N.J. Admin. Code § 11:24C-3.3

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

Section 11:24C-3.3 - Carrier' obligation to provide benefits or services for the home treatment of bleeding episodes associated with hemophilia

(a) Every carrier shall provide for, in its managed care plans, in-network benefits or services for the home treatment of bleeding episodes associated with hemophilia.

(b) No carrier shall arrange with any person for the provision of home treatment of bleeding episodes associated with hemophilia unless that person shall be a designated provider of such services, nor shall a carrier refer any covered person or cause a covered person to be referred to a person that is not a designated health care provider of services and supplies for the home treatment of bleeding episodes associated with hemophilia.

(c) Carriers with an aggregate enrollment of 50,000 covered persons or more in managed care plans shall arrange for the provision of home treatment of bleeding episodes associated with hemophilia with at least two designated health care providers, unless there are fewer than two designated health care providers designated in New Jersey, in which event, the carrier shall arrange for the provision of home treatment services with the lone designated health care provider, regardless of the carrier's enrollment.

(d) Carriers with aggregate enrollment of fewer than 50,000 covered persons in managed care plans shall arrange for the provision of home treatment of bleeding episodes associated with hemophilia with at least one designated health care provider.

(e) Nothing in this subchapter shall be construed to limit the obligation of a carrier to provide out-of-network benefits for home treatment services accessed at the option of the covered person through a health care provider that is not designated, when the managed care plan has an out-of-network benefits component.

(f) Nothing in this subchapter shall be construed to limit the obligation of a carrier to provide benefits or services on an in-network basis when a covered person accesses home treatment services from a health care provider, designated or not, because the carrier fails to have an agreement with a designated health care provider to provide services for the home treatment of bleeding episodes associated with hemophilia to the covered person at the time that such services are prescribed.

N.J. Admin. Code § 11:24C-3.3