N.J. Admin. Code § 11:22-5.8

Current through Register Vol. 56, No. 8, April 15, 2024

Section 11:22-5.8 - Network and out-of-network coverage

(a) POS contracts issued by health maintenance organizations and health service corporations, and SCA policies issued by insurance companies, shall provide coverage for covered services and supplies regardless of whether rendered by a network or an out-of-network provider, with the following exceptions:

1. The following services and supplies may be covered only when provided by a network provider, and are not required to be covered when provided by an out-of-network provider:

i. Health club membership;

ii. Prescription drugs, other than insulin and oral agents for controlling blood sugar as mandated by 17:48-6n, 17:48A-7l, 17:48E-35.1 1, 17B:26-2.1l, 17B:27-46.1m and 26:2J-4.1 1, and medications to treat infertility as mandated by 17:48-6x, 17:48A-7w, 17:48E-35.2 2, 17B:27-46.1x and 26:2J-4.2 3;

iii. Dental services and supplies, other than services and supplies for injury to sound natural teeth, bony impacted teeth and as required by P.L. 1999, c. 49;

iv. Routine eye care and appliances;

v. Routine foot care;

vi. Routine hearing care and appliances;

vii. Smoking cessation programs; and

viii. Travel companion benefits.

(b) All contracts issued by health maintenance organizations and health service corporations, and all SCA policies issued by insurance companies, shall provide the following:

1. That a covered person's liability for services rendered during a hospitalization in a network hospital, including, but not limited to, anesthesia and radiology, where the admitting physician is a network provider and the covered person and/or provider has complied with all required preauthorization or notice requirements, shall be limited to the copayment, deductible and/or coinsurance applicable to network services; and

2. That a covered person's liability for services rendered during a hospitalization in a network hospital, including, but not limited to, anesthesia and radiology, where the admitting physician is an out-of-network provider, shall be limited to the copayment, deductible and/or coinsurance applicable to network services.

(c) Carriers shall not calculate benefits for services provided by out-of-network providers by using negotiated fees agreed to by network providers.

N.J. Admin. Code § 11:22-5.8

Amended by R.2006 d.189, effective 5/15/2006.
See: 37 N.J.R. 4510(a), 38 N.J.R. 2159(a).
Added (c).
Recodified from N.J.A.C. 11:22-5.6 and amended by R.2009 d.265, effective 9/8/2009 (operative September 8, 2010).
See: 40 N.J.R. 6915(a), 41 N.J.R. 3302(b).
Rewrote (a)1iii. Former N.J.A.C. 11:22-5.8, Dental benefits, recodified to N.J.A.C. 11:22-5.10.