New Jersey Administrative Code

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) The purpose of this subchapter is to implement N.J.S.A. 26:2S-39, and having concluded a study and issued a report to the Governor and Legislature demonstrating that such a rule is necessary, provide that health benefit plans delivered, issued, executed, or renewed in this St…

Except in the case of a religious employer that is granted an exclusion, pursuant to N.J.A.C. 11:241.2, an HMO shall provide coverage, without limit or exclusion, for medical and surgical abortion in accordance with this subchapter. The HMO may apply cost sharing, including deduc…

(a) A religious employer may request, and the HMO shall grant, an exclusion for medical and surgical abortion coverage if coverage conflicts with the religious employer's bona fide religious beliefs and practices. An exclusion granted pursuant to this section shall not be constru…

(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.…

Each HMO shall establish and maintain an informal internal appeal process (stage 1 appeal) whereby any member, or any provider acting on behalf of a member, with the member's consent, who is dissatisfied with any HMO adverse benefit determination, except where the adverse benefit…

(a) Each HMO shall establish and maintain a formal internal appeal process (stage 2 appeal) whereby any member covered by a group health benefits plan or any provider acting on behalf of a member covered by a group health benefits plan with the member's consent, who is dissatisfi…

(a) Any HMO member, and any provider acting on behalf of a member, with the member's consent, may appeal a final internal adverse benefit determination, except where the adverse benefit determination was based on a determination of group or member ineligibility, including resciss…

(a) The Department shall, from time to time, enter into contracts with as many independent utilization review organizations as it deems necessary to conduct the external appeals provided for under N.J.A.C. 11:24-8.7. The physician reviewers of the IUROs selected by the Department…

(a) Pursuant to N.J.S.A. 26:2S-14.1 and 45:9-22.26 and applicable rules of the Department of Health and the Board of Medical Examiners, respectively, all general hospitals licensed pursuant to N.J.S.A. 26:2H-12 et seq. and all physicians licensed pursuant to N.J.A.C. 13:35 are re…

(a) The HMO shall establish and implement written policies and procedures regarding the rights of members and the implementation of these rights. (b) The HMO shall provide each member with a current copy of a member's benefit handbook, including at least: 1. A complete statement …

(a) The purpose of this chapter is to set forth the minimum standards which carriers, as defined at N.J.A.C. 11:24A-1.2, must meet in order to be in compliance with the requirements of the Health Care Quality Act, P.L. 1997, c. 192, enacted August 8, 1997. (b) A carrier shall com…

For the purposes of this chapter, the words and terms set forth below shall have the following meanings, unless the word or term is further defined within a subchapter of this chapter, or the context clearly indicates otherwise: "Act" means the Health Care Quality Act, P.L. 1997,…

Notes N.J. Admin. Code § 11:24A-1.3 Repealed by R.2011 d.097, effective 4/4/2011. See: 42 N.J.R. 2920(a), 43 N.J.R. 880(a). Section was "Compliance time frames".

(a) This subchapter shall apply to all carriers that have delivered any inforce, or are offering for delivery, health benefits plans in this State. (b) This subchapter shall apply to all health benefits plans of a carrier that have been or will be delivered or offered for deliver…