New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 22 - HEALTH BENEFIT PLANS
Subchapter 5 - MINIMUM STANDARDS FOR HEALTH BENEFIT PLANS, PRESCRIPTION DRUG PLANS AND DENTAL PLANS
Section 11:22-5.10 - Dental benefits
Universal Citation: NJ Admin Code 11:22-5.10
Current through Register Vol. 56, No. 6, March 18, 2024
(a) The following standards apply to health benefit plans and stand-alone dental plans that provide benefits for dental services only when rendered by network providers, and plans that provide benefits for dental services rendered by both network and out-of-network providers:
1. The
in-network benefit provided by the carrier shall result in average cost
sharing, through coinsurance or copayments, of no more than 75 percent of the
carrier's contracted cost of that service or for the cost of a class of similar
services.
i. An aggregate deductible for all
services and any dollar benefit maximums may be disregarded in determining the
cost-sharing, but a per service deductible shall be considered a
copayment.
ii. A scheduled
in-network benefit shall be considered a benefit with a copayment equal to the
difference between the contracted rate and the scheduled benefit.
iii. A carrier shall not use the cost of
periodic examinations in determining the average cost sharing
requirement.
2. A
carrier that provides no in-network benefit for a service may allow the
subscriber to receive that service by having the subscriber pay to the provider
the carrier's in-network contracted rate. In such cases, the services are not
considered to be covered services for purposes of meeting the maximum 75
percent copayment/coinsurance requirement.
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