of Premiums-Grace Period
section may be omitted, at the carrier's option.
33. The definition of "You, Your and Yours"
may be omitted by carriers that elect to refer to the employee as Employee,
rather than use the personal "You". Throughout the text, the words "You,"
"Your" and "Yours" must be replaced with "Employee" terminology.
Plan HMO Contract and Evidence of Coverage
(Appendix Exhibits G and Y)
All text which is enclosed in brackets [] is variable.
Enclosure in Brackets does not give Carriers liberty to deviate from the
standard text which is enclosed in brackets, except as expressly stated. In
many instances, variable text is text which a carrier elects to either include
or exclude. When the forms are prepared as issue documents, no brackets should
appear, since the forms, as issued, should specify all the elections the
Carrier has made. Such text may generally be categorized in the following
ways.
a Some areas of variability are
self-explanatory. Examples include: [Carrier], [Contractholder], and
[ABC].
b Some areas of variability
are noted with brief explanations within the text.
c Some areas of variability are intended to
allow for flexibility in terms of a carrier's administrative
practices.
d Some areas of
variability are subject to ranges and parameters specified in statute and/or
regulation.
e Some areas of
variability are intended solely to accommodate plans that only allow coverage
for employees. That is, no dependent coverage is available. In such
circumstances, references to dependents and provisions that apply to
dependents, as enclosed in brackets, may be omitted. When dependent coverage is
provided under the plan, all dependent text must be included in the
plan.
f Variable text is included
throughout the forms to address the potential for coverage for domestic
partners. Carriers should include the text only if the employer elects coverage
for domestic partners on the employer application. In lieu of including the
text in the body of the form, carriers may use the Open Face Rider (Exhibit D)
to include the domestic partner text as included in the standard
plans.
g Some areas of variability
apply to the limited circumstance of plans to be issued in the Small Business
Health Options Program created under the Patient Protection and Affordable Care
Act, Public Law
111-148, as amended by the Health Care and
Education Reconciliation Act,
Public Law
111-152 (SHOP).
Areas of variability, which may require clarification and
explanation as to use, are explained below. The order of the list is consistent
with the order of appearance in Contract and Evidence of Coverage forms.
1. The Health Care Quality Act requires
carriers to specify the legal name, trade name fax and e-mail numbers. Carriers
may include this information on a separate page, immediately following the face
page, as illustrated in the standard forms. Alternatively, carriers may include
this information directly on the face page.
2. The definition of an Approved Cancer
Clinical Trial and the corresponding benefit provision should be included only
by those carriers that wish to make such coverage available and want to specify
such coverage in the contract form.
3. Copayments may be elected by the Employer,
subject to the availability specified in regulation.
4. Deductible, coinsurance and maximum out of
pocket provisions may be included for network benefits. Applicable text to
address the deductible, coinsurance and maximum out of pocket features must be
included on the schedule page and in the benefit provisions.
5. One of the schedule pages illustrates a
tiered network design. Carriers should adapt the schedule page to illustrate
the services for which a tiered network design is applicable. Additional
variable text addressing a tiered network is included in other coverage
sections of the contract.
6.
Actively At Work requirement can be deleted. Federally Qualified HMOs cannot
apply Active Work Requirements. To accomplish the deletion of the actively at
work requirement, carriers must delete the definition of Actively at Work, and
delete the bracketed text in the following sections: Eligible Employees,
Full-Time Requirement, When Employee Coverage Starts, Exception to the Actively
at Work Requirement, and When Employee Coverage Ends.
7. The method a Carrier chooses to make the
optional cancer treatment benefits available will determine which transplant
benefit text the Carrier would include. NOTE: ALL plans issued by a Carrier
must make the optional benefit available in the same manner.
8. The bracketed dispensing limit text
contained in the prescription drug coverage should be deleted by carriers that
provide the in-plan prescription drug coverage subject to
coinsurance.
9. Eligible class
references can be removed.
10. The
Waiting Period provision of the Employee Coverage Provision may be omitted or
included at the option of the Carrier. If included, the period may not exceed
90 days and must satisfy the requirements of regulation. The text may address a
date certain following a waiting period, such as first of the month following
60 days. If included, the carrier may include the bracketed definition of
Waiting Period in the Definitions section.
11. The date Employee and Dependent coverage
begins or ends may vary to accommodate Employer and/or Carrier administration
practices. For example, Coverage may begin as of the first of the month
following any waiting period, or coverage may end immediately or may end at the
end of the month following a termination event.
12. Percentage participation requirement as
noted in the Participation Requirements and in the Termination of the Policy
Renewal Privilege provisions of the General Provisions may be determined by the
Carrier, provided the requirements comply with the requirements permitted in
Statute and regulation.
13.
Transfer of Primary Care Physician can occur according to carrier
administration, but may not be more restrictive to the member than stated in
the form.
14. Carriers should
include variable material contained in the Provider Payment section to
correctly address the compensation arrangement the carriers have with the
network.
15. Carriers that wish to
apply pre-approval requirements to the Prescription Drugs coverage should
include the variable pre-approval text.
16. The Reinstatement provision should be
included by carriers that will allow reinstatement. The provision includes two
options for a reinstatement fee. Carriers should include the applicable
text.
17. The Dental Benefits text
is enclosed in brackets. For policies sold on the SHOP the Dental Benefits
provision may be excluded if the SHOP offers a standalone dental plan with a
pediatric dental essential health benefit. Such bracketed text must be included
in plans otherwise issued in New Jersey unless a carrier is reasonably assured
that an employer is providing such pediatric dental coverage through a
SHOP-certified stand-alone dental plan. Dental benefits may be limited to
services provided by a network provider.
In addition to the above items, Carriers must consider the
following in connection with the evidence of coverage forms:
18. The face page text may be modified to be
consistent with a carrier's methods of evidence of coverage personalization.
The evidence of coverage level data that is illustrated on the face page of the
standard forms may appear on a separate schedule, or sticker, or may be
incorporated in the body of the document. Carriers may also elect to issue
"no-name" certificates, which would fully describe eligibility and effective
date provisions such that the covered persons could apply the rules to
determine the terms of their coverage.
19. The term "evidence of coverage" may be
replaced with a similar term used to identify the document provided to
employees covered under an employer's group plan.
Plan HMO-POS Contract and Evidence of Coverage
(Appendix Exhibits HH and II)
All text which is enclosed in brackets is variable.
Enclosure in Brackets does not give Carriers liberty to deviate from the
standard text which is enclosed in brackets, except as expressly stated. In
many instances, variable text is text which a carrier elects to either include
or exclude. When the forms are prepared as issue documents, no brackets should
appear, since the forms, as issued, should specify all the elections the
Carrier has made. Such text may generally be categorized in five ways.
1. Some areas of variability are
self-explanatory. Examples include: [Carrier], [Contractholder],
[date].
2. Some areas of
variability are noted with brief explanations within the text.
3. Some areas of variability are intended to
allow for flexibility in terms of a Carrier's administrative
practices.
4. Some areas of
variability are subject to ranges specified in statute or regulation.
5. Some areas of variability are determined
by Carrier elections. [Examples include terms to identify the member, network
and non-network benefits.]
6.
Variable text is included throughout the forms to address the potential for
coverage for domestic partners. Carriers should include the text only if the
employer elects coverage for domestic partners on the employer application. In
lieu of including the text in the body of the form, carriers may use the Open
Face Rider (Exhibit D) to include the domestic partner text as included in the
standard plans.
7. Some areas of
variability apply to the limited circumstance of plans to be issued in the
Small Business Health Options Program created under the Patient Protection and
Affordable Care Act, Public Law 111-148, as amended
by
The following explanations apply to the Contract and
Evidence of Coverage, unless otherwise stated.
1. The Health Care Quality Act requires
carriers to specify the legal name, trade name, e-mail and fax numbers.
Carriers may include this information on a separate page, immediately following
the face page, as illustrated in the standard forms. Alternatively, carriers
may include this information directly on the face page.
2. The definition of an Approved Cancer
Clinical Trial and the corresponding benefit provision should be included only
by those carriers that wish to make such coverage available and want to specify
such coverage in the contract form.
3. The forms define and use the terms
"Network" or "In-Network" and "Non-Network" or "Out-of-Network." Carriers may
replace those terms as they appear in the definitions section, and elsewhere
throughout the forms, with alternate terms. (Example: Participating,
Non-Participating)
4. The forms
define and use the term "Member." Carriers may replace that term as it appears
in the definitions section, and elsewhere throughout the forms, with an
alternate term. (Examples: Subscriber, Enrollee)
5. The plan may be issued as employee only
coverage. Text which addresses dependent coverage, as enclosed in brackets, may
be deleted for plans which only make coverage available to employees.
6. Carriers should include variable material
contained in the Provider Payment section to correctly address the compensation
arrangement the carriers have with the network.
7. Copayment, deductible, coinsurance and
maximum out of pocket amounts may be elected by the Contractholder, subject to
the availability specified in regulation. The applicable schedule page and
benefit provision text should be included, consistent with whether deductible
and coinsurance provision applies to both network and non-network benefits or
only to non-network benefits.
8.
One of the schedule pages illustrates a tiered network design. Carriers should
adapt the schedule page to illustrate the services for which a tiered network
design is applicable. Additional variable text addressing a tiered network is
included in other coverage sections of the contract.
9. The "Actively at Work" requirement may be
deleted. To accomplish the deletion of the actively at work requirement,
carriers must delete the definition of Actively at Work, and delete the
bracketed text in the following sections: Eligible Employees, Full-Time
Requirement, When Employee Coverage Starts, Exception to the Actively at Work
Requirement, and When Employee Coverage Ends.
10. The definition of "Employer" should
identify the name of the employer or specify the location in the Contract and
Evidence of Coverage where the employer name is specified.
11. The "Waiting Period" provision may be
omitted, or included, at the option of the Contractholder. If included, the
duration of the waiting period may not exceed 90 days. The text may address a
date certain following a waiting period, such as first of the month following
60 days. If included, the carrier may include the bracketed definition of
Waiting Period in the Definitions section.
12. The date employee or dependent coverage
begins or ends may vary, to accommodate Contractholder, or Carrier
administration practices. (Example: Coverage may begin as of the first of the
month following any waiting period. Coverage may end immediately, or at the end
of the month in which the termination event occurs.)
13. The Selection or Change of a Primary Care
Physician or Health Center, and the effective date of the selection or transfer
may vary according to Carrier administration, but may not be more restrictive
to the member than stated in the form.
14. Carriers may elect to make the optional
cancer treatment benefit available as part of the standard plan or as an
optional benefit rider. The selected option determines which text the Carrier
should include. note: All plans issued by a Carrier must
reflect the same Carrier election to either include the optional benefit, or
make the benefit available by rider.
15. The bracketed dispensing limit text
contained in the network prescription drug coverage should be deleted by
carriers that provide the in-plan prescription drug coverage subject to
coinsurance.
16. Carriers that wish
to apply pre-approval requirements to the Prescription Drugs coverage should
include the variable pre-approval text.
17. Carriers that wish to apply pre-approval
requirements to non-network prescription drug coverage should include the
variable pre-approval text.
18. The
Utilization Review Features may be omitted in its entirety, or specific
sections may be omitted. The penalty for non-compliance may be adjusted to
specify a percentage or a dollar penalty. A Carrier that wishes to use
alternate text to describe utilization review provisions must submit the text
to the Board and the Department of Insurance, pursuant to
N.J.A.C. 11:21-4.2.
19. The "Specialty Case Management" provision
may be omitted. Carriers may provide for such "case management"
administratively. If included in the form, the text must conform to the text of
the standard form.
20. The "Centers
of Excellence" provision may be omitted. If included in the form, the text must
conform to the text of the standard form.
21. Percentage participation requirements
(specified as 75% in the forms) may be modified by the Carrier, provided the
Carrier complies with
N.J.A.C. 11:21-7.6.
22. The Reinstatement provision should be
included by carriers that will allow reinstatement. The provision includes two
options for a reinstatement fee. Carriers should include the applicable
text.
23. The "Notice of Loss"
section of the "Claims Provisions" may be omitted, at the option of the
Carrier.
24. The third sentence of
the "Payment of Claims" section of the "Claims Provisions" should be omitted,
if not applicable.
20. The Dental
Benefits text is enclosed in brackets. For policies sold on the SHOP the Dental
Benefits provision may be excluded if the SHOP offers a standalone dental plan
with a pediatric dental essential health benefit. Such bracketed text must be
included in plans otherwise issued in New Jersey unless a carrier is reasonably
assured that an employer is providing such pediatric dental coverage through a
SHOP-certified stand-alone dental plan. Dental benefits may be limited to
services provided by a network provider.
The following explanations apply only to the Evidence of
Coverage.
1 The face page
of the Evidence of Coverage may be modified to reflect a Carrier's method of
personalization. Only that text which pertains to the manner of identifying the
covered person may be modified.
2
The term "Evidence of Coverage" may be replaced with another term which the
Carrier uses to name the document given to covered persons. If another name is
used, the Carrier should make similar name changes in the corresponding
Contract form.
3 The Introduction
contains bracketed areas which should be omitted, if not applicable, or
modified to specify appropriate information.
The
amended version of this exhibit 55 N.J.R. 196(a), effective
1/1/2023 is not yet
available
