N.J. Admin. Code § 11:4-37.4

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

Section 11:4-37.4 - Selective contracting arrangement approval and amendment procedures

(a) No carrier shall issue health benefits plans utilizing selective contracting arrangements unless the carrier has entered into such arrangements directly with network providers or has contracted with a licensed or certified ODS, an HMO, or a PPO for prescription drug benefits.

(b) For the purposes of obtaining the Commissioner's approval under this subchapter, a carrier issuing health benefit plans utilizing a selective contracting arrangement shall submit four copies of a complete selective contracting arrangement approval application on a form to be provided by the Department.

For the purposes of obtaining the Commissioner's approval under this subchapter, a carrier issuing health benefit plans utilizing a selective contracting arrangement shall submit four copies of a complete selective contracting arrangement approval application on a form to be provided by the Department.

(c) A complete selective contracting arrangement approval application shall include the following:

1. A narrative description of the health benefits plan(s) to be offered, including, but not limited to, the nature of the services and/or supplies, the market for the plan and a description of the geographic area to be served;

2. A statement that the carrier is entering into a selective contracting arrangement directly with network providers, or is contracting with a licensed or certified ODS, an HMO, or a PPO for prescription drug coverage. Where the carrier is contracting with a licensed or certified ODS, an HMO, or a PPO, the carrier shall include the following:

i. The identity and a description of the ODS, HMO or PPO that will operate and/or administer the selective contracting arrangement;

ii. A description of the relationship between the carrier and the ODS, HMO or PPO, and a copy of the contract between the carrier and the ODS, HMO or PPO; and

iii. A description of any risk transfer to the ODS, HMO or PPO;

3. A description and map of the geographic area to be served, identified by county. If sub-areas of counties are to be proposed as boundaries of the service area, the map should also include zip codes;

4. If the carrier is contracting directly with network providers, a description of the criteria and method used to select network providers, including any credentialing plan;

5. If the carrier is contracting directly with network providers or a PPO, the names and addresses of network providers by specialty, county, municipality and zip code, accompanied by maps of the geographic service areas identifying the location of these providers, and a copy of the provider directory to be distributed to covered persons;

6. If the carrier is contracting directly with network providers or with a PPO, a description of the utilization review program, including:

i. A description of the criteria and methods to be used in utilization control, particularly the criteria for determining over- and under-utilization; and

ii. A description of the mechanisms for evaluating the success or failure of the utilization review program;

7. If the carrier is contracting directly with network providers or with a PPO, a description of the quality assurance program. At a minimum, this shall include:

i. A clear description of how quality of care will be monitored and controlled;

ii. The criteria used to define and measure quality;

iii. The criteria used to determine the success or failure of the quality assurance program; and

iv. A description of the staff and their qualifications that will be responsible for the quality assurance program; and

8. The provider agreement of the PPO, licensed or certified ODS, or carrier shall state in substance that:

Provider agrees that in no event, including but not limited to nonpayment by the health carrier or intermediary, payment by the health carrier or intermediary that is other than what the provider believed to be in accordance with the reimbursement provision of the provider agreement or is otherwise inadequate, insolvency of the health carrier or intermediary, or breach of this agreement, shall the provider bill, charge or collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a covered person or a person (other than the health carrier or intermediary) acting on behalf of the covered person for services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles or copayments, as specifically provided in the evidence of coverage. Nor does this agreement prohibit a provider (except for a health care professional who is employed full-time on the staff of a health carrier and has agreed to provide services exclusively to that health carrier's covered persons and no others) and a covered person from agreeing to continue services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier may not cover or continue to cover a specific service or services.

(d) The Commissioner, in consultation with the Commissioner of Health and Senior Services as necessary, shall review these documents and grant approval, within 60 days of the carrier's filing its complete application to those carriers whose selective contracting arrangements are determined to meet the criteria set forth in this subchapter. The Commissioner shall notify a carrier of any deficiencies in its application within the 60-day period and the carrier shall have 60 days from such notice to respond to the deficiency notice. Carriers that do not respond within the 60-day period shall have their applications deemed withdrawn. A final decision to deny approval shall be accompanied by a written explanation by the Department of the reasons for denial. A carrier whose selective contracting arrangement has been denied approval may request an administrative hearing pursuant to the procedures at N.J.A.C. 11:4-37.5.

(e) A carrier shall complete an annual report on a form provided by the Commissioner. The report shall be submitted to the Department no later than May 1 of each year, and shall include information for the previous calendar year regarding membership, number of employer contracts and plan experience.

(f) In addition to the requirements set forth in this section, a carrier contracting directly with network providers shall comply with the requirements set forth at N.J.A.C. 11:24C-4.

N.J. Admin. Code § 11:4-37.4

Amended by 51 N.J.R. 618(a), effective 5/6/2019