N.J. Admin. Code § 11:24C-3.4

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:24C-3.4 - Loss of designated status

(a) When a designated health care provider with which the carrier has arranged for the provision of services and supplies for the home treatment of bleeding episodes associated with hemophilia loses designation, the carrier shall not continue to refer covered persons to the services and supplies of that health care provider for home treatment of bleeding episodes associated with hemophilia.

(b) With respect to covered persons that have been receiving services and supplies from a health care provider that has lost its designation, the carrier shall continue to provide services or benefits to or on behalf of the covered person at an in-network level for home treatment services and supplies, until such time as arrangements are made for the covered person to receive home treatment services and supplies from another in-network designated health care provider, or for four months following the date of the loss of designation, whichever occurs first.

1. Notwithstanding (b) above, the carrier shall not be required to continue to provide services or benefits to a covered person at an in-network level when the health care provider's loss of designation is the result of revocation or surrender of a license, permit or registration, or is the result of a suspension of a license, permit or registration that cannot be corrected by reinstatement within 45 days following the date of the suspension, except as may be necessary for the carrier and health care provider to transition the covered person's care to another designated health care provider, consistent with N.J.A.C. 11:24C-2.1 1(a).

(c) Nothing in this subchapter shall be construed to necessarily require termination of the agreement between the carrier and health care provider, or otherwise affect the agreement to the extent that it addresses the provision of services or supplies to covered persons by the health care provider, or the performance of other functions under the terms of the agreement, separate from those related to the home treatment of bleeding episodes associated with hemophilia.

(d) Nothing in this section shall be construed to require a carrier to provide more extensive benefits for covered services than that which is specified in the underlying health benefits plan.

N.J. Admin. Code § 11:24C-3.4