N.J. Admin. Code § 11:24-14.6

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

Section 11:24-14.6 - POS under a group health contract master policy arrangement

(a) The master policy form, certificate form, and any other form that becomes a part of the group health contract, as applicable, shall be submitted by the carrier electronically, pursuant to N.J.A.C. 11:4-40.4.

(b) The master policy form shall comply with all applicable insurance laws in this State.

(c) The master policy form and certificate form shall clearly indicate that the contract shall be used in conjunction with an HMO service contract, wherein the group policyholder is an HMO and the insureds are a class of HMO subscribers and members.

(d) The master policy shall provide indemnity benefits for all of the out-of-network covered services, except that the HMO and carrier may elect not to insure the HMO's emergency and out-of-area care through the master policy.

(e) The POS contract and evidence of coverage shall specify all of the covered services under the POS contract, clearly indicating when services covered vary between the network and out-of-network covered services (for instance, due to differences between mandates between HMOs and carriers).

(f) The certificate to be delivered to HMO members and the evidence of coverage to be delivered to HMO members may be contained in a single document, in which instance, the document shall be submitted by the HMO to the Health Bureau of the Department, and the carrier shall include a statement in its form submission to the Health Bureau of the Department that the certificate shall be combined with the evidence of coverage and shall be submitted by the HMO in accordance with this subchapter, which statement shall be certified to by a duly authorized officer of the carrier.

(g) The informational rate filing submitted by the HMO shall specify the premium and premium rating methodology for all services covered under the POS contract, including the cost to the HMO of purchasing the master policy to provide indemnity benefits for the out-of-network covered services.

N.J. Admin. Code § 11:24-14.6

Amended by R.1997 d.68, effective 2/18/1997 (operative July 1, 1997).
See: 28 N.J.R. 2456(a), 28 N.J.R. 3118(b), 29 N.J.R. 625(a).
In (f), amended Department names.
Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).

Amended by 54 N.J.R. 73(a), effective 1/3/2022