N.J. Admin. Code § 11:22-5.2
The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:
"Brand name drug" means a prescription drug whose manufacture and sale is controlled by a single company as a result of a patent or similar right.
"Capitation" means a fixed per member, per month payment or percentage of premium payment for which the provider assumes the risk for the cost of contracted services without regard to the type, value or frequency of the services provided.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, dental service corporation, dental plan organization, prepaid prescription service organization or health maintenance organization authorized to issue health benefit plans, dental plans or prescription drug plans in this State.
"Family network deductible" means the fixed dollar amount of covered charges that a family shall pay to network providers before the health benefits plan provides members of the covered family with coverage for services or supplies rendered by network providers.
"Family network out-of-pocket limit" means the maximum dollar amount that a family shall pay in combination as copayment, deductible and coinsurance for network covered services and supplies in a calendar, contract or policy year.
"Formulary" means a list of prescription drugs that are preferred for use in a health benefit plan or prescription drug plan through lower cost sharing (for example, co-payment, coinsurance, deductible or out of pocket limits) or other financial incentives (for example, quantity limits or inclusion or exclusion from accumulation toward the out-of-pocket limit). A formulary may have multiple tiers. A plan that provides benefits for all brand name drugs at one level of cost sharing and for all generic drugs at another level of cost sharing is not considered a formulary for purposes of this subchapter.
"Generic drug" means any prescription drug which is not a brand name drug.
"Health benefit plan" means a hospital and medical expense insurance policy, health service corporation contract, hospital service corporation contract, medical service corporation contract, health maintenance organization subscriber contract, or other plan for medical care delivered or issued for delivery in this State.
1. "Health benefit plan" shall not include one or more, or any combination of, the following:
i. Coverage for accident only, disability income insurance;
ii. Coverage issued as a supplement to liability insurance, including general liability insurance and automobile liability insurance;
iii. Stop loss or excess risk insurance; workers' compensation or similar insurance;
iv. Automobile personal injury protection medical expense benefits or medical payment insurance;
v. Credit only insurance;
vi. Coverage for on-site medical clinics; and
vii. Other similar insurance coverage as specified in Federal regulations under which benefits for medical care are secondary or incidental to other insurance benefits.
2. "Health benefit plan" shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance, or are otherwise not an integral part of the plan:
i. Limited scope vision benefits;
ii. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and
iii. Such other similar, limited benefits as are specified in Federal regulations.
3. "Health benefit plan" shall not include hospital confinement indemnity coverage if:
i. The benefits are provided under a separate policy, certificate or contract of insurance;
ii. There is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefit plan maintained by the same plan sponsor; and
iii. Those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.
4. "Health benefit plan" shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
i. Medicare supplemental health insurance as defined at Section 1882(g)(1) of the Federal Social Security Act (42 U.S.C. § 1395ss(g)(1));
ii. Coverage that is supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (10 U.S.C. §§ 1071 et seq.); and
iii. Similar supplemental coverage provided to coverage under a group health plan.
"Individual network deductible" means the fixed dollar amount of covered charges that a covered person shall pay to network providers before the health benefit plan provides the covered person with coverage for services or supplies rendered by network providers.
"Individual network out-of-pocket limit" means the maximum dollar amount that a covered person shall pay as copayment, deductible and coinsurance for services and supplies provided by network providers in a calendar, contract or policy year.
"Individual out-of-network out-of-pocket limit" means the maximum dollar amount that a covered person shall pay as copayment, deductible and coinsurance for out-of-network covered services and supplies in a calendar, contract or policy year.
"Network coinsurance" means the percentage of the contractual fee of the network provider for covered services and supplies specified in the contract between the provider and the carrier that must be paid by the covered person, under the health benefit plan, subject to network deductible and network out-of-pocket limit.
"Network copayment" means the specified dollar amount a covered person must pay for covered services and supplies rendered by network providers under the health benefit plan. Network copayment shall never exceed the contractual fee of the network provider for the service or supply.
"Physician" means a doctor of medicine (M.D.) or osteopathy (D.O.) licensed to practice medicine and surgery by the New Jersey State Board of Medical Examiners or similarly licensed by a comparable agency of the state in which he or she practices.
"Point of service contract" or "POS contract" means a health benefit plan issued by a health maintenance organization or health service corporation that provides covered services and supplies through a network of providers, and pays benefits for covered services and supplies provided by out-of-network providers. The term also includes dual contracts issued pursuant to N.J.A.C. 8:38-14.7, whereby a health maintenance organization contract provides network benefits and an insurance company contract provides out-of-network benefits.
"Preventive care" means services or supplies that are not provided in connection with the treatment of injury or illness. Preventive care includes, but is not limited to: routine physical examinations including related laboratory tests and x-rays, immunizations and vaccines, screening tests, well baby care, well child care and well adult care.
"Primary care provider" means a participating physician or other health care professional who is licensed or otherwise authorized to provide health care services in the state or jurisdiction in which the services are furnished and who supervises, coordinates and maintains continuity of care for covered persons. Primary care providers include nurse practitioners/clinical nurse specialists, physician assistants and certified nurse midwives who satisfy the requirements of N.J.A.C. 11:24-6.2(c)1 through 3.
"Selective contracting arrangement contract" or "SCA policy" means a health benefit plan issued by an insurance company that provides covered services and supplies through a network of providers, and pays benefits for covered services and supplies provided by out-of-network providers.
"Specialist physician" means a fully licensed physician who:
1. Is a diplomat of a specialty board approved by the American Board of Medical Specialties or the Advisory Board of the American Osteopathic Association;
2. Is a fellow of the appropriate American specialty college or a member of an osteopathic specialty college;
3. Is currently admissible to take the examination administered by a specialty board approved by the America Board of Medical Specialties or the Advisory Board of the American Osteopathic Association, or has evidence of completion of an appropriate qualifying residency approved by the American Medical Association or American Osteopathic Association;
4. Holds an active staff appointment with specialty privileges in a voluntary or governmental hospital which is approved for training in the specialty in which the physician has privileges; or
5. Is recognized in the community as a specialist by his or her peers.
N.J. Admin. Code § 11:22-5.2
See: 37 N.J.R. 4510(a), 38 N.J.R. 2159(a).
Added definitions "Brand name drug", "Formulary" and "Generic drug"; in definition "Carrier", inserted "dental plan organization, prepaid prescription service organization" and ", dental plans or prescription drug plans"; in definition "Health benefit plan", deleted former 1i. and recodified existing 1ii.-1viii. as 1i.-1vii., and in 2i., deleted "dental, drug or"; in definition "Network coinsurance", inserted "under the health benefit plan,"; in definition "Network co-payment", inserted "under the health benefit plan"; and rewrote definition "Network out-of-pocket limit".
Amended by R.2009 d.265, effective 9/8/2009 (operative September 8, 2010).
See: 40 N.J.R. 6915(a), 41 N.J.R. 3302(b).
Added definitions "Capitation", "Family network deductible", "Family network out-of-pocket limit", "Individual network deductible", "Individual network out-of-pocket limit", "Individual out-of-network out-of-pocket limit", "Physician", "Primary care provider" and "Specialist physician"; in definition "Network coinsurance", inserted "network" preceding "deductible" and "out-of-pocket" and deleted the last sentence; substituted definition "Network copayment" for definition "Network co-payment"; in definition "Network copayment", inserted the last sentence; and deleted definitions "Network deductible" and "Network out-of-pocket limit".