N.J. Admin. Code § 11:24-2.4

Current through Register Vol. 57, No. 1, January 6, 2025

Section 11:24-2.4 - Comprehensive assessment reviews

(a) After issuance of a certificate of authority, the HMO shall undergo a comprehensive assessment review by the Department on a triennial basis.

(b) The comprehensive assessment review conducted by the Department may include an on-site review and shall be based upon the Department's review of the following:

1. A filing of information by the HMO of any substantial change to operations identified in N.J.A.C. 11:24-2.7 not previously filed with the Department. This filing shall not require the submission of any documents previously filed with the Department, if such documents have remained valid and unchanged since their original filing;

2. The results of the HMO's external quality audit, as required at N.J.A.C. 11:24-7.2;

3. A statement from the HMO attesting that it or any affiliate certified or licensed as an HMO or health insuror has been in substantial compliance with all applicable state and Federal rules and/or regulations for the last 12 months in any other state in which it has been approved to do business; and

4. All network adequacy, utilization management, continuous quality improvement, performance and outcome measurements or other data or information provided for in this chapter.

(c) The comprehensive assessment review required at (b) above shall be conducted by the Department in accordance with the following schedule:

1. For HMOs with a valid certificate of authority issued between January 1, 1973 and December 31, 1985, the first review shall be conducted in the year beginning January 1, 1997, no more than 180 days and no less than 90 days prior to the anniversary date of original issuance;

2. For HMOs with a valid certificate of authority issued between January 1, 1986 and December 31, 1994, the first review shall be conducted in the year beginning January 1, 1998, no more than 180 days and no less than 90 days prior to the anniversary date of original issuance;

3. For HMOs with a valid certificate of authority issued between January 1, 1995 and July 1, 1997, the first review shall be conducted in the year beginning January 1, 1999, no more than 180 days and no less than 90 days prior to the anniversary date of original issuance; and

4. For HMOs with a valid certificate of authority issued after July 1, 1997, reviews shall be conducted every third year, no more than 180 days and no less than 90 days prior to the anniversary date of issuance.

(d) An HMO that does not demonstrate compliance with the requirements of this chapter based on the Department's findings resulting from the comprehensive assessment review may be subject to enforcement actions pursuant to N.J.A.C. 11:24-2.1 4. Notice of violations shall be provided, pursuant to N.J.A.C. 11:24-2.1 3 to the HMO. The Department may also issue a narrative assessment of HMO performance based upon the comprehensive assessment review and require a corrective action plan from the HMO. This report shall become public information in the manner specified in N.J.A.C. 11:24-2.1 3(d).

N.J. Admin. Code § 11:24-2.4