N.J. Admin. Code § 11:24A-2.3

Current through Register Vol. 56, No. 12, June 17, 2024

Section 11:24A-2.3 - Disclosure requirements

(a) Carriers shall provide to each subscriber within no more than 30 days following the effective date of coverage, and upon request thereafter, through a handbook, certificate, or other evidence of coverage designed for covered persons, information describing the following:

1. The services or benefits therefor to which a covered person is entitled under the policy or contract, including:

i. All exclusions and limitations with respect to at least physical and occupational therapy, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, radiological examinations and behavioral health services;

ii. All restrictions on accessing covered services, such as the requirement to obtain prior authorization, preadmission certification, or periodic review of ongoing treatment;

iii. A full and clear description of the carrier's policies and procedures governing the provision of emergency and urgent care services or the payment of benefits therefor, including a statement that emergency or urgent care services are not covered, if that is the case;

iv. All dollar, day, visit, or procedure limitations applicable to at least those services set forth at (a)1i above, and the method for exchanging inpatient for outpatient services or vice versa, when such exchanges are permitted under the policy or contract; and

v. The right to request to use an out-of-network provider at network level cost sharing where the network does not contain a qualified, accessible, and available provider to perform a service.

2. The responsibility of the covered person to pay deductibles, coinsurance or copayments, as appropriate.

i. Carriers shall clearly distinguish any differences in the covered person's financial responsibility for accessing services within and outside of a carrier's network, when applicable;

ii. Carriers shall explain the covered person's responsibility to pay for charges incurred that are not covered under the policy or contract.

iii. Carriers shall explain the covered person's responsibility to pay for charges that exceed what the carrier determines are customary and reasonable charges (usual and customary, or usual, customary and reasonable, as appropriate to the carrier) for services that are covered under the policy or contract in those instances in which service is rendered by an out-of-network provider;

3. Where and in what manner covered services may be obtained.

i. Even in the instance in which the contract or policy is not subject to any network requirements or differentials, carriers shall specify if benefits are payable for certain services only when rendered by a specified class or classes of provider(s); and

ii. The process a covered person or provider must follow to request to use an out-of-network provider and be responsible only for network level cost sharing where the network does not contain a qualified, accessible, and available provider to perform the service.

4. Use of the "911" emergency response system whenever a covered person has a potentially life-threatening condition, and a statement that "911" information is included on the covered person's insurance identification card.

i. In addition to (a)4 above, carriers shall provide "911" information on all insurance identification cards.

ii. In complying with (a)4i above, carriers may elect to phase-in the 911 information on insurance identification cards, so long as all covered persons of a carrier has an insurance identification card that meets the requirements of (a)4i above no later than 24 months following (the operative date of this chapter);

5. The right of the covered person to obtain information concerning the carrier's policies and procedures required pursuant to 11:24A-2.5(b);

6. The right to prompt written notification of changes to or termination of benefits, or services which in no event shall be provided no later than 30 days following the date of any change or termination; and

7. The right of the covered person to file a complaint with the Department.

(b) A carrier shall provide written notice to subscribers of any additions of any services or benefits therefor to the contract or policy within no more than 30 days following the date that the change is effective.

(c) All information provided to subscribers shall meet the readability requirements of 17B:17-17 et seq. (the Life and Health Insurance Policy Language Simplification Act), and any rules promulgated pursuant thereto.

N.J. Admin. Code § 11:24A-2.3

Amended by 50 N.J.R. 575(a), effective 1/16/2018