New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 14 - INDEMNITY BENEFITS OFFERED BY A HEALTH MAINTENANCE ORGANIZATION
Section 11:24-14.4 - Out-of-network benefit restriction under an HMO POS contract with a reinsurance-type or group master policy arrangement

Universal Citation: NJ Admin Code 11:24-14.4

Current through Register Vol. 56, No. 18, September 16, 2024

(a) An HMO may offer a POS contract with or without a gatekeeper system for out-of-network covered services, except that any POS contract offered without a gatekeeper system for out-of-network covered services shall meet the following:

1. The deductible for the out-of-network covered services shall be no less than $ 250.00 per person per benefit period, or $ 500.00 per family per benefit period, and the coinsurance requirement shall be no less than 20 percent for the next $ 5,000 of covered charges for covered services per individual per benefit period, and no less than 20 percent for the next $ 10,000 of covered charges for covered services per family per benefit period; or

2. The deductible and coinsurance requirements are otherwise designed so that, in combination, there is a substantial disincentive to accessing out-of-network covered services, as determined satisfactory to the Commissioner, consistent with (a)1 above.

(b) Notwithstanding that an HMO elects to utilize a gatekeeper system for out-of-network covered services, the HMO shall provide that the deductible and coinsurance requirements for the access of out-of-network covered services are otherwise designed so that, in combination, there is a reasonable, disincentive to accessing such out-of-network covered services, as determined satisfactory to the Commissioner.

(c) Notwithstanding (a) and (b) above, the actuarial value of the out-of-network covered services shall not vary by more than 30 percent from the actuarial value of the in-network covered services under any POS contract, as further specified at 11:4-37.3(b)6.

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