New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 17 - PLAN DOCUMENTS FOR GROUP CONTRACTS
Section 11:24-17.5 - Standards for optional provisions
Universal Citation: NJ Admin Code 11:24-17.5
Current through Register Vol. 56, No. 18, September 16, 2024
(a) If an HMO intends to coordinate benefits under the health benefits plan, the plan documents shall include a statement specifying that coordination may occur, and an explanation of how coordination will be achieved.
1. Coordination of benefits shall be
accomplished in accordance with N.J.A.C. 11:4-28, and the explanation of
coordination of benefits shall not be inconsistent with those rules.
2. If an HMO fails to include a provision
regarding coordination of benefits consistent with N.J.A.C. 11:4-28, the health
benefits plan shall be primary coverage for all members.
(b) If an HMO will allow reinstatement of the group health benefits plan, and/or coverage for a member, the plan documents shall include any terms and conditions for reinstatement.
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