Current
through Register Vol. 56, No. 6, March 18, 2024
(a) An organized delivery system that
receives compensation on a basis that entails the assumption of financial risk
shall submit an application for licensure to the Commissioner.
1. This subchapter shall apply to any
contract issued and/or renewed on or after October 21, 2002.
(b) An organized delivery system
that receives compensation on a basis that entails the assumption of financial
risk, but meets the criteria set forth in this subsection, may apply to the
Commissioner for an exemption from the licensure requirements based on the
system's current contractual arrangements. Any organized delivery system
seeking an exemption shall file an application in the format and containing the
information set forth at
www.state.nj.us/dobi/division_insurance/managedcare/mcapps.htm,
as described in
11:22-4.4(a)1,
with a non-refundable filing fee in the amount of $ 1,000, payable to the
Treasurer, State of New Jersey.
1. The
Commissioner may grant the exemption for such period of time that he or she
determines that the financial risk of the organized delivery system is de
minimis because the organized delivery system's exposure to financial loss is
limited in amount or likelihood to the degree that it reasonably will not
prevent the system from satisfying the liabilities imposed under the terms of
its contracts. In making this determination, the Commissioner shall consider
various factors in conjunction with the terms of contract with the carrier,
including, but not limited to:
i. The
existence of stop loss insurance maintained by the organized delivery system
from an insurer(s) acceptable to the Commissioner;
ii. Whether the carrier has taken a deduction
or credit against the liability it is required to maintain pursuant to law for
any risk transferred to the organized delivery system; and
iii. The nature of the risk assumed and the
type of coverage related to that risk; and/or
iv. Any limit on the organized delivery
system's liability.
v. In any
event, the financial risk shall be deemed de minimis if the total annual
compensation received by the organized delivery system from any one carrier is
less than $ 250,000.
2.
The Commissioner may revoke the organized delivery system's exemption from
licensure, after notice and an opportunity for hearing, if he or she determines
that the system's contracts no longer meet the requirements for exemption set
forth in this subsection. Any hearing shall be conducted pursuant to the
Administrative Procedure Act,
52:14B-1 et seq. and 52:14F-1 et
seq., and Uniform Administrative Procedure Rules, N.J.A.C. 1:1. Upon revocation
of the exemption, the system shall be required to obtain licensure from the
Department within 90 days.
(c) An organized delivery system that is
granted an exemption from licensure shall apply to and obtain certification as
an organized delivery system from the Department pursuant to
17:48H-1 et seq.
(d) A licensed organized delivery system
shall not directly issue health benefits plans.
