Current through Register Vol. 56, No. 6,
March 18, 2024
(a) Group
policies and certificates providing health insurance in which some portion of
the benefits are subject to pre-authorization provisions shall comply with the
following:
1. There shall be a caption for
the pre-authorization provision in both the policies and certificates that
shall clearly state in prominent boldface type that benefits will be reduced
for noncompliance with the requirements of the pre-authorization
provision.
2. The pre-authorization
provision shall include a process by which a covered person shall be able to
appeal benefit denials (including, but not limited to, hospitalization
admission denials, a reduction of benefits payable, rejected admissions and
non-reviewed admissions), which process shall be described in detail and shall
state a reasonable time period within which the covered person may expect the
insurer (or any entity with which the insurer has contracted to perform such
reviews on its behalf) to respond.
3. The penalty for noncompliance shall not
exceed 50 percent of the charges which would otherwise be covered under the
contract, policy or certificate. Schedules of penalties to be offered to
policyholders (outlining the range of penalties for non-compliance with the
pre-authorization provision) shall be submitted to the Department with the
policy form filing.
4. If the
pre-authorization provision incorporates an emergency treatment
post-notification requirement with a notice deadline and penalty, the provision
shall include a statement that post-deadline notice shall be accepted and the
penalty waived if the covered person provides notification as soon as
reasonably possible.
5. Inpatient
and/or outpatient treatment for alcoholism as described at
17B:27-46.1 shall only be subject
to pre-authorization provisions if all inpatient and/or outpatient treatments
for other injuries and illnesses are subject to the same review.
(b) Incorporation of the required
pre-authorization warning text in a certificate booklet, through certificate
riders and/or insert pages shall not be acceptable.
(c) If an identification card is used for
benefit certification purposes, a pre-authorization requirement warning similar
to that contained in the policy and certificate shall be displayed on the
identification card, along with a telephone number by which to contact the
insurer regarding the pre-authorization provision.
1. A sample of the identification card along
with a copy of any promotional and/or informational material which describes
the preauthorization requirement shall be included with the initial form
submission made to the Department.
