New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE
Section 11:4-16.6A - Minimum standards for individual health benefits plans
Universal Citation: NJ Admin Code 11:4-16.6A
Current through Register Vol. 56, No. 18, September 16, 2024
(a) This section sets forth the minimum standards that are prescribed for individual health insurance policies that are health benefits plans.
(b) All individual health benefits plans shall comply with N.J.A.C. 11:20.
(c) No individual benefits plan shall be delivered or issued for delivery in this State that does not also meet the following required minimum standards for the specified categories:
1. In a policy that provides a second
surgical opinion benefit, the following conditions must be met:
i. The benefit includes a definition of
elective surgery that is sufficiently clear to permit the average insured to
distinguish between "elective" and "nonelective" surgery;
ii. Second surgical opinions will be rendered
only by specialists who are clearly qualified in their field, who are
independent of the physician who makes the original recommendation for surgery,
and who have no financial interest in the outcome (for or against surgery) of
their recommendations. "Clearly qualified" will be deemed satisfied by board
certification in the field of proposed surgery or in the field of medical
specialization concerned with the organ involved. "Independent" will be assumed
if names of qualified second opinion specialists are provided by the insurer,
although the insurer may provide other methods of designating specialists that
result in an equal degree of independence. "No financial interest" will be
deemed to exist if the specialist providing a second opinion is prohibited from
performing the recommended surgery, if his or her remuneration is not dependent
on the nature of his or her recommendation, and if he or she has no financial
involvement of any nature in a partnership, corporation, or office with the
first physician recommending surgery, or the facility and/or location at which
the surgery will occur;
iii. A
second surgical opinion cannot be mandatory, unless the insurer is able to
provide to the insured names of qualified specialists who are within convenient
access to the insured. "Mandatory" means that payment of claims for elective
surgery is conditioned on having obtained a second opinion; and
iv. If the policy requires the insured to pay
for any part of the second surgical opinion (copayment, deductible, and/or
maximum amount), the premium for the policy cannot exceed the premium payable
for a comparable policy without second surgical opinion benefits, and the
insurer shall disclose to the insured that his or her out-of-pocket expenses
may exceed the expenses that would result from an otherwise comparable policy
without a second surgical opinion benefit. See
N.J.A.C.
11:4-16.8(d), (e), and (f)
for disclosure requirements; and
2. Any policy providing coverage for the
recipient in a transplant operation shall also provide reimbursement of any
medical expenses of a live donor to the extent that benefits remain and are
available under the recipient's policy, after benefits for the recipient's own
expenses have been paid.
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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