N.J. Admin. Code § 11:3-4.4

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

Section 11:3-4.4 - Deductibles and co-pays

(a) Each insurer shall offer a standard $ 250.00 deductible and 20 percent copayment on medical expense benefits payable between $ 250.00 and $ 5,000.

(b) Each insurer shall also offer, at appropriately reduced premiums, the option to select medical expense benefit deductibles of $ 500.00, $ 1,000, $ 2,000 and $ 2,500 in accordance with the following provisions:

1. Any medical expense deductible elected by the named insured shall apply only to the named insured and any resident relative in the named insured's household, who is not a named insured under another automobile policy and not to any other person eligible for personal injury protection benefits required to be provided in accordance with 39:6A-3.1 and 39:6A-4;

2. Premium credits calculated and represented as a percentage of the applicable premium shall be provided for each deductible. The premium percentage shall be uniform by filer on a statewide basis; and

3. The deductible option elected by the named insured shall continue in force as to subsequent renewal or replacement policies until the insurer or its authorized representative receives a properly executed coverage selection form to eliminate or change the deductible.

(c) All deductibles and co-pays in (a) and (b) above shall apply on a per accident basis.

(d) An insurer may file policy language that waives the co-payment and deductible in (a) and (b) above when the insured receives medical treatment from a provider that is part of an ODS that has contracted with the insurer or its PIP vendor. The insured shall not be required to elect to use the providers or facilities in such an ODS either at issuance of the policy or when the claim is made.

1. Upon receipt of notification of a claim, the insurer or its PIP vendor shall make available to the insured information about physicians and facilities in any ODS with which it has a contract.

i. The information shall include a notice that the insured is not required to use the providers or facilities of an ODS with which the insurer or its PIP vendor has contracted and indicate that if the insured chooses to receive covered services from such providers or facilities, the deductible and copayments in (a) and (b) above would not apply.

ii. The information shall also indicate that the insured may seek treatment from providers and facilities that are not part of an ODS with which the insurer or its PIP vendor has contracted, in which case the deductible and copayments in (a) and (b) above would apply.

2. The actual ODS access fee or 25 percent of the reduction in charges resulting from the use of the ODS provider, whichever is less, may be included within the policy limits for any single bill from an in-network provider in the ODS with billed charges of $ 10,000 or more.

Example: A $ 10,000 charge is reduced by the ODS contract with the insurer by 45 percent to $ 5,500. The insurer could include the ODS access fee or $ 1,125 (25 percent of the $ 4,500 reduction), whichever is less, within the policy limits.

(e) Failure to request decision point review or precertification where required or failure to provide clinically supported findings that support the treatment, diagnostic test or durable medical equipment requested shall result in an additional co-payment not to exceed 50 percent of the eligible charge for medically necessary diagnostic tests, treatments or durable medical goods that were provided between the time notification to the insurer was required and the time that proper notification is made and the insurer has an opportunity to respond in accordance with its approved decision point review plan.

Example: Assume that all days are business days and the insurer's Decision Point Review Plan gives the insurer three days to respond to decision point review and precertification requests. By the terms of the insurer's Decision Point Review Plan, a treating medical provider is required to make a decision point review request on day 21 of treatment (time notification was required). The provider does not give the required notification in a timely manner but continues to treat the patient. The provider then makes the notification and it is received by the insurer on day 35 (time proper notification made). The insurer responds on day 38 that the treatment can proceed (time for insurer to respond). Assuming that the treatment made between day 21 and 38 was medically necessary, it is subject to the 50 percent co-payment.

1. No insurer may impose the additional co-payment where the insurer received the required notice but failed to act in accordance with its approved decision point review plan to request further information, modify or deny reimbursement of further treatment, diagnostic tests or durable medical equipment.

(f) An insurer may require that the insured advise and inform the insurer about the injury and the claim. This requirement may include the production of information from the insured regarding the facts of the accident, the nature and cause of the injury, the diagnosis and the anticipated course of treatment.

1. This information may be required to be provided as promptly as possible after the accident, and periodically thereafter.

2. An insurer may impose an additional co-payment as a penalty for failure to supply the required information. Such penalties shall result in a reduction in the amount of reimbursement of the eligible charge for medically necessary expenses that are incurred after notification to the insurer is required and until notification is received. The additional co-payment shall be an amount no greater than:

i. Twenty-five percent when received 30 or more days after the accident; or

ii. Fifty percent when received 60 or more days after the accident.

3. Any reduction in the amount of reimbursement for PIP claims shall be in addition to any other deductible or co-payment requirement.

4. Information about this requirement and how to comply with it shall be included in the informational materials required by 11:3-4.7(d).

(g) An insurer may impose an additional co-payment not to exceed 30 percent of the eligible charge for failure to use an approved network pursuant to 11:3-4.8 for the medically necessary non-emergency benefits listed in 11:3-4.8(b).

(h) For the purpose of the co-payments permitted in (e), (f) and (g) above, the percentage reduction shall be applied to the amount that the insurer would otherwise have paid to the insured or the provider after the application of the provisions of N.J.A.C. 11:3-29. Insurers may apply the co-payments and deductibles in (a) through (g) above in any order, provided that they use the same order of application for all insureds. Upon receipt of a request for PIP benefits under the policy, the insurer or its PIP vendor shall make its co-payment and deductible application methodology available to the insured and the treating medical provider upon request.

(i) For private passenger automobiles insured under a commercial automobile insurance policy where no natural person is a named insured, insurers shall only provide personal injury protection with medical expense benefits coverage in an amount not to exceed $ 250,000 per person, per accident, with the deductible and copayment amount set forth in (a) above.

N.J. Admin. Code § 11:3-4.4

Amended by R. 2000 d.454, effective 11/6/2000.
See: 31 N.J.R. 4210(a), 32 N.J.R. 4005(c).
Inserted a new (e); and recodified former (e) as (f).
Amended by R.2004 d.218, effective 6/7/2004 (operative October 27, 2004).
See: 35 N.J.R. 3072(a), 36 N.J.R. 2890(a), 36 N.J.R. 4319(a).
Rewrote (d); added (f); recodified former (f) as (h).
Amended by R.2004 d.218, effective 6/7/2004 (operative March 4, 2005).
See: 35 N.J.R. 3072(a), 36 N.J.R. 2890(a), 36 N.J.R. 4319(a).
Rewrote (g).
Amended by R.2008 d.46, effective 3/3/2008.
See: 39 N.J.R. 4056(a), 40 N.J.R. 1353(a).
In (g), substituted the last two sentences for "Such amount may have already been reduced by the application of the co-payments and/or deductibles in (a) and (b) above.".
Amended by R.2010 d.142, effective 7/6/2010.
See: 41 N.J.R. 2609(a), 42 N.J.R. 1385(a).
Added new (d); recodified former (d) through (h) as (e) through (i); in (g), inserted "the" preceding "medically", substituted "non-emergency benefits listed" for "diagnostic tests as specified", and deleted ", durable medical equipment and/or prescriptions" from the end; and in (h), substituted "(e), (f) and (g)" for "(d), (e) and (f)" and "(g)" for "(f)" following "through".
Administrative correction.
See: 42 N.J.R. 2129(a).
Amended by R.2012 d.187, effective 11/5/2012 (operative January 4, 2013).
See: 43 N.J.R. 1640(a), 44 N.J.R. 383(a), 44 N.J.R. 2652(c).
In the Example in (d)2, substituted "45" for "40".