Current through Register Vol. 56, No. 24, December 18, 2024
(a) A selective
contracting arrangement that involves direct contracting between the carrier
and network providers or that involves a contract between the carrier and a PPO
shall contain an adequate number of network providers by specialty to render
the particular covered services in the geographic service area where it
operates. A selective contracting arrangement that involves direct contracting
between the carrier and a licensed or certified ODS, or under which an HMO
makes its network available to a carrier, shall be presumed to have an adequate
provider network.
(b) Health
benefits plans utilizing selective contracting arrangements shall meet the
following criteria:
1. The health benefits
plan utilizing a selective contracting arrangement shall provide that covered
persons shall not be financially liable for payments to network providers for
any sums, other than required co-payments, coinsurance or deductibles, owed for
covered services, if the carrier fails to pay for the covered services for any
reason;
2. The health benefits plan
shall provide that the cost sharing applied to the covered person for emergency
care shall be the same regardless of whether the services were rendered by
network or out-of-network providers;
3. The health benefits plan shall provide
that the carrier shall provide each covered person with a current evidence of
coverage within 30 days of enrollment and no later than 30 days after any
policy or contract changes;
4. The
health benefits plan shall provide that covered persons shall be permitted to
change their selection of primary care physician, and such changes shall be
effective no later than 15 days after receipt of a request to change a primary
care physician;
5. The health
benefits plan shall provide that covered persons shall be provided with a
current directory of network providers in the licensed or certified ODS, HMO,
or PPO, or who have directly contracted with the carrier, including addresses
and telephone numbers, and a listing of the providers who speak languages other
than English. The directory may be made available online provided that covered
persons can obtain a hard copy of the directory upon request;
6. The benefit design of health benefits
plans utilizing selective contracting arrangements shall be subject to N.J.A.C.
11:22-5; and
7. Carriers shall not
calculate benefits for services provided by out-of-network providers by using
negotiated fees agreed to by network providers.
