N.J. Admin. Code § 11:24-5.2

Current through Register Vol. 56, No. 11, June 3, 2024

Section 11:24-5.2 - Basic comprehensive health care services

(a) The HMO shall provide or arrange for the provision of the following basic comprehensive health services as medically necessary:

1. Periodic examinations and office visits to a primary care provider for routine and urgent care;

2. Diagnostic and disease detection studies, including laboratory and radiological services;

3. Prenatal care and obstetric care:

i. In accordance with 26:2J-4.9, obstetric care includes 48 hours of inpatient care following a vaginal delivery or a minimum of 96 hours of inpatient care following a caesarean section.

ii. Notwithstanding the provisions of (a)3i above, a member agreement that provides health care services for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of inpatient care unless such inpatient care is determined to be medically necessary by the attending physician or is requested by the mother.

4. Regular pediatric care including newborn care and immunizations as set forth at N.J.A.C. 8:57-8, Childhood Immunization Insurance Coverage;

5. Radiation therapy;

6. Consultations and specialists' services as requested by the primary care provider;

7. In accordance with N.J.S.A. 26:2J-4.3a(4), out-of-hospital physical examinations, including related x-rays and diagnostic tests, to include, at a minimum, the following:

i. For members who are less than two years of age, up to six examinations during the first two years of life; for members who are minors of two years of age or older, one examination at age three, six, nine, 12, 15 and 18 years; and

ii. For members who are adults less than 40 years of age, one examination every five years; for members who are 40 or more years of age but less than 60 years of age, one examination every three years; and for members who are 60 years of age or older, one examination every two years;

8. Screening examinations prescribed at 26:2J-1 et seq., including:

i. Pap smears in accordance with 26:2J-4.1 2; and

ii. Mammograms in accordance with 26:2J-4.4;

9. Physical medicine and rehabilitation services including, but not limited to physical therapy;

10. Equipment and supplies for the treatment of diabetes in accordance with 26:2J-4.1 1, and any rules promulgated pursuant thereto, including N.J.A.C. 11:4-49;

11. Outpatient evaluative, crisis intervention and short term therapeutic mental health services;

12. Outpatient substance abuse care;

13. Medically necessary eye care services for detection and treatment of disease or injury to the eye and children's eye examinations conducted to determine the need for vision correction;

14. Inpatient hospital care, including semi-private room accommodations, physicians' and surgeons' services, anesthesia, lab, x-ray and other diagnostic services, drugs and medication, therapeutic services and other services and supplies that are usually provided by the hospital;

15. Outpatient surgical care;

16. Inpatient psychiatric care;

17. Inpatient substance abuse care (a minimum of 30 days during any contract year) in a facility licensed to provide residential alcohol and drug abuse services;

18. Skilled nursing care (a minimum of 30 days during any contract year) in a licensed long term care facility, as well as services or benefits provided consistent with 26:2J-4.2 1;

19. Home health services (a minimum of 60 home care visits during any contract year); and

20. Hospice services from a Medicare certified hospice agency.

N.J. Admin. Code § 11:24-5.2

Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
Rewrote (a)4.
Amended by R.2002 d.265, effective 8/19/2002.
See: 34 N.J.R. 885(a), 34 N.J.R. 3014(a).
In (a), substituted " N.J.S.A. 26:2J-4.9" for "P.L. 1995, c.138" in 3i, amended the N.J.S.A. reference in 7 and rewrote 10 and 18.