N.J. Admin. Code § 11:22-5.4

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

Section 11:22-5.4 - Network coinsurance

(a) Network coinsurance 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. The contract or policy complies with the requirements set forth in N.J.A. C. 11:22-5.3(a)1;

i. If a carrier offers a contract with an individual network out-of-pocket limit in excess of $ 3,000, it shall also offer a contract with an individual network out-of-pocket limit of $ 2,500 or less.

2. The network coinsurance level, and the out-of-network coinsurance level (if any), is 50 percent or less;

3. The network coinsurance obligation of the covered person is computed by applying the coinsurance percentage to the contractual fee schedule of the provider, not to the billed charges of the provider;

4. Network coinsurance shall not be applied to preventive care;

5. Network coinsurance shall not be applied to services or supplies provided by capitated providers; and

6. Network coinsurance shall not be applied to any service or supply to which network copayment is applied.

N.J. Admin. Code § 11:22-5.4

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