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 11:22-5.8 - Network and out-of-network coverage
Universal Citation: NJ Admin Code 11:22-5.8
Current through Register Vol. 56, No. 24, December 18, 2024
(a) POS contracts issued by health maintenance organizations and health service corporations, and SCA policies issued by insurance companies, shall provide coverage for covered services and supplies regardless of whether rendered by a network or an out-of-network provider, with the following exceptions:
1. The following services and supplies may be
covered only when provided by a network provider, and are not required to be
covered when provided by an out-of-network provider:
i. Health club membership;
ii. Prescription drugs, other than insulin
and oral agents for controlling blood sugar as mandated by
N.J.S.A. 17:48-6n,
17:48A-7l,
17:48E-35.11, 17B:26-2.1l,
17B:27-46.1m and 26:2J-4.11, and medications to treat infertility as mandated
by N.J.S.A. 17:48-6x,
17:48A-7w,
17:48E-35.22, 17B:27-46.1x and
26:2J-4.23;
iii. Dental services
and supplies, other than services and supplies for injury to sound natural
teeth, bony impacted teeth and as required by
P.L.
1999, c. 49;
iv. Routine eye care and
appliances;
v. Routine foot
care;
vi. Routine hearing care and
appliances;
vii. Smoking cessation
programs; and
viii. Travel
companion benefits.
(b) All contracts issued by health maintenance organizations and health service corporations, and all SCA policies issued by insurance companies, shall provide the following:
1. That a covered person's liability for
services rendered during a hospitalization in a network hospital, including,
but not limited to, anesthesia and radiology, where the admitting physician is
a network provider and the covered person and/or provider has complied with all
required preauthorization or notice requirements, shall be limited to the
copayment, deductible and/or coinsurance applicable to network services;
and
2. That a covered person's
liability for services rendered during a hospitalization in a network hospital,
including, but not limited to, anesthesia and radiology, where the admitting
physician is an out-of-network provider, shall be limited to the copayment,
deductible and/or coinsurance applicable to network services.
(c) Carriers shall not calculate benefits for services provided by out-of-network providers by using negotiated fees agreed to by network providers.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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