New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 2 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS
Section 11:24-2.2 - Application for a new or amended certificate of authority

Universal Citation: NJ Admin Code 11:24-2.2

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

(a) Any person, organization, or corporation desiring to establish and/or operate an HMO shall apply to the Commissioner for a certificate of authority, pursuant to N.J.S.A. 26:2J-1 et seq. Applications for a certificate of authority may be obtained from:

New Jersey Department of Banking and Insurance

Valuations Bureau

Office of Solvency Regulation 20 West State Street

PO Box 325

Trenton, NJ 08625-0325

http://www.state.nj.us/dobi/division insurance/managedcare/mcapps.htm#hmo

1. Two copies of the entire application shall be submitted to the Department at the above address; and

2. If the applicant proposes to be a Medicaid program participant, one copy of the application shall be submitted to:

New Jersey Department of Human Services

Office of Managed Health Care

Division of Medical Assistance and Health Services

PO Box 712

Trenton, NJ 08625-0712

(b) The applicant shall submit to the Department a nonrefundable fee of $ 100.00, or as specified in N.J.S.A. 26:2J-23, as may be amended, payable to the New Jersey Department of Banking and Insurance for the filing of an application for a certificate of authority as an HMO, or for any renewal or amendments thereto.

(c) The application for a certificate of authority shall be deemed complete only when filed on forms prescribed by the Department and when accompanied by the following:

1. A copy of the basic organizational documents of the applicant such as the articles of incorporation, articles of association, partnership agreement, trust agreement or other applicable documents and all amendments thereto;

2. A copy of the bylaws, rules and policies or similar documents regulating the conduct of the internal affairs of the applicant;

3. A list of persons who are to be responsible for the conduct of the affairs of the HMO including names, addresses, official positions and a biographical affidavit for each person, including all officers and directors;

4. A specimen copy of the contract between the HMO and each participating provider, and an attestation by the HMO's CEO as to the execution of contracts by participating providers consistent with the information submitted by the HMO to demonstrate network adequacy and made in accordance with N.J.A.C. 11:24-15, including a description of any compensation program involving incentive or disincentive payment arrangements permitted under the laws of this State. As required by N.J.S.A. 26:2J-26, any copies of any contract made between the HMO and any provider, insurer, hospital or medical service corporation shall be considered confidential;
i. Executed signature pages shall be made available to the Department upon request, but such documents shall otherwise remain confidential;

5. A copy of any merger or acquisition documents of the applicant or the applicant's parent if the merger or acquisition is with respect to the parent, management agreements for administrative services, and asset sale agreements.

6. A copy of the form of evidence of coverage to be issued to the subscriber;

7. A copy of the form of the individual and group contract, if any, which is to be issued to subscribers and contract holders;

8. The most recent audited financial statements (or other documentation as specified by N.J.A.C. 11:24-11for newly-formed applicants) showing the applicant's assets, liabilities, sources of financial support, a statement as to the sources of funding and all other financial requirements as delineated in N.J.A.C. 11:24-11;

9. A description of the proposed method of marketing and financing;

10. A power of attorney duly executed by such applicant, if not domiciled in this State, appointing the Commissioner and his or her successors in office, and duly authorized designees, as the true and lawful attorney of such applicant in and for this State upon whom all lawful process in any legal action or proceeding against the HMO on a cause of action arising in this State may be served;

11. A description and map of the geographic area to be served, identified by county. If sub-areas of counties are to be proposed as boundaries of the service area, the map should also include zip codes;

12. Enrollment projections presented on a quarterly basis for the first three years of operation for each county or sub-area proposed as the service area. The enrollment projections should be accompanied by a description of the demographic characteristics of the population, including at least sex and age;

13. A description of the methods used by the HMO to facilitate access to services for culturally and linguistically diverse members;

14. A description of the complaint and appeal procedures delineated in N.J.A.C. 11:24-3.6;

15. A description of the continuous quality improvement program delineated in N.J.A.C. 11:24-7;

16. A description of the utilization management program, including the process for appealing utilization management determinations delineated in N.J.A.C. 11:24-8;

17. A list of all participating providers by county, municipality and zip code, accompanied by maps of the service area identifying the location of these providers. This list shall include all PCPs, specialists, hospitals and ancillary providers. The list of PCPs and specialists shall include the individual's name, address and, if applicable, hospital affiliation;

18. The criteria regarding geographic accessibility and availability of its health care provider network and why the applicant believes these criteria meet or exceed the rules in this chapter. This shall be related to the applicant's enrollment projections, the access guidelines contained in this chapter, and the applicant's experience;

19. The criteria to be used to maintain the appropriate numbers and types of providers as enrollment increases in accordance with N.J.A.C. 11:24-6;

20. The criteria used to ensure access to specialized services identified in N.J.A.C. 11:24-6;

21. A description of the method of informing affected members and providers of changes in the health care delivery network, as delineated in N.J.A.C. 11:24-3.5;

22. A description of the mechanism by which members and providers will be afforded an opportunity to participate in matters of policy and operation through establishment of advisory panels, by the use of advisory referendum on major policy decisions, or through the use of other mechanisms;

23. A statement from the applicant attesting that it or any affiliated entity operating as an HMO or regulated health insurance business has been in substantial compliance with all applicable state and Federal regulations for the last 12 months in any state in which approval to operate has been granted by the official state licensing and/or certification agency. A description and explanation of any enforcement action or settlement thereof affecting the HMO or its affiliate must be submitted including and not limited to fines, suspension of marketing, or revocation of a license or certificate to do business. The Commissioner may request further information from the applicant or from the official state or Federal agency to determine compliance; and

24. Such other information as the Commissioner may require on a case by case basis from a specific applicant, to make the determination required by N.J.S.A. 26:2J-4.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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