Current through Register Vol. 56, No. 24, December 18, 2024
(a) The
Commissioner may order carriers and other HMOs to offer the members of an
insolvent HMO an opportunity to become insured or to enroll with the carriers
and other HMOs, during no less than a 30-day open enrollment period to be
determined by the Commissioner, except as (b) below may apply.
1. If more than a single choice was offered
to the members of a group during the group's last regular enrollment period,
the Commissioner's order shall be limited to those carriers and HMOs that
participated in the enrollment process with the insolvent HMO during the
group's last regular enrollment period, except that if the Commissioner
determines that the other HMOs and/or managed care plans of the carriers that
participated with the insolvent HMO lack sufficient capacity to assure that
health care services shall be available and accessible to the group's members,
then the Commissioner may order all HMOs operating within the same service
areas as the insolvent HMO to enroll an equitable portion of the insolvent
HMO's members, as determined by the Commissioner.
i. Carriers and HMOs that participated with
the insolvent HMO at the group's last regular enrollment period shall offer the
members of the insolvent HMO the same coverage at the same rates that the
carriers and HMOs offered to the group's members at the group's last regular
enrollment period, which shall be effective until the group's regular renewal
period.
ii. HMOs that did not
participate with the insolvent HMO at the group's last regular enrollment
period shall offer the members of the insolvent HMO coverage that is most
similar to the coverage the members have with the insolvent HMO, as determined
by the Commissioner, at the successor HMO's then-current rates for the coverage
offered.
2. When the
members of the insolvent HMO are not members of a group, or are members of a
group that did not have multiple choices of carriers or HMOs with whom to
become insured or enrolled during the group's last regular enrollment period,
the Commissioner may order that all HMOs within the service area of the
insolvent HMO shall enroll an equitable portion of the insolvent HMO's members,
as determined by the Commissioner.
i. The
successor HMO shall offer the members of the insolvent HMO coverage that is
most similar to the coverage the members have with the insolvent HMO, at the
successor HMO's then-current rates for the coverage offered.
3. In allocating members to other
HMOs, the Commissioner shall consider the capacity of the HMOs to assure that
health care services will be available and accessible to the members.
(b) The Commissioner shall act in
consultation with the Director of the Division of Medical Assistance and Health
Services in allocation of Medicaid members of an insolvent HMO.
(c) With respect to Medicaid recipients and
Medicare beneficiaries who are members or other members under special State
government contracts, such members of an insolvent HMO shall only be allocated
to HMOs within the same service area as the insolvent HMO that have a similar
contract with the Medicare, Medicaid or other special State government
programs.
(d) With respect to
members under standard individual health benefits plans or members who are
members of small employer groups as defined by
N.J.S.A. 17B:27A-17 et seq., such members
of an insolvent HMO shall only be allocated to HMOs within the same service
area as the insolvent HMO that have elected to offer coverage to individuals
and members of small employer groups.
