New Jersey Administrative Code

(a) If an HMO intends to coordinate benefits under the health benefits plan, the plan documents shall include a statement specifying that coordination may occur, and an explanation of how coordination will be achieved. 1. Coordination of benefits shall be accomplished in accordan…

Forms of plan documents in effect on May 1, 2000 shall be deemed withdrawn on May 1, 2001 if not in compliance with this subchapter. Notes N.J. Admin. Code § 11:24-17.6

(a) A formulary provided pursuant to a health benefits plan issued by an HMO shall be developed by a pharmacy and therapeutics committee composed of health care professionals with recognized knowledge and expertise in clinically appropriate prescribing, dispensing and monitoring …

(a) Every health benefits plan issued by an HMO that provides benefits for formulary medications shall also provide benefits for nonformulary medications. Increased benefits may apply to formulary medications provided the difference between the total benefit value of formulary me…

(a) The HMO shall publish and distribute, at least quarterly, either its current formulary or a list of nonformularies, to all network providers in electronic or paper form. Such list shall clearly indicate whether the medications included are formulary or nonformulary. Alternati…

(a) This subchapter shall become operative on July 1, 2001. (b) All noncomplying HMO contract forms submitted for approval pursuant to N.J.A.C. 11:4-40 shall be deemed withdrawn effective July 1, 2001. Notes N.J. Admin. Code § 11:24-18.4

Any health maintenance organization (HMO) which proposes the establishment and/or operation of a health care facility or any change in or expansion of a health care facility, or the institution of new health care services as defined in the Health Care Facilities Planning Act (N.J…

(a) Except as the Holding Company Systems Act, N.J.S.A. 17:27A-1 et seq. and rules promulgated pursuant thereto may apply and require otherwise, in the event that an HMO voluntarily ceases operation, it shall provide at least 90 business days advance notice to all members, employ…

Each HMO shall maintain an office in New Jersey and provide the Department with the name and address of its registered agent or else a power of attorney duly executed by such applicant, if not domiciled in this State, appointing the Commissioner and his or her successors in offic…

(a) The Department may conduct an examination of the HMO annually, but in no case less than once every three years, concerning the quality of health care services and other affairs of the HMO, including providers with whom such organization has contracts, agreements, or other arr…

(a) A violation may be cited by the Commissioner or his or her designee upon determination that the HMO does not comply with the rules in this chapter and N.J.S.A. 26:2J-1 et seq. (b) At the conclusion of an examination, or within 30 business days thereafter, the Department shall…

(a) The Commissioner may impose the following enforcement remedies against an HMO for violations of regulations in this chapter or other statutory requirements: 1. A monetary penalty may be imposed for each violation in an amount determined by the Commissioner, which shall be in …

(a) Pursuant to N.J.S.A. 26:2J-22, if the Commissioner proposes to suspend, revoke, or deny a certificate of authority, or issues a cease and desist order, the Commissioner shall notify the HMO in writing, specifically stating the grounds for such denial, suspension, revocation, …

(a) Any person, organization, or corporation desiring to establish and/or operate an HMO shall apply to the Commissioner for a certificate of authority, pursuant to N.J.S.A. 26:2J-1 et seq. Applications for a certificate of authority may be obtained from: New Jersey Department of…

(a) A certificate of authority to establish and operate an HMO to service commercial enrollees shall be issued upon approval of the Commissioner. (b) A certificate of authority to establish and operate an HMO to service both Medicaid and commercial enrollees shall not be approved…

(a) After issuance of a certificate of authority, the HMO shall undergo a comprehensive assessment review by the Department on a triennial basis. (b) The comprehensive assessment review conducted by the Department may include an on-site review and shall be based upon the Departme…

Subject to the provisions of N.J.S.A. 26:2J-22, an application for a certificate of authority or amendment thereto may be denied if the Commissioner finds noncompliance with these rules or any provision of N.J.S.A. 26:2J-1 et seq., or otherwise finds the HMO or other affiliated e…

(a) After issuance of a certificate of authority, any HMO which proposes to expand or reduce its service area, change the operational model of its health care delivery system, subcontract its complaint and appeal process, quality improvement, utilization management functions, cre…

(a) Following issuance of a certificate of authority, the HMO shall notify the Department, in writing, of any substantial change to items identified at N.J.A.C. 11:24-2.2(c)1 through 24, at least 30 days prior to the date when such change is expected to occur. The Department shal…

In addition to the requirements set forth in N.J.A.C. 11:24-2.7, any HMO proposing to enter into an arrangement for the provision of out-of-network covered services to members shall also comply with the requirements delineated in N.J.A.C. 11:24-14. Notes N.J. Admin. Code § 11:24-…

Any change of control of the HMO shall be subject to review and approval by the Commissioner pursuant to the New Jersey Insurance Holding Company Systems Act, N.J.S.A. 17:27A-1 et seq., and implementing rules, including N.J.A.C. 11:1-35. Notes N.J. Admin. Code § 11:24-2.9 Amended…

(a) The HMO shall comply with the provisions of the New Jersey Health Maintenance Organizations Act, N.J.S.A. 26:2J-1 et seq. (b) The HMO shall comply with applicable Federal, state, and local laws, rules and regulations. Notes N.J. Admin. Code § 11:24-3.1

(a) Except as provided in N.J.A.C. 11:24-3.4(a), an HMO shall not refuse to renew the coverage of a member covered under a contract for basic health care services, or alter the terms of, or cancel, an existing contract solely on the basis of the following: 1. The health of the me…

(a) After an HMO has been in operation for 24 months, it shall have an annual open enrollment period for its group contracts for basic health care services of at least one month during which it accepts members up to the limits of its capacity, as determined by the HMO, in the ord…

(a) A member shall not have his or her membership in an HMO cancelled except for the following reasons: 1. Failure to pay the premiums and other applicable charges for such coverage, including copayment coinsurance and deductibles; 2. Failure to abide by the rules and/or policies…

(a) The HMO shall establish a policy governing termination of health care professionals and other providers. The policy shall include at least: 1. Standards by which the HMO will provide notice to the provider of termination of his or her participation in the time and manner spec…

(a) A health care professional shall have the right to request in writing a hearing within 10 business days following the date of receipt of notice of termination of the health care professional occurring prior to the date of termination from an HMO's network stated in the provid…

(a) Every HMO shall establish and maintain a system to provide for the presentation and resolution of complaints brought by members or by providers acting on behalf of a member and with the member's consent, regarding any aspect of the HMO's health care services, including, but n…

(a) The HMO shall submit all membership, utilization, financial, and descriptive plan information to the Department as requested. This shall include, but is not limited to: 1. A quarterly report on forms prescribed by the Department and specified at N.J.A.C. 11:24-11.6(d). This r…

(a) No later than August 29, 2000, an HMO shall establish a committee to review applications submitted by licensed providers to become members of the HMO network. 1. The HMO may combine the functions of this committee with another committee, so long as when performing its applica…

(a) The HMO shall designate a physician to serve as medical director. (b) The medical director or his or her designee shall be designated to serve as the medical director for medical services provided to the HMO's New Jersey members. This physician shall be licensed to practice m…

(a) The medical director shall be responsible for the direction, provision, and quality of medical services provided to members, including, but not limited to: 1. Defining responsibilities and inter-relationships of professional services; 2. Coordinating, supervising and overseei…

(a) The HMO shall, at a minimum, provide or arrange for the provision to its members all basic comprehensive health care services and all other services enumerated in this subchapter and in N.J.S.A. 26:2J-1 et seq., as it may be amended from time to time.1. If the HMO refers a me…

(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, incl…

(a) The HMO shall establish written policies and procedures governing the provision of emergency and urgent care which shall be distributed to each subscriber at the time of initial enrollment. (b) Emergency and urgent care services shall include, but are not limited to: 1. Medic…

(a) The HMO shall provide or arrange for the provision of the following supportive services: 1. Ambulance or invalid coach services, as defined at N.J.A.C. 8:40 (therein as "mobility assistance vehicle services"), when authorized by the HMO for non-emergency medical transport; 2.…

(a) In accordance with N.J.S.A. 26:2J-4.6, and rules promulgated pursuant thereto, including N.J.A.C. 11:22-2, HMOs shall provide a health promotion program. (b) An HMO shall not be required to provide health wellness promotion program services to members in values exceeding the …

In accordance with N.J.S.A. 26:2J-4.1, the HMO shall provide health care services to any member for the treatment of Wilm's tumor, including, but not limited to, autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such…

(a) HMOs which provide pharmacy services, prescription drugs or a prescription drug plan shall comply with the requirements set forth at N.J.S.A. 26:2J-4.7, as well as the requirements set forth at N.J.A.C. 11:24-18, in the event that the HMO imposes a formulary upon the pharmacy…

(a) Each HMO shall maintain primary, specialty, ancillary, and institutional services sufficient to meet the requirements in N.J.A.C. 11:24-5. (b) Nothing contained in this subchapter shall preclude the New Jersey Department of Human Services, Division of Medical Assistance and H…

(a) The HMO shall maintain an adequate network of primary care providers, specialists, and other ancillary health care personnel to serve the enrolled population at all times. For certificate of authority applications to initiate operations within a service area, this adequacy sh…

(a) The HMO shall maintain contracts or other arrangements acceptable to the Department with institutional providers which have the capability to meet the medical needs of members and are geographically accessible. The network of providers shall include: 1. At least one licensed …

(a) The HMO shall have a system-wide continuous quality improvement program to monitor the quality and appropriateness of care and services provided to members. This program shall be under the direction of the medical director or his or her designee, who shall be a physician, and…

(a) Each HMO shall submit, as part of the comprehensive assessment review process, evidence of the most recent external quality audit that has been conducted within three years of the date of the comprehensive assessment review. Such audit shall be performed by an external qualit…

(a) The Department shall develop a performance and outcome measurement system for monitoring the quality of care provided to HMO members. The data collected through this system may be used by the Department to: 1. Assist HMOs and their providers in quality improvement efforts; 2.…

(a) The Department shall establish a Healthcare Data Committee (HeDaC) to assist the Department in developing a performance measurement and assessment system for monitoring the quality of care provided to HMO members as described in N.J.A.C. 11:24-7.3. 1. The HeDaC shall be compr…

(a) The HMO shall establish and implement a comprehensive utilization management program to monitor access to and appropriate utilization of health care and services. The program shall be under the direction of the medical director or his or her designee, who shall be a physician…

(a) A registered professional nurse or physician shall be immediately available by phone seven days a week, 24 hours a day, to render utilization management determinations for providers. (b) For routine utilization-related inquiries, the HMO shall provide all members and provider…

(a) The HMO shall have written policies and procedures that address responsibilities and qualifications of staff who render determinations to authorize admissions, services, procedures or extensions of stay. (b) All determinations to deny or limit an admission, service, procedure…

(a) All HMO members, and any provider acting on behalf of a member with the member's consent, may appeal any adverse benefit determination resulting in a denial, termination or other limitation of covered health care services in accordance with the provisions of N.J.A.C. 11:24-8.…