N.J. Admin. Code § 11:24-14.7

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

Section 11:24-14.7 - POS under a dual contract arrangement

(a) No HMO shall enter into a dual contracting arrangement until both the HMO contract forms and rates thereof and the indemnity policy forms and rates thereof, as applicable, have been submitted to the Department for filing, each with unique identifying numbers for the dual contract arrangement product; neither riders, amendments nor endorsements of an HMO contract or an indemnity policy shall be filed for use as a dual contracting arrangement.

(b) An indemnity policy designed to provide benefits for out-of-network covered services in conjunction with an HMO's network-based arrangement shall be subject to the following:

1. The policy form shall specify that it shall be issued and delivered in conjunction with an HMO contract, and shall contain reciprocal language incorporating the other contract;

2. The policy form shall not be designed, nor shall it be offered, as a stand-alone policy;

3. The policy form shall require execution of the indemnity policy by the contractholder; and

4. The policy form, application, certificate and other documents that make up the contract, as well as the rating formula, shall be filed by the Department as required by N.J.S.A. 17B:27-49, 17:48-1 et seq., 17:48A-1 et seq., or 17:48E-1 et seq. and N.J.A.C. 11:4-40, as appropriate for the carrier.

(c) An HMO contract designed to provide services on a network-based arrangement in conjunction with a carrier's indemnity policy shall be subject to the following:

1. The contract form shall specify that it shall be issued and delivered in conjunction with an indemnity policy, and shall contain reciprocal language incorporating the other contract;

2. The contract form shall not be designed nor offered as a stand-alone contract;

3. The contract form shall require execution of the HMO contract by the contractholder; and

4. The contract form, application, certificate and other documents that make upon the contract, as well as the rating formula, shall be submitted to the Department for filing, and the forms shall not be used until so filed by the Department.

(d) The HMO informational rate filing shall specify, by formula, the portion of the dual contract arrangement's full premium that shall be charged by the HMO for the network-based covered services; any modifications thereof shall be on a prospective basis only.

(e) The carrier's rate filing, if a rate filing is required pursuant to statute, shall specify, by formula, the portion of the dual contract arrangement's full premium that shall be charged by the carrier for the out-of-network covered services.

(f) Descriptive material (evidences of coverage, certificates, booklets) required to be provided to enrollees shall specify how both the HMO provisions and the indemnity provisions apply to the services and expenses covered under the dual contract arrangement.

(g) The HMO shall submit a detailed description to the Department specifying the responsibilities of the HMO and the carrier to one another, both administratively and financially, prior to implementation of any dual contracting arrangement. Arrangements established by an HMO and carrier to implement a dual contract that have the effect of violating the HMO or insurance laws of this State shall not be permitted.

N.J. Admin. Code § 11:24-14.7

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).
Substituted "Department of Banking and Insurance" for "Department of Insurance" throughout.