N.J. Admin. Code § 11:24-12.2

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

Section 11:24-12.2 - Alternate methodology for assuring continuation of services to HMO members

(a) The Commissioner may order carriers and other HMOs to offer the members of an insolvent HMO an opportunity to become insured or to enroll with the carriers and other HMOs, during no less than a 30-day open enrollment period to be determined by the Commissioner, except as (b) below may apply.

1. If more than a single choice was offered to the members of a group during the group's last regular enrollment period, the Commissioner's order shall be limited to those carriers and HMOs that participated in the enrollment process with the insolvent HMO during the group's last regular enrollment period, except that if the Commissioner determines that the other HMOs and/or managed care plans of the carriers that participated with the insolvent HMO lack sufficient capacity to assure that health care services shall be available and accessible to the group's members, then the Commissioner may order all HMOs operating within the same service areas as the insolvent HMO to enroll an equitable portion of the insolvent HMO's members, as determined by the Commissioner.

i. Carriers and HMOs that participated with the insolvent HMO at the group's last regular enrollment period shall offer the members of the insolvent HMO the same coverage at the same rates that the carriers and HMOs offered to the group's members at the group's last regular enrollment period, which shall be effective until the group's regular renewal period.

ii. HMOs that did not participate with the insolvent HMO at the group's last regular enrollment period shall offer the members of the insolvent HMO coverage that is most similar to the coverage the members have with the insolvent HMO, as determined by the Commissioner, at the successor HMO's then-current rates for the coverage offered.

2. When the members of the insolvent HMO are not members of a group, or are members of a group that did not have multiple choices of carriers or HMOs with whom to become insured or enrolled during the group's last regular enrollment period, the Commissioner may order that all HMOs within the service area of the insolvent HMO shall enroll an equitable portion of the insolvent HMO's members, as determined by the Commissioner.

i. The successor HMO shall offer the members of the insolvent HMO coverage that is most similar to the coverage the members have with the insolvent HMO, at the successor HMO's then-current rates for the coverage offered.

3. In allocating members to other HMOs, the Commissioner shall consider the capacity of the HMOs to assure that health care services will be available and accessible to the members.

(b) The Commissioner shall act in consultation with the Director of the Division of Medical Assistance and Health Services in allocation of Medicaid members of an insolvent HMO.

(c) With respect to Medicaid recipients and Medicare beneficiaries who are members or other members under special State government contracts, such members of an insolvent HMO shall only be allocated to HMOs within the same service area as the insolvent HMO that have a similar contract with the Medicare, Medicaid or other special State government programs.

(d) With respect to members under standard individual health benefits plans or members who are members of small employer groups as defined by N.J.S.A. 17B:27A-17 et seq., such members of an insolvent HMO shall only be allocated to HMOs within the same service area as the insolvent HMO that have elected to offer coverage to individuals and members of small employer groups.

N.J. Admin. Code § 11:24-12.2