New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 3 - GENERAL REQUIREMENTS
Section 11:24-3.4 - Member contract termination
Universal Citation: NJ Admin Code 11:24-3.4
Current through Register Vol. 56, No. 24, December 18, 2024
(a) A member shall not have his or her membership in an HMO cancelled except for the following reasons:
1. Failure to pay the
premiums and other applicable charges for such coverage, including copayment
coinsurance and deductibles;
2.
Failure to abide by the rules and/or policies and procedures of the
HMO;
3. Fraud or material
misrepresentation affecting coverage, including misuse of a member
identification card; or
4. The
group of which the individual is a member is not renewed in accordance with the
HMO's underwriting guidelines or is cancelled for failure to pay
premiums.
(b) Before a member's coverage can be terminated for (a)1 and 2 above, the member shall be given written notice of the violation and a reasonable opportunity to come into compliance. Following any decision to terminate a member's coverage, the HMO shall notify the member of his or her right to appeal such decision as set forth in N.J.A.C. 11:24-3.7.
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