N.J. Admin. Code § 11:10-1.2

Current through Register Vol. 56, No. 23, December 2, 2024

Section 11:10-1.2 - Scope and application

(a) This subchapter applies to dental plan organizations as defined in N.J.S.A. 17:48D-2c and 11:10-1.3. Such organizations may offer group and individual dental plans on other than a pure fee-for-service basis.

(b) If the dental plan organization utilizes more than one full-time equivalent dentist to serve dental plan covered persons, it is subject to the Act and this subchapter.

(c) An individual dentist in solo practice is not required to comply with the Act or this subchapter.

(d) An individual dentist in solo practice may apply for a certificate of authority to act as a DPO, and shall comply with all the requirements of this subchapter.

(e) Supplemental dental plans as defined at 11:10-1.3 are subject to the Act and this subchapter. A DPO may not offer a supplemental dental plan unless it can be actuarially demonstrated that the capitation rate for such a plan is proportionate to the rate for an identical plan that provides 100 percent full coverage for the same services provided under the supplemental plan.

(f) An organization which provides coverage of dental services exclusively on a fee-for-service basis cannot qualify as a dental plan organization. Such organizations may not operate in this State without a certificate of authority as a health insurer or hospital, medical, dental or health service corporation, since fee-for-service coverage is either insurance or service benefits.

N.J. Admin. Code § 11:10-1.2

Amended by R.2011 d.227, effective 9/6/2011.
See: 43 N.J.R. 124(a), 43 N.J.R. 2347(a).
In (a), substituted "other than a pure fee-for-service" for "a prepaid and postpaid capitation"; in (b), substituted "covered persons" for "enrollees"; and in (c), deleted "who capitates his services" following "practice".