26:2J-4.3 - Limitations on basic health care services
26:2J-4.3. Limitations on basic health care services
59. a. The coverages for basic health care services offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2) shall be limited to the following services:
(1) Basic hospital expense coverage for a period of 21 days in a benefit year for each enrollee for services provided for medically necessary treatment and services rendered as a result of injury or sickness, including:
(a) Daily hospital room and board, including general nursing care and special diets;
(b) Miscellaneous hospital services, including services and supplies which are customarily rendered by the hospital and provided for use only during any period of confinement;
(c) Hospital outpatient services consisting of hospital services on the day surgery is performed; hospital services rendered within 72 hours after accidental injury; and X-ray and laboratory tests to the extent that benefits for such services would have been provided if rendered to an inpatient of the hospital;
(2) Basic medical-surgical services for each enrollee for medically necessary services for treatment of injury or sickness for the following:
(a) Surgical services;
(b) Anesthesia services consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical services rendered by a physician other than the physician performing the surgical services;
(c) In-hospital services rendered to a person who is confined to a hospital for treatment of injury or sickness other than that for which surgical care is required;
(3) Maternity services, including delivery and prenatal care;
(4) Out-of-hospital physical examination, including related X-rays and diagnostic tests, on the following basis:
(a) For enrollees who are less than two years of age, up to six examinations during the first two years of life; for enrollees who are minors of two years of age or older, one examination at age 3, 6, 9, 12, 15 and 18 years;
(b) For enrollees who are adults less than 40 years of age, one examination every five years; for enrollees who are 40 or more years of age but less than 60 years of age, one examination every three years; and for enrollees who are 60 years of age or older, one examination every two years.
Notwithstanding the provisions of this section to the contrary, a health maintenance organization may provide alternative coverage for services from those required by this subsection if they are approved by the Commissioner of Insurance and are within the intent of this amendatory and supplementary act.
b. (1) No person who is eligible for coverage under Medicare pursuant to Pub. L. 89-97 (42 U.S.C. s.1395 et seq.) shall be an enrollee under coverage required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2).
(2) A health maintenance organization shall not provide coverage for services required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2) to a group which was covered by health benefits or health insurance anytime during the 12-month period immediately preceding the effective date of coverage.
c. (1) Coverage for services required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2) may contain or provide coinsurance or deductibles, or both; except that no deductible shall be payable in excess of a total of $250 by an individual or family unit during any benefit year, no coinsurance shall be payable in excess of a total of $500 by an individual or family unit during any benefit year, and neither coinsurance nor deductibles shall apply to physical examinations or maternity services covered pursuant to paragraphs (3) or (4) of subsection a. of this section.
(2) Managed care systems may be utilized for coverage of services required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2), subject to the review and approval of the Commissioner of Insurance.
d. Notwithstanding any other law to the contrary, a health maintenance organization shall file copies of all forms for coverages required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2) for approval with the Commissioner of Insurance in accordance with the provisions of section 26 of P.L.1995, c.73 (C.26:2J-44) provided, however, that coverage forms shall be effective only with respect to those coverage form filings which are accompanied by an explanation and identification of the changes being made on a form prescribed by the commissioner.
These forms shall not be unfair, inequitable, misleading or contrary to law, nor shall they produce rates that are excessive, inadequate or unfairly discriminatory.
e. Notwithstanding any other law to the contrary, a health maintenance organization shall file all rates and supplementary rate information and all changes and amendments thereof for the coverages required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2) for approval with the Commissioner of Insurance at least 60 days prior to becoming effective. Unless disapproved by the commissioner prior to their effective date specifying in what respects the filing is not in compliance with the standards set forth in this subsection, any such rates, supplementary rate information, changes or amendments filed with the commissioner shall be deemed approved as of their effective date.
Rates shall not be excessive, inadequate or unfairly discriminatory.
f. The Commissioner of Insurance shall issue regulations to establish minimum standards for loss ratios under coverages required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2).
g. Notwithstanding any provision of law to the contrary, a health maintenance organization shall not be required, in regard to coverages required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2), to provide mandatory health care benefits or services or provide benefits for services rendered by providers of health care services as otherwise required by law.
h. The Commissioner of Insurance and the Commissioner of Health shall, pursuant to the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), adopt rules and regulations necessary to effectuate the purposes of this section and section 58 of P.L.1991, c.187 (C.26:2J-4.2), including standards for terms and conditions of health care service coverages required to be offered pursuant to this section and section 58 of P.L.1991, c.187 (C.26:2J-4.2) and schedules of benefits for coverage of services provided for in subsection a. of this section.
i. Every health maintenance organization shall report annually on or before March 1 to the Department of Insurance the number of individual and group coverages required to be offered pursuant to section 58 of P.L.1991, c.187 (C.26:2J-4.2) that were sold in the preceding calendar year and the number of enrollees under each type of coverage. The department shall compile and analyze this information and shall report annually on or before July 1 its findings and any recommendations it may have to the Governor and the Legislature.
j. A health maintenance organization which complies with the basic health benefits, underwriting and rating standards established by the federal government pursuant to subchapter XI of Pub.L. 93-222 (42 U.S.C. s.300e et seq.), shall be deemed in compliance with this section and section 58 of P.L.1991, c.187 (C.26:2J-4.2).
L.1991,c.187,s.59; amended 1995,c.73,s.27.