N.J. Admin. Code § 11:24-13.4
Current through Register Vol. 56, No. 24, December 18, 2024
Section 11:24-13.4 - Disclosure of provider compensation arrangements(a) HMOs shall make the following disclosure statements, as applicable, in all applications for enrollment and member handbooks: 1. Every HMO shall make the following disclosure: "[Different] providers in our network have agreed to be paid [in different ways by us. Your provider may be paid] [each time s/he treats you ("fee for service")][, or may be paid] [a set fee each month for each member whether or not the member actually receives services ("capitation")][, or may receive] [a salary]."
2. The HMO shall add the following statement if the HMO contracts directly or indirectly with providers to participate in financial incentive arrangements (for example, this includes financial incentive arrangements between an intermediate entity and a physician or physician group): "These payment methods may include financial incentive agreements to pay some providers more ("bonuses") or less ("withholds") based on many factors: member satisfaction, quality of care, and control of costs and use of services among them."
3. Each HMO shall make the following statement: "If you desire additional information about how our primary care physicians or any other provider in our network are compensated, please call us (or carrier name) at (telephone number) or write (address)."
4. Every HMO shall make the following statement: "The laws of the State of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make referrals to other health care providers in which s/he has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care provider or facility when making a referral to that health care provider or facility. If you want more information about this, contact your physician, chiropractor or podiatrist. If you believe that you are not receiving the information to which you are entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (973) 504-6200 OR (800) 242-5846."
(b) The HMO may propose alternate stylistic language for the statement in (a) above which may be utilized only with the prior written approval from the Department. Any modification must be written in plain language and cannot substantively alter the meaning and/or intent of the above section.(c) All statements are required in (a) and (b) above shall be prominently displayed and printed in at least the same point and print as used for other material contained in the application and handbook other than captions or headings.(d) HMOs shall be required to provide information in response to requests made pursuant to the disclosure requirement set forth in (a) above with respect to provider compensation by disclosing the method by which a specific provider is compensated. An HMO shall not be required to state the dollar amount of compensation or otherwise provide more specific information about the compensation arrangement it has with a specific provider.(e) HMOs shall provide a copy of this revised disclosure statement to all prospective members beginning June 30, 2000, and shall provide the revised statement to all current members no later than the anniversary date of the contract under which the member is covered first occurring on or after June 30, 2000.N.J. Admin. Code § 11:24-13.4
Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
Rewrote (a) and (e).