New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 17 - PLAN DOCUMENTS FOR GROUP CONTRACTS
Section 11:24-17.4 - Specific standards for required provisions

Universal Citation: NJ Admin Code 11:24-17.4

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

(a) With respect to information about the HMO, the name, address and telephone number of the HMO shall be included, with a telephone number by which members may contact the HMO without incurring toll charges.

(b) With respect to eligibility requirements, the plan documents shall state what conditions must be met in order to enroll as a subscriber or a subscriber's dependent, the limiting age for subscribers and dependents, if any, including the effects of Medicare upon continued eligibility of the subscriber or dependent for some or all of the covered services under the health benefits plan, and a clear statement regarding the coverage of newborns.

1. The statement regarding newborns shall be consistent with N.J.A.C. 11:24-3.2.

2. There shall be a provision regarding special enrollment periods for employees and dependents, consistent with the requirements of the Health Insurance Portability and Accountability Act, Pub. L. 104-191, and the laws of this State regarding group health insurance, N.J.S.A. 17B:27-54 et seq.

3. All other provisions regarding eligibility shall be consistent with Federal and State laws, including eligibility of children also eligible for Medicaid, and dependency established as a matter of court order.

(c) With respect to the description of benefits and services, the descriptions shall be consistent with the rules in this chapter regarding required benefits and services, emergency services, and out-of-area services, and shall set forth any limitations and exclusions that may apply with respect to services and the receipt of services.

1. Statements regarding limitations and exclusions shall include any limitations or exclusions due to preexisting conditions, waiting periods or affiliation periods, or a member's refusal of treatment.

2. In no instance shall an HMO include statements in the plan documents requiring or suggesting that a member may only obtain emergency services through a participating or otherwise affiliated provider.

(d) With respect to member termination, the provision shall not be inconsistent with N.J.A.C. 11:24-3.4, nor may the HMO cancel or nonrenew a member's coverage solely on the basis of the items set forth at N.J.A.C. 11:24-3.2(a).

(e) With respect to the claims processing information, the information shall include, but not be limited to, the requirements for filing proper proof of loss, any time limit on the filing of claims or payment of claims, explanations of how disputed claims may be resolved, any restrictions on assignment of a claim, and whether a standard claim form is required to be used.

(f) With respect to the continuation of coverage of a member when the member is admitted to the health care facility on the date that the group health benefits plan is terminated, the provision shall specify that the HMO shall continue to provide benefits for the member until the date of the member's discharge from the health care facility, or exhaustion of the member's benefits under the terms of the health benefits plan, whichever occurs first, and in no event shall the provisions be inconsistent with the standards of N.J.A.C. 11:2-13.

(g) With respect to coordination of benefits, if the HMO will coordinate benefits under the health benefit plan, the HMO shall comply with N.J.A.C. 11:4-28; otherwise, the HMO shall include a statement that coverage under the health benefits plan shall be primary coverage for all members.

(h) With respect to the extension of benefits for total disability, the provisions shall not be inconsistent with N.J.S.A. 17B:27-51.12.

(i) With respect to the entire contract provision, the HMO shall include a statement that the contract, all applications and any amendments thereto constitute the entire agreement between the parties, and the HMO shall not include any portion of its charter, bylaws or other documents as part of the contract or plan document unless set forth in full in the contract or attached to it.

(j) With respect to the term of the coverage, termination of the group contract and renewal, the HMO shall include a provision that specifies the date or occurrence upon which coverage becomes effective, the anniversary date of the contract, conditions upon which cancellation or termination may be effected by the HMO, the contractholder and/or the subscriber, and the conditions for and any restrictions upon renewal.

(k) With respect to the grace period, the HMO shall provide for a grace period of no less than 30 days for the payment of any premium other than the initial premium, during which time the coverage shall remain in effect.

1. The provision shall specify that the HMO shall remain liable for providing the services and benefits covered under the health benefits plan, the contractholder remains liable for payment of the required premium, and the members remain liable for any copayments, deductibles, coinsurance or other costs that may be applicable under the terms of the health benefits plan.

2. The provision shall specify that if the premium is not paid during the grace period, coverage is automatically terminated at the end of the grace period, effective as of the end of the grace period, and that the HMO shall provide notice of the effective date of the termination to the contractholder no more than 30 days following the effective date of the termination.

(l) With respect to the conformity of law provision, the HMO shall provide that any portion of the contract that is not otherwise in conformity with the laws of this State, including but not limited to, N.J.S.A. 26:2J-1 et seq., 26:2S-1 et seq., and rules promulgated pursuant thereto, and 17B:27-49 et seq., as amended by P.L. 1997, c. 146, shall not be rendered invalid but shall be construed and applied as if it were in full compliance with the applicable laws and regulations of this State.

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