N.J. Admin. Code § 11:10-1.6

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

Section 11:10-1.6 - Evidence of coverage and group contracts

(a) The DPO shall prepare and issue the evidence of coverage to each enrollee within 60 days of the effective date of coverage or of a change in coverage. Covered groups may distribute the forms to covered persons on behalf of the DPO.

(b) The evidence of coverage must contain all the information required by N.J.S.A. 17:48D-9. A card containing only basic identifying information is not sufficient to meet these requirements.

(c) No evidence of coverage, or group contract, or amendment thereto, may be issued or delivered until a copy of the form has first been filed with, and has not been disapproved by, the Commissioner. A form or amendment, which differs from that previously filed with the Commissioner, may not be issued until it has first been filed with, and has not been disapproved by, the Commissioner. All forms and amendments shall be filed at least 60 days prior to the planned date of issuance, and shall include a unique identifying form number which reflects the effective date of the form or revision. Submissions of amended forms shall include two copies of the amended form(s) or page(s) only, if practicable. One copy shall be marked to show the changes from the prior approved form, and one copy shall be unmarked.

(d) All evidences of coverage shall clearly identify the name of the dental plan organization on its cover and in the text.

(e) All exclusions, exceptions, limitations, items not covered, and services not provided by the plan should be clearly identified in the evidence of coverage and group contract.

(f) Coordination of benefits provisions, which limit payment to 100 percent of allowable expenses when more than one dental plan covers a covered person, are permitted only if all of the following conditions are met:

1. Covered persons are covered under a group, not an individual contract;

2. The DPO follows the coordination of benefits rules set forth at N.J.A.C. 11:4-28; and

3. Both the group contract and evidence of coverage issued to group enrollees shall include the coordination of benefits provisions.

(g) Non-duplication of benefits provisions are not permitted.

(h) Provisions which exclude coverage for services provided by other dental plans or by dental insurance are not permitted in a contract issued by a DPO.

(i) A DPO may arrange for the provision of dental services on a fee-for service, expense incurred or indemnity basis by purchasing coverage or such service from a duly authorized insurer, or a hospital, medical, dental or health service corporation.

(j) An evidence of coverage issued to a non-group enrollee is subject to the plain language requirements of 56:12-1 et seq. All evidences of coverage, including those issued to covered persons of a group, shall be written in a simple, clear, understandable and easily readable manner. In writing an evidence of coverage form to be issued to an enrollee of a group, a DPO may use the guidelines set forth in 56:12-10 to assure compliance with this subsection.

(k) Any DPO offering a stand-alone dental plan that is intended to be sold as a pediatric dental plan to satisfy the Essential Health Benefits requirement of 45 CFR 156.110(a)(10) must satisfy the following requirements:

1. The evidence of coverage shall include identical policy form language for the coverage of pediatric dental benefits as set forth at N.J.A.C. 11:20 Exhibit A or, if alternative language is used, the DPO must provide a cross-walk document to demonstrate that each required pediatric dental service from Exhibit A is contained in the text of the DPO's evidence of coverage;

2. The evidence of coverage shall indicate that pediatric dental benefits are provided for all covered persons through the end of the month in which the covered person turns age 19, regardless of the covered person's enrollment status; and

3. The evidence of coverage may only include the frequency limits, limitations, and exclusions that appear in the dental benefits provision set forth at N.J.A.C. 11:20 Exhibit A and such coverage may not be denied on the basis of pre-existing conditions.

(l) Evidences of coverage and group contracts, including amendments, shall be submitted to:

Chief, Health Insurance Bureau

Office of Life and Health

New Jersey Department of Banking and Insurance

P.O. Box 325

20 West State Street

Trenton, NJ 08625-0325

N.J. Admin. Code § 11:10-1.6

Amended by 51 N.J.R. 215(b), effective 2/19/2019