New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION
Section 11:24-14.3 - General standards

Universal Citation: NJ Admin Code 11:24-14.3

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

(a) Except as set forth in (b) below, an HMO shall not enter into any arrangement for the provision of out-of-network covered services to any subscriber or member that is not in compliance with this subchapter.

(b) An HMO providing out-of-network covered services under an arrangement approved by the Department on or before April 15, 1996 shall bring the arrangement and any contracts issued under that arrangement into compliance with this subchapter beginning on the first 12 month anniversary date of each of the subscriber contracts occurring on or after October 12, 1996.

(c) An HMO shall not offer or provide any POS contract to groups of 50 or more until the form of that contract, along with applicable evidence of coverage forms, has been filed and approved or deemed approved, by the Department; an HMO shall not offer or provide a POS contract by rider, amendment or endorsement of any HMO contract.

1. If not disapproved within 60 days of the date of receipt by the Department, the form shall be deemed filed, if not affirmatively approved prior thereto.

2. Disapproval of the form shall be in writing, and shall specify the reasons for the disapproval.

3. An HMO whose form has been disapproved shall have 60 days following the date of the initial disapproval within which to correct any deficiencies set forth in the notice of disapproval, and shall have 30 days following the date of notice of any subsequent disapproval within which to correct deficiencies. A resubmission of a form shall be deemed approved upon the expiration of 30 days following resubmission of the filing to the Department unless the Department approves or disapproves the resubmission within the 30 day period.

4. If an HMO does not respond to a notice of disapproval within the required time frame, the matter shall be considered closed by the Department; if the HMO desires further consideration of its form, it shall submit the form anew to the Department.

(d) Contemporaneous with the submission of the POS contract form, the HMO shall make an informational rate filing with the Department meeting the requirements of this subchapter.

(e) Submission of forms and rates to the Department shall be made to (and accompanied by the appropriate service fee, if any, specified at N.J.A.C. 11:1-32):

Health Bureau

Life and Health Division

New Jersey Department of Banking and Insurance

PO Box 325

20 West State Street

Trenton, NJ 08625-0325

(f) The requirements of this subchapter shall be in addition to, and not in lieu of, more specific standards that may be established for compliance with the Individual Health Coverage Program, N.J.S.A. 17B:27A-2 et seq., and the Small Employer Health Benefits Program, N.J.S.A. 17B:27A-17 et seq., and rules promulgated pursuant thereto.

(g) At least one of the POS products offered by an HMO shall permit members to receive covered services out-of-network without being required to obtain a referral or prior authorization to go to an out-of-network health care professional from the HMO, except as N.J.A.C. 11:24-14.2(a)1, 2 or 3 applies.

1. In the instance in which the required POS contract is held by a group contract holder, the HMO shall provide members under the contractholder's group health plan an opportunity to elect coverage under the required POS contract(s) at least annually following the dissemination of written notice to the members detailing the POS contract.

(h) The HMO shall maintain an adequate network for its POS contracts, pursuant to N.J.A.C. 11:24-5, to assure that members are able to access services in-network and take full advantage of the in-network benefit levels.

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