N.J. Admin. Code § 11:4-37.3

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

Section 11:4-37.3 - Standards for selective contracting arrangements

(a) A selective contracting arrangement that involves direct contracting between the carrier and network providers or that involves a contract between the carrier and a PPO shall contain an adequate number of network providers by specialty to render the particular covered services in the geographic service area where it operates. A selective contracting arrangement that involves direct contracting between the carrier and a licensed or certified ODS, or under which an HMO makes its network available to a carrier, shall be presumed to have an adequate provider network.

(b) Health benefits plans utilizing selective contracting arrangements shall meet the following criteria:

1. The health benefits plan utilizing a selective contracting arrangement shall provide that covered persons shall not be financially liable for payments to network providers for any sums, other than required co-payments, coinsurance or deductibles, owed for covered services, if the carrier fails to pay for the covered services for any reason;

2. The health benefits plan shall provide that the cost sharing applied to the covered person for emergency care shall be the same regardless of whether the services were rendered by network or out-of-network providers;

3. The health benefits plan shall provide that the carrier shall provide each covered person with a current evidence of coverage within 30 days of enrollment and no later than 30 days after any policy or contract changes;

4. The health benefits plan shall provide that covered persons shall be permitted to change their selection of primary care physician, and such changes shall be effective no later than 15 days after receipt of a request to change a primary care physician;

5. The health benefits plan shall provide that covered persons shall be provided with a current directory of network providers in the licensed or certified ODS, HMO, or PPO, or who have directly contracted with the carrier, including addresses and telephone numbers, and a listing of the providers who speak languages other than English. The directory may be made available online provided that covered persons can obtain a hard copy of the directory upon request;

6. The benefit design of health benefits plans utilizing selective contracting arrangements shall be subject to N.J.A.C. 11:22-5; and

7. Carriers shall not calculate benefits for services provided by out-of-network providers by using negotiated fees agreed to by network providers.

N.J. Admin. Code § 11:4-37.3

Amended by R.1998 d.302, effective 6/15/1998.
See: 30 N.J.R. 267(a), 30 N.J.R. 2214(a).
Rewrote (b) and (c).
Amended by R.2006 d.189, effective 5/15/2006.
See: 37 N.J.R. 4510(a), 38 N.J.R. 2159(a).
Rewrote (a); in (b), substituted "network" for "preferred" and a semicolon for a period, at the end of (b)1; rewrote (b)2 through (b)6; added (b)7; and deleted (c).