17:48E-22.2. Provisions of basic health care contract
55. a. A basic health care contract offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1) shall provide:
(1) Basic hospital expense coverage for a period of 21 days in a benefit year for each covered person for expenses incurred for medically necessary treatment and services rendered as a result of injury or sickness, including:
(a) Daily hospital room and board, including general nursing care and special diets;
(b) Miscellaneous hospital services, including expenses incurred for charges made by the hospital for services and supplies which are customarily rendered by the hospital and provided for use only during any period of confinement;
(c) Hospital outpatient services consisting of hospital services on the day surgery is performed; hospital services rendered within 72 hours after accidental injury; and X-ray and laboratory tests to the extent that benefits for such services would have been provided if rendered to an inpatient of the hospital;
(2) Basic medical-surgical expense coverage for each covered person for expenses incurred for medically necessary services for treatment of injury or sickness for the following:
(a) Surgical services;
(b) Anesthesia services consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical services rendered by a physician other than the physician performing the surgical services;
(c) In-hospital services rendered to a person who is confined to a hospital for treatment of injury or sickness other than that for which surgical care is required;
(3) Maternity benefits, including cost of delivery and prenatal care;
(4) Out-of-hospital physical examination, including related X-rays and diagnostic tests, on the following basis:
(a) For covered minors of less than two years of age, up to six examinations during the first two years of life; for covered minors of two years of age or older, one examination at age 3, 6, 9, 12, 15 and 18 years;
(b) For covered adults of less than 40 years of age, one examination every five years; for covered adults 40 or more years of age but less than 60 years of age, one examination every three years; and for covered adults 60 years of age or older, one examination every two years.
Notwithstanding the provisions of this section to the contrary, a health service corporation may provide alternative benefits or services from those required by this subsection if they are approved by the Commissioner of Insurance and are within the intent of this amendatory and supplementary act.
b. (1) No person who is eligible for coverage under Medicare pursuant to Pub. L. 89-97 (42 U.S.C. s.1395 et seq.) shall be a covered person under a contract required to be offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1).
(2) A health service corporation shall not sell a contract required to be offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1) to a group which was covered by health benefits or health insurance any time during the 12-month period immediately preceding the effective date of coverage.
c. (1) Contracts required to be offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1) may contain or provide for coinsurance or deductibles, or both; except that no deductible shall be payable in excess of a total of $250 by an individual or family unit during any benefit year, no coinsurance shall be payable in excess of a total of $500 by an individual or family unit during any benefit year, and neither coinsurance nor deductibles shall apply to physical examinations or maternity benefits covered pursuant to paragraphs (3) or (4) of subsection a. of this section.
(2) Managed care systems may be utilized for coverages required to be offered pursuant to this section, subject to the review and approval of the Commissioner of Insurance.
d. Notwithstanding any other law to the contrary, a health service corporation shall file copies of all forms of contracts required to be offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1) for approval with the Commissioner of Insurance at least 60 days prior to becoming effective. Unless disapproved by the commissioner prior to its effective date specifying in what respects the form is not in compliance with the standards set forth in this subsection, any such contract form filed with the commissioner shall be deemed approved as of its effective date, provided, however, that contract forms shall be effective only with respect to those contract form filings which are accompanied by an explanation and identification of the changes being made on a form prescribed by the commissioner. In his discretion, the commissioner may waive the 60-day waiting period or any portion thereof.
Contract forms shall not be unfair, inequitable, misleading or contrary to law, nor shall they produce rates that are excessive, inadequate or unfairly discriminatory.
e. Notwithstanding any other law to the contrary, a health service corporation shall file all rates and supplementary rate information and all changes and amendments thereof for the contracts required to be offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1) for approval with the commissioner at least 60 days prior to becoming effective. Unless disapproved by the commissioner prior to their effective date specifying in what respects the filing is not in compliance with the standards set forth in this subsection, any such rates, supplementary rate information, changes or amendments filed with the commissioner shall be deemed approved as of their effective date. In his discretion, the commissioner may waive the 60-day waiting period or any portion thereof.
Rates shall not be excessive, inadequate or unfairly discriminatory.
f. The commissioner shall issue regulations to establish minimum standards for loss ratios under contracts required to be offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1).
g. Notwithstanding any provision of law to the contrary, a health service corporation shall not be required, in regard to contracts required to be offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1), to provide mandatory health care benefits or provide benefits for services rendered by providers of health care services as otherwise required by law.
h. The commissioner shall, pursuant to the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), adopt rules and regulations necessary to effectuate the purposes of this section and section 54 of P.L.1991, c.187 (C.17:48E-22.1), including standards for terms and conditions of contracts required to be offered pursuant to this section and section 54 of P.L.1991, c.187 (C.17:48E-22.1) and schedules of benefits for coverages provided for in subsection a. of this section.
i. Every health service corporation shall report annually on or before March 1 to the Department of Insurance the number of individual and group contracts required to be offered pursuant to section 54 of P.L.1991, c.187 (C.17:48E-22.1) that were sold in the preceding calendar year and the number of persons covered under each type of contract. The department shall compile and analyze this information and shall report annually on or before July 1 its findings and any recommendations it may have to the Governor and the Legislature.
L.1991,c.187,s.55..
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Last modified: October 11, 2016