N.J. Admin. Code § 11:20-11.9

Current through Register Vol. 57, No. 1, January 6, 2025

Section 11:20-11.9 - Exceptions for health maintenance organizations due to lack of capacity

(a) Any member health maintenance organization (HMO) asserting that it is not required to offer coverage or accept applications pursuant to the requirements of the Act because it does not have the capacity to enroll additional members, pursuant to N.J.S.A. 17B:27A-8a, shall file the following information with the Commissioner:

1. A cover letter stating:

i. The name of the member HMO;

ii. A statement that the member is not required to offer coverage or accept applications pursuant to the Act because it does not have the capacity in its facilities to enroll additional members, and the basis for that assertion, with supporting documentation, certified by the president or duly authorized officer of the member;

iii. The number of the member's current individual and group members, listed by provider and classified by the provider's specialty, which shall be updated annually each year the member asserts a waiver pursuant to N.J.S.A. 17B:27A-8a; and

iv. A certification signed by the president or duly authorized officer that the member, pursuant to N.J.S.A. 17B:27A-8a:

(1) Will not offer coverage to or accept any new group members. Individual additions to existing groups shall not be considered new group members; and

(2) Upon denying individual health benefits coverage, will not offer such coverage in the individual market for a period of 180 days after the date the coverage is denied.

(b) The member shall concurrently file the information required pursuant to (a) above with the IHC Program.

N.J. Admin. Code § 11:20-11.9

Amended by R.1998 d.454, effective 9/8/1998.
See: 30 New Jersey Register 2192(a), 30 New Jersey Register 3308(a).
Rewrote (a)1iv.