N.J. Admin. Code § 11:22-5.10

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:22-5.10 - Dental benefits

(a) The following standards apply to health benefit plans and stand-alone dental plans that provide benefits for dental services only when rendered by network providers, and plans that provide benefits for dental services rendered by both network and out-of-network providers:

1. The in-network benefit provided by the carrier shall result in average cost sharing, through coinsurance or copayments, of no more than 75 percent of the carrier's contracted cost of that service or for the cost of a class of similar services.

i. An aggregate deductible for all services and any dollar benefit maximums may be disregarded in determining the cost-sharing, but a per service deductible shall be considered a copayment.

ii. A scheduled in-network benefit shall be considered a benefit with a copayment equal to the difference between the contracted rate and the scheduled benefit.

iii. A carrier shall not use the cost of periodic examinations in determining the average cost sharing requirement.

2. A carrier that provides no in-network benefit for a service may allow the subscriber to receive that service by having the subscriber pay to the provider the carrier's in-network contracted rate. In such cases, the services are not considered to be covered services for purposes of meeting the maximum 75 percent copayment/coinsurance requirement.

N.J. Admin. Code § 11:22-5.10

New Rule, R.2006 d.189, effective 5/15/2006.
See: 37 N.J.R. 4510(a), 38 N.J.R. 2159(a).
Recodified from N.J.A.C. 11:22-5.8 by R.2009 d.265, effective 9/8/2009 (operative September 8, 2010).
See: 40 N.J.R. 6915(a), 41 N.J.R. 3302(b).
Rewrote (a)1; and added (a)2.