New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION
Section 11:24-14.2 - Requirement to offer a point of services contract

Universal Citation: NJ Admin Code 11:24-14.2

Current through Register Vol. 56, No. 24, December 18, 2024

(a) An HMO shall offer a point of service product in this State that allows a member to receive covered services from an out-of-network health care professional without obtaining a referral or prior authorization from the HMO, except if:

1. Its only members are Medicaid recipients;

2. It is a Federally-qualified, nonprofit HMO; or

3. The HMO is affiliated with an insurance company or health service corporation that offers a contract or policy for delivery in this State in conjunction with a selective contracting arrangement approved in accordance with N.J.A.C. 11:4-37, Selective Contracting Arrangements, and that policy or contract allows a covered person to receive services covered under the policy or contract or receive payment of benefits therefor from providers not in the insurance company's or health service corporation's network of participating providers without obtaining a referral or prior authorization from the insurance company or health service corporation.
i. In addition to (a)3 above, the insurance company or health service corporation shall provide subscribers under a group health plan in which the contractholder offers one of the insurance company's or health service corporation's contracts or policies provided in conjunction with a selective contracting arrangement an opportunity to elect coverage under the contract(s) or policy(ies) provided in conjunction with a selective contracting arrangement on at least an annual basis following a written notice to the subscribers setting forth the details of the contract(s) and policy(ies) provided in conjunction with the selective contracting arrangement.

(b) An HMO that meets the exceptions of (a) above shall not be required to offer any point-of service contract.

(c) An HMO that fails to meet the exceptions of (a) above shall not be required to offer more than one point-of-service contract meeting the standards of (a) above so long as the point-of-service contract offered in compliance with (a) above is available to all group contract holders.

(d) An HMO that fails to meet the exceptions of (a) above shall not be required to offer any other point-of-service contracts, so long as the HMO complies with (c) above.

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