Current through Register Vol. 56, No. 18, September 16, 2024
(a) The standard health benefits plans
established by the Board contain the benefits, limitations, exclusions and
other terms set forth in exhibits in the Appendix to this chapter, which is
incorporated herein by reference.
1. Plan B,
"The Small Group Health Benefits Policy B," set forth in Exhibits F and W
features carrier coinsurance of 50 percent or 60 percent.
2. Plan C, "The Small Group Health Benefits
Policy C," set forth in Exhibits F and W features carrier coinsurance of 70
percent.
3. Plan D, "The Small
Group Health Benefits Policy D," set forth in Exhibits F and W features carrier
coinsurance of 80 percent.
4. Plan
E, "The Small Group Health Benefits Policy E," set forth in Exhibits F and W
features carrier coinsurance of 90 percent.
5. Exhibit F contains those items of Plans B,
C, D, and E which are common among the plans as well as text which is unique to
Plans B, C, D, and E, where such Plan-unique text is clearly identified and
Exhibit W contains corresponding certificate text for each of the
plans.
6. HMO Plan, "The Small
Group Health Maintenance Organization Contract," is set forth in Exhibits G and
Y.
7. HMO-POS Plan, "The Small
Group Health Maintenance Organization Point of Service ("POS") Contract," is
set forth in Exhibits HH and II.
8.
Exhibits G and HH contain the group contract text for the HMO Plan and the
HMO-POS Plan. Exhibits Y and II contain the evidence of coverage text for the
HMO Plan and the HMO-POS Plan.
(b) In accordance with this chapter, members
that offer small employer health benefits plans in this State shall offer at
least three of the health benefits plans designated as Plans B, C, D, and E as
set forth in Exhibits V and W, in the Appendix, subject to (b)1 and 2 below and
except as set forth in (c) below.
1. Members
offering Plans B, C, D, and/or E shall include annual deductible provisions
consistent with the following specifications:
i. The per covered person annual deductible
may not exceed the maximum deductible permitted by
45 CFR
156.130
and 11:22-5.3(a)
.
ii. The per covered
family annual deductible shall be two times the per covered person annual
deductible, satisfied on an aggregate basis.
2. Members offering Plans B, C, D, and/or E
shall include maximum out of pocket provisions such that the maximum out of
pocket amount shall not exceed the annual limitation on cost sharing specified
in
45 CFR
156.130 for both self-only and other than
self-only coverage.
(c)
HMO members may offer the HMO Plan, as set forth in Exhibit G of the Appendix,
in lieu of at least three of the plans designated as Plans B through E in (a)
above. HMO members shall offer one or more HMO plans using copayments as
described in (c)1 below and may also offer HMO plans using deductible and
coinsurance provisions consistent with (c)2 below. All HMO plans shall comply
with (c)3 below and shall be made available to every small employer seeking
coverage.
1. Copayment Design:
i. The hospital inpatient copayment shall be
consistent with
11:22-5.5(a).
ii. The copayment for all services and
supplies other than hospital inpatient, emergency room, and prescription drugs
shall be consistent with
11:22-5.5(a).
2. Deductible and Coinsurance
Design:
i. The copayment for primary care
physician services shall be consistent with
11:22-5.5(a).
ii. The cash deductible, which shall not
apply to primary care physician visits, preventive care, immunizations and lead
screening for children, or pre-natal care shall be consistent with the
requirements of
11:22-5.3 and
45 CFR
156.130. The covered family deductible shall
be two times the per person deductible satisfied on an aggregate
basis.
iii. The coinsurance, which
shall not apply to services to which a copayment applies, shall be a percentage
between 10 percent and 50 percent, inclusive.
iv. The maximum out of pocket shall be a
dollar amount, which shall not exceed the annual limitation on cost sharing set
forth at
45 CFR
156.130, and the maximum out of pocket for a
covered family shall not exceed two times the per person maximum out of
pocket.
3. Common
Features:
i. The emergency room copayment,
which shall be paid in addition to other copayments, deductible, and
coinsurance, shall not exceed the amount permitted by
11:22-5.5(a).
ii. Pre-natal care shall be covered without
cost sharing.
iii. Prescription
drugs covered under the HMO plan, as opposed to under a separate prescription
drug rider, shall be subject to deductible and/or coinsurance, or copayment(s)
consistent with
11:22-5.5(a).
(d) The standard health
benefits Plans B, C, D, and E and optional riders may be offered through or in
conjunction with a selective contracting arrangement approved pursuant to P.L.
1993, c.162, section 22 (17B:27A-54
). The standard health benefits Plans B, C, D, and E and optional
riders may be offered with the same selective contracting arrangement by a
carrier that is exempt from the requirements of P.L. 1993, c.162, section 22,
pursuant to 11:4-37.1(b)
, but which is permitted to enter into agreements with participating
providers pursuant to any statute. Plans issued through an approved selective
contracting arrangement and plans with selective contracting arrangement
features issued by an entity exempt from the requirements shall be subject to
the following:
1. All of the requirements of
45 CFR
156.130
and 11:4-37.3(b)
6 and 11:22-5;
2. The
network annual deductible shall be consistent with the requirements of
11:22-5.3 and
45 CFR
156.130 and for a covered family shall not
exceed two times the per covered person annual deductible, satisfied on an
aggregate basis. If a carrier elects to use a common annual deductible for both
network and non-network benefits, the network annual deductible amount shall
apply to both network and non-network services and supplies;
3. The network maximum out of pocket shall
not exceed the annual limitation on cost sharing set forth at
45 CFR
156.130 and for a covered family shall not
exceed two times the per covered person maximum out of pocket. If a carrier
elects to use a common maximum out of pocket for both network and non-network
benefits, the network maximum out of pocket amount shall apply to both network
and non-network services and supplies;
4. The non-network annual deductible shall be
no more than three times the network annual deductible per covered person, and
for a covered family shall equal two times the per covered person annual
deductible;
5. The non-network
maximum out of pocket shall be no more than three times the network maximum out
of pocket per covered person, and for a covered family shall equal two times
the per covered person maximum out of pocket; and
6. The HMO Plan standard copayment levels for
practitioner visits, emergency room and hospital confinements may be
substituted for deductibles applicable to network benefits.
(e) An insurer with an approved
selective contracting agreement, like all other carriers, shall offer at least
three of the standard health benefits plans, whether as indemnity plans or
through or in conjunction with a selective contracting arrangement, in all
geographic areas in the State in which the insurer is authorized to write
health benefit plans.
1. If an insurer's
approved service area for its selective contracting arrangement includes all
geographic areas in the State, the insurer shall offer at least three of the
standard health benefits plans as either indemnity plans or through or in
conjunction with a selective contracting arrangement, or both, in all
geographic areas in the State.
2.
If an insurer's approved service area for its selective contracting arrangement
does not include all geographic areas in the State, the insurer shall offer:
i. At least three of the standard health
benefits plans as indemnity plans in all areas in the State in which the
insurer is authorized to write health benefit plans that otherwise are not
included in its approved selective contracting arrangement service area;
and
ii. At least three of the
standard health benefit plans as either indemnity plans or in conjunction with
a selective contracting arrangement, or both, in all geographic areas within
its approved service area.
3. If an insurer with a limited approved
service area chooses to offer at least three of the standard health benefit
plans only through or in conjunction with a selective contracting arrangement
in its limited approved service area, and later receives approval for its
selective contracting arrangement in additional geographic areas in the State,
the insurer shall not be required to offer the standard health benefits plans
as indemnity plans in the newly approved areas, but shall be required to renew
the in force standard health benefits plans in the newly approved service
areas.
(f) A carrier
that is exempt from the requirements of P.L. 1993, c.162, section 22, pursuant
to 11:4-37.1(b)
, but which is permitted to enter into agreements with participating
providers pursuant to any statute shall offer the standard health benefits
plans whether as indemnity plans or as PPO, POS, or EPO plans in all geographic
areas of the State.
1. If such a carrier has
agreements with participating providers in all geographic areas of the State,
the carrier shall offer the standard health benefits plans either as indemnity
plans or as PPO, POS, or EPO plans or any such combination in all geographic
areas of the State.
2. If such a
carrier has agreements with participating providers only in certain geographic
areas of the State, the carrier shall offer:
i. The standard health benefits plans as
indemnity plans in all geographic areas of the State in which the carrier is
authorized to write health benefits plans where it does not have agreements
with participating providers; and
ii. The standard health benefits plans
whether as indemnity plans or as PPO, POS, or EPO plans or any such combination
in all geographic areas of the State where it has agreements with participating
providers.
3. If such a
carrier which has agreements with participating providers only in certain
geographic areas of the State chooses to offer the standard health benefits
plans only as PPO, POS, or EPO plans in such areas and later expands the area
in which it has agreements with providers, the carrier shall not be required to
offer the standard health benefits plans as indemnity plans in the expanded
area, but shall be required to renew the in force standard health benefits
plans in the newly expanded area.
(g) HMO members may offer the HMO POS plan,
as set forth in Exhibit HH of the Appendix, so long as the member is in
compliance with N.J.A.C. 11:24-14, which regulations set forth requirements for
HMOs offering indemnity benefits. HMO members offering the HMO POS plan may
offer the following arrangements set forth in (g)1, 2, and 3 below with respect
to their network services and supplies. The non-network deductible, coinsurance
and maximum out of pocket must comply with 11:21-3.1(d)
.
1. Copayment Design:
i. The hospital inpatient copayment shall be
consistent with
11:22-5.5(a).
ii. The copayment for all services and
supplies other than hospital inpatient, emergency room, and prescription drugs
shall be consistent with
11:22-5.5(a).
2. Deductible and Coinsurance
Design:
i. The copayment for primary care
physician services shall be consistent with
11:22-5.5(a).
ii. The cash deductible, which shall not
apply to primary care physician visits, preventive care, immunizations and lead
screening for children, or pre-natal care shall be consistent with the
requirements of
11:22-5.3 and
45 CFR
156.130. The covered family deductible shall
be two times the per person deductible satisfied on an aggregate
basis.
iii. The coinsurance, which
shall not apply to services to which a copayment applies, shall be a percentage
between 10 percent and 50 percent, inclusive, in five percent
increments.
iv. The maximum out of
pocket shall be a dollar amount not to exceed the annual limitation on cost
sharing set forth at
45 CFR
156.130
, and for a covered family
shall not exceed two times the per person maximum out of pocket.
3. Common Features:
i. The emergency room copayment, which shall
be paid in addition to other copayments, deductible and coinsurance, shall not
exceed the amount permitted by
11:22-5.5(a).
ii. Pre-natal care shall be covered without
cost sharing.
iii. Prescription
drugs covered under the HMO-POS plan, as opposed to under a separate
prescription drug rider, shall be subject to deductible and/or coinsurance or
copayment(s) consistent with
11:22-5.5(a).
