N.J. Admin. Code § 11:22-5.3

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

Section 11:22-5.3 - Network deductible

(a) A network deductible is permitted in a contract issued by a health maintenance organization that provides out-of-network benefits only for emergency and urgent care, in a POS contract issued by a health maintenance organization or health service corporation, and in an SCA policy providing hospital and medical coverage issued by an insurance company, provided that:

1. Effective with contracts or policies effective on or after January 1, 2019, health carriers shall use an individual network out-of-pocket limit that is no greater than the maximum annual limitation on cost sharing provided under 45 CFR 156-130 and a family network out-of-pocket limit that is no greater than two times the individual network out-of-pocket limit, unless the Commissioner issues an Order within 45 days of the issuance of final Federal rules governing benefits and payment parameters to freeze the out-of-pocket limit at the prior policy year maximum;

2. The individual network per covered person annual deductible is no greater than $ 2,500, except as stated in (a)3 and 4 below;

3. For a network-based bronze contract or policy available in the individual health coverage or small employer health benefits markets, meaning a plan with a 60 percent actuarial value, the network per covered person annual deductible shall not exceed $ 3,000;

4. For a contract or policy to be offered as a catastrophic contract or policy in the individual health coverage market, the per covered person annual deductible shall equal the greatest permissible maximum out-of-pocket as defined in 45 CFR 156.130(a)(2), except the deductible shall be waived for three physician visits per calendar year and shall not apply to preventive health services;

5. The individual network deductible is not applied to preventive care;

6. The contract contains a family network deductible no greater than two times the individual network deductible; and

7. The network deductible shall not be applied to services or supplies provided by capitated providers.

N.J. Admin. Code § 11:22-5.3

Amended by 51 N.J.R. 501(b), effective 4/15/2019