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 11:22-5.4 - Network coinsurance
Universal Citation: NJ Admin Code 11:22-5.4
Current through Register Vol. 56, No. 24, December 18, 2024
(a) Network coinsurance is permitted in a contract issued by a health maintenance organization that provides out-of-network benefits only for emergency and urgent care, in a POS contract issued by a health maintenance organization or health service corporation, and in an SCA policy providing hospital and medical coverage issued by an insurance company, provided that:
1. The contract or
policy complies with the requirements set forth in N.J.A. C. 11:22-5.3(a)1;
i. If a carrier offers a contract with an
individual network out-of-pocket limit in excess of $ 3,000, it shall also
offer a contract with an individual network out-of-pocket limit of $ 2,500 or
less.
2. The network
coinsurance level, and the out-of-network coinsurance level (if any), is 50
percent or less;
3. The network
coinsurance obligation of the covered person is computed by applying the
coinsurance percentage to the contractual fee schedule of the provider, not to
the billed charges of the provider;
4. Network coinsurance shall not be applied
to preventive care;
5. Network
coinsurance shall not be applied to services or supplies provided by capitated
providers; and
6. Network
coinsurance shall not be applied to any service or supply to which network
copayment is applied.
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