N.J. Admin. Code § 11:24-3.2

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

Section 11:24-3.2 - Nondiscriminatory enrollment practices

(a) Except as provided in 11:24-3.4(a), an HMO shall not refuse to renew the coverage of a member covered under a contract for basic health care services, or alter the terms of, or cancel, an existing contract solely on the basis of the following:

1. The health of the member;

2. The age of the member;

3. The sex of the member;

4. The frequency of the member's use of the health care services of the HMO;

5. The filing of a complaint or appeal by the member as permitted by these rules; or

6. Other reasons prohibited by the Trade Practices Act, N.J.S.A. 17B-30-1 et seq., or the New Jersey Law Against Discrimination, N.J.S.A. 10:5-1.1 et seq.

(b) In accordance with N.J.S.A. 17B:48E-20, contracts of an HMO which provide coverage of a family member or dependents of a member shall also provide coverage to a newborn child of a member from the moment of birth until 31 days after the date of birth as if that child were enrolled, without additional premium for these 31 days. The coverage for newly-born children shall consist of coverage of at least injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

(c) Contracts of an HMO which provide coverage of a member but do not provide coverage for a family member or dependent of the member shall nevertheless provide for coverage of newborn children of the member from the moment of birth until 31 days after the date of birth as if that child were enrolled, unless the contracts are such as provide no dependent coverage whatsoever for the member's class. The coverage for newly-born children shall consist of coverage of at least injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, provided application and payment of the required premium are submitted to the HMO to include coverage for a newly-born child within 31 days from the date of birth. The services under this section must be authorized by the HMO.

N.J. Admin. Code § 11:24-3.2