N.J. Admin. Code § 11:20-3.1

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

Section 11:20-3.1 - The standard health benefits plans

(a) The standard individual health benefits plans established by the Board contain the benefits, limitations and exclusions set forth in the Appendix to this chapter as follows:

1. Plan A/50, Appendix Exhibit A with pages identified as unique to Plan A/50;

2. Plan B, Appendix Exhibit A with pages identified as unique to Plan B;

3. Plan C, Appendix Exhibit A with pages identified as unique to Plan C;

4. Plan D, Appendix Exhibit A with pages identified as unique to Plan D; and

5. HMO Plan, Appendix Exhibit B.

(b) Members that offer individual health benefits plans in this State and members that offer small employer health benefits plans in this State pursuant to N.J.S.A. 17B:27A-17 et seq., and N.J.A.C. 11:21 shall offer at least three of the standard health benefits Plans A/50, B, C, D, and HMO as set forth in chapter Appendix Exhibits A and B, incorporated herein by reference with variable text as specified on the Explanation of Brackets, which is set forth as chapter Appendix Exhibit C, incorporated herein by reference, subject to the provisions set forth in (b)1 through 9 below and except as provided in (c) below.

1. Members shall offer Plan A/50 which is designated as the basic plan.

2. Members shall offer at least two of the Plans designated as Plans B, C, D and HMO.

3. Members offering Plan A/50, and at least two of the plans designated as Plans B, C, D, and HMO shall offer at least two of the selected plans B, C, and/or D if not also offering HMO, and at least one of the selected Plans B, C, and/or D if offering the HMO, with annual deductible provisions as follows:

i. For a network-based plan, the network per covered person annual deductible shall not exceed $ 2,500, except as stated in (b)3ii and iii below.

ii. For a network-based bronze plan, meaning a plan with a 60 percent actuarial value, the network per covered person annual deductible shall not exceed $ 3,000.

iii. For a plan to be offered as a catastrophic plan, the per covered person annual deductible shall equal the greatest permissible maximum out of pocket as defined in (b)5 below except the deductible shall be waived for three physician visits per calendar year and shall not apply to preventive health services.

iv. For a plan without a network, the per covered person annual deductible shall not exceed the maximum out-of-pocket as defined in (b)5 below.

v. The corresponding per covered family annual deductible shall be an amount equal to two times the per covered person annual deductible, satisfied on an aggregate basis.

4. Members offering Plans A/50, B, C, and D may offer the plans with deductible provisions such that the plans may qualify as high deductible health plans:

i. In the case of single coverage, an amount to qualify as a High Deductible Health Plan under Internal Revenue Code § 223(c)(2)(A) for the calendar year in which coverage is issued or renewed, per covered person;

ii. In the case of other than single coverage, an amount to qualify as a High Deductible Health Plan under Internal Revenue Code § 223(c)(2)(A) for the calendar year in which coverage is issued or renewed, per covered family, with single and other than single deductibles accumulated in accordance with the requirements of Federal law.

5. When issued using deductible provisions set forth in (b)3 and 4 above, Plans A/50, B, C, and D shall contain maximum out of pocket provisions as follows:

i. The per covered person maximum out of pocket shall not exceed the maximum out of pocket specified in sections 223(c)(2)(A)(ii)(I) and 223(c)(2)(A)(ii)(II) of the Internal Revenue Code of 1986;

ii. The per covered family maximum out of pocket for Plans A/50, B, C and D shall be two times the per covered person maximum out of pocket, satisfied on an aggregate basis; and

iii. Deductible, coinsurance, and copayment under a standalone pediatric dental benefit plan issued to replace the pediatric dental benefits contained in Plans A/50, B, C, and D shall not count toward the maximum out of pocket.

6. Plan A/50 features 50 percent coinsurance, Plan B features 40 percent coinsurance, Plan C features 30 percent coinsurance, and Plan D may feature coinsurance of 20 percent or 10 percent.

(c) Members that are HMOs may offer the HMO Plan, as set forth in N.J.A.C. 11:20 Appendix Exhibit B, in lieu of offering at least three of Plans A/50, B, C, and D in (a) above. HMO carriers offering the HMO Plan may offer a copayment plan design set forth in (c)1 below and/or the HMO plan using deductible and coinsurance provisions set forth in (c)2 below. All options offered by the HMO member shall be made available to every eligible individual seeking coverage. Specifications for the use of copayments are set forth in (c)1 below. Specifications for the use of deductible and coinsurance are set forth in (c)2 below. Specifications for features that are common to plans that use copayment and plans that use deductible and coinsurance are set forth in (d) below.

1. Carriers issuing HMO plans with a Copayment Design shall use the copayments consistent with the copayments permitted in N.J.A.C. 11:22-5.5 with no copayment required for preventive care.

2. Carriers issuing HMO plans with a Deductible and Coinsurance Design shall use the copayments, cash deductible, and coinsurance consistent with the requirements of N.J.A.C. 11:22-5.3 through 5.5. The maximum out of pocket shall be consistent with the maximum out of pocket described in (b)5 above.

(d) Carriers issuing Plans A/50, B, C, D, and HMO shall include the following features which are common to all plans:

i. The emergency room copayment, which shall be paid in addition to other copayments, deductible and coinsurance, shall not exceed $ 100.00.

ii. Pediatric dental and pediatric vision benefits may be subject to cost sharing at the discretion of the carrier provided any copayments for providers who qualify as specialists do not exceed the copayment as permitted by N.J.A.C. 11:22-5.5.

iii. Prescription drugs may be subject to 50 percent coinsurance or other types of cost sharing provisions such as copayments.

(e) The standard health benefits Plans A/50, B, C, and D may be offered through or in conjunction with a selective contracting arrangement approved pursuant to P.L. 1993, c. 162, § 22. The standard health benefits Plans A/50, B, C, and D may be offered with the same selective contracting arrangement by a carrier that is exempt from the requirements of P.L. 1993, c. 162, § 22, pursuant to N.J.A.C. 11:4-37.1(b), but is permitted to enter into agreements with participating providers pursuant to any statute. Plans issued through or in conjunction with an approved selective contracting arrangement and plans with selective contracting arrangement features issued by an entity exempt from the requirements of P.L. 1993, c. 162, § 22 shall be subject to the following:

1. All of the requirements of N.J.A.C. 11:4-37.3;

2. The network annual deductible shall be no greater than $ 2,500 per covered person, or $ 3,000 per covered person, as applicable, to bronze plans and for a covered family shall equal two times the per covered person annual deductible, satisfied on an aggregate basis. If a carrier elects to use a common annual deductible for both network and non-network benefits, the network annual deductible amount shall apply to both network and non-network services and supplies;

3. The HMO Plan copayment amounts for physician visits and hospital confinements and the prescription drug coinsurance may be substituted for deductibles applicable to network benefits;

4. The coinsurance for network services shall be consistent with the coinsurance for one of Plans A/50, B, C, or D and the coinsurance for non-network services must be consistent with the coinsurance for one of Plans A/50, B, C, or D;

5. The network maximum out of pocket shall be no greater than the amount specified in (b)5 above per covered person, and for a covered family shall be no greater than two times the per covered person network maximum out of pocket. If a carrier elects to use a common maximum out of pocket for both network and non-network benefits, the network maximum out of pocket amount shall apply to both network and non-network services and supplies;

6. If a separate non-network deductible is included, the non-network annual deductible shall be two times or three times the network annual deductible per covered person, and for a covered family shall equal two times the per covered person annual deductible, satisfied on an aggregate basis; and

7. If a separate non-network maximum out of pocket is included, the non-network maximum out of pocket shall be two times or three times the network maximum out of pocket per covered person, and for a covered family shall equal two times the per covered person maximum out of pocket.

(f) Network plans as permitted in (d) above and HMO plans may feature a tiered network.

1. If the deductibles for tier 1 and tier 2 are separately satisfied, the sum of the tier 1 deductible and the tier 2 deductible shall not exceed $ 2,500, or $ 3,000 for a bronze plan.

2. If the tier 1 deductible may be separately satisfied and is also applied toward the tier 2 deductible, the tier 2 deductible shall not exceed $ 2,500, or $ 3,000 for a bronze plan.

3. If the tier 1 and tier 2 maximum out of pocket amounts are separately satisfied, the sum of the tier 1 maximum out of pocket and the tier 2 maximum out of pocket shall not exceed the maximum out of pocket specified in sections 223(c)(2)(A)(ii)(I) and 223(c)(2)(A)(ii)(II) of the Internal Revenue Code of 1986.

4. If the tier 1 maximum out of pocket may be separately satisfied and is also applied toward the tier 2 maximum out of pocket, the tier 2 maximum out of pocket shall not exceed the maximum out of pocket specified in sections 223(c)(2)(A)(ii)(I) and 223(c)(2)(A)(ii)(II) of the Internal Revenue Code of 1986.

N.J. Admin. Code § 11:20-3.1

Amended by R.1995 d.531, effective 10/2/1995.
See: 27 N.J.R. 1127(a), 27 N.J.R. 3793(b).
Amended by R.1997 d.3, effective 12/5/1996.
See: 28 N.J.R. 4856(a), 29 N.J.R. 138(a).
Inserted new (b)2; recodified former (b)2 as (b)3; and, in (c), inserted reference to (b)2 deductible options.
Amended by R.1997 d.279, effective 7/7/1997 (operative September 1, 1997).
See: 29 N.J.R. 1011(a), 29 N.J.R. 2854(a).
Substituted Plan B for Plan A as the "The Basic Health Benefits Plan" and amended deductible and copayment amounts.
Amended by R.1998 d.26, effective 1/5/1998.
See: 29 N.J.R. 1089(a), 30 N.J.R. 237(a).
Inserted (d)6.
Administrative correction.
See: 30 N.J.R. 1318(b).
Amended by R.1998 d.443, effective 8/7/1998.
See: 30 N.J.R. 2581(a), 30 N.J.R. 3289(a).
Rewrote the section.
Amended by R.1998 d.503, effective 9/16/1998 (operative November 1, 1998).
See: 30 N.J.R. 3235(b), 30 N.J.R. 3838(a).
In (a), substituted "Individual" for "Basic" in 2, and added 7; in (b), inserted a reference to Plan A/50, deleted a reference to Plan E, inserted a reference to Exhibit U and substituted a reference to Exhibit D for a reference to Exhibit E in the introductory paragraph, deleted a reference to Plans B and E in the introductory paragraph of 1, and inserted a reference to Plans A/50 and B in the introductory paragraph of 2; in (c), substituted a reference to Plans A/50, B, C, and D for a reference to Plans B through E in the first sentence, and added 3; and in (d), inserted a reference to Plan A/50 in the first sentence, substituted a reference to Exhibit D for a reference to Exhibit E in 2, inserted a reference to $ 30.00 copayment levels in 3, and deleted ", and Plan E shall have an out-network level of 99 percent" at the end of 4.
Amended by R.1999 d.131, effective 3/25/1999.
See: 31 N.J.R. 834(a), 31 N.J.R. 1104(a).
In (b)3, rewrote i and ii.
Amended by R.2002 d.95, effective 3/18/2002 (operative August 1, 2002).
See: 33 N.J.R. 4057(a), 34 N.J.R. 1277(a).
Added (b)4.
Amended by R.2002 d.331, effective 10/7/2002.
See: 34 N.J.R. 1786(a), 34 N.J.R. 3527(a).
In (b)4, substituted "may" for "shall".
Amended by R.2003 d.91, effective 1/28/2003.
See: 35 N.J.R. 73(a), 35 N.J.R. 1290(a).
Amended by R.2005 d.160, effective 4/22/2005.
See: 37 N.J.R. 1481(a), 37 N.J.R. 1736(a).
In (b), added iii through vi in 3.
Repeal and New Rule by R.2006 d.15, effective 1/3/2006 (operative July 1, 2006).
See: 37 N.J.R. 2994(a), 38 N.J.R. 311(a), 1005(a).
Amended by R.2009 d.45, effective 12/29/2008.
See: 40 N.J.R. 6904(a), 41 N.J.R. 799(b).
Rewrote (b); in the introductory paragraph of (c), inserted "offering at least three of" and "at least two of", and substituted "(a)" for "(b)" and "$ 30.00" for "$ 15.00"; in (c)1i and (c)1ii(1), substituted "$ 300.00" for "$ 150.00" and "$ 30.00" for "$ 15.00"; in (c)2i(4) and (d)5, substituted "no greater than $ 7,500" for "5,000"; in (d)2, substituted "no greater than" for "$ 1,000 or"; in (d)5, substituted "no greater than two times the per covered person network maximum out of pocket" for "$ 10,000"; and added (e).
Amended by R.2013 d.130, effective 10/1/2013 (operative January 1, 2014).
See: 45 N.J.R. 2310(a), 45 N.J.R. 2385(a).
Rewrote the section.
Amended by R.2016 d.127, effective 10/17/2016 (operative January 1, 2017).
See: 48 N.J.R. 1555(a), 48 N.J.R. 2153(a).
In the introductory paragraph of (e), substituted "§ 22" for "§ 22" throughout; and in (e)1, updated the N.J.A.C. reference.
Amended by R.2018 d.197, effective 6/12/2018.
See: 50 N.J.R. 1412(a), 50 N.J.R. 2329(a).
In the introductory paragraph of (b), inserted a comma following "et seq."; rewrote (b)3 and the introductory paragraph of (c); in (e)2, inserted "or $ 3,000 per covered person, as applicable, to bronze plans"; and in (f)1 and (f)2, inserted ", or $ 3,000 for a bronze plan".