N.J. Admin. Code § 11:22-5.6

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

Section 11:22-5.6 - Out-of-pocket limits

(a) The following shall apply to individual network, family network and individual out-of-network out-of-pocket limits:

1. Carriers shall track the accumulation of copayment, deductible and coinsurance payments to identify when the out-of-pocket limit has been satisfied, and shall not require covered persons to report payment of copayments, coinsurance or deductible for inclusion in the out-of-pocket limit;

2. All amounts paid as copayment, coinsurance and deductible shall count toward the out-of-pocket limit, and shall not be excluded because of the nature of the service rendered, the illness or condition being treated, or for any other reason, except carriers may, provided the terms of the health benefit plan so state, elect to exclude from the out-of-pocket limit the cost sharing associated with prescription drug coverage, whether provided as part of the health benefit plan or as a rider; and

3. When the out-of-pocket limit has been reached, the covered person, or the covered members of the family in the case of a family network out-of-pocket limit, shall have no further obligation to pay any amounts as copayment, coinsurance or deductible for services and supplies provided by providers for the remainder of the calendar, contract or policy year, except for prescription drugs if, under the terms of the applicable plan, prescription drugs do not accumulate toward the out-of-pocket limit.

N.J. Admin. Code § 11:22-5.6

New Rule, 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).
Former N.J.A.C. 11:22-5.6, Network and out-of-network coverage, was recodified to N.J.A.C. 11:22-5.8.