N.J. Admin. Code § 11:21-15.9

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:21-15.9 - Exceptions for health maintenance organizations due to lack of capacity

(a) Any member HMO asserting that it is not required to offer coverage or accept applications pursuant to the requirements of the Act because it reasonably anticipates that it will not have the capacity in its network of providers within the service area to deliver service adequately to the members of the additional small employer groups, pursuant to N.J.S.A. 17B:27A-26a, 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 anticipates that it will not have the capacity in its network of providers within the service area to deliver service adequately to the members of the additional small employer groups, and the basis for that assertion, with supporting documentation, certified by the president or duly authorized officer of the member; and

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-26a.

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

(c) Any member HMO denying coverage pursuant to (a) above shall not offer coverage in the small employer market within such service area for a period of at least 180 days after the date that the carrier first denies coverage.

N.J. Admin. Code § 11:21-15.9

Amended by R.1998 d.533, effective 11/16/1998.
See: 30 New Jersey Register 2978(a), 30 New Jersey Register 4045(a).
Added (c).