N.J. Admin. Code § 11:24-15.1

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

Section 11:24-15.1 - Assumption of financial risk or risk-sharing

(a) No person shall assume financial risk, in whole or in part, for the cost or provision of, or arrangements for, one or more health services to others unless the person is:

1. An authorized payor as defined at N.J.A.C. 11:24-1.2;

2. A provider actually performing the health services (including providing supplies) within the scope of his or her license; or

3. An employer with respect to its own employees, and dependents of those employees.

(b) A secondary contract shall not be considered to have assumed financial risk for the delivery of health care services to residents of this State for which licensure as an authorized payor would otherwise be required if the secondary contractor enters into a contractual agreement with an authorized payor to provide the delivery of health care services to the individuals covered by the authorized payor which meets the requirements of N.J.A.C. 11:24-15.2 and 15.3

(c) Contracts with secondary contractors shall not contain provisions that cede some or all of the financial risk of the authorized payor to the secondary contractors, whether through compensation formula, stop loss insurance requirements or other means, and an HMO shall not reduce its reserves or minimum net worth requirements on the basis of a contractual agreement with any secondary contractors.

N.J. Admin. Code § 11:24-15.1

Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
In (c), substituted ", and an HMO shall not reduce its reserves or minimum net worth requirements" for "except in accordance with N.J.A.C. 8:38-15.2, and an HMO shall not reduce its reserves" following "means".