N.J. Admin. Code § 11:24-17.3 - Terms and conditions for plan documents

(a) Every plan document shall contain the following:

1. Information about the HMO and how to contact and obtain information from the HMO, including, but not limited to, the HMO's legal name, its trade name, and phone, fax and e-mail numbers by which consumers and members may contact the HMO, including at least one number that is a toll-free number for members;

2. The eligibility requirements for the health benefits plan;

3. A specific description of benefits and services available within the service area under the health benefits plan, including emergency services, and out-of-area benefits and services;

4. A specific description of amounts that must be paid by members upon receipt of health care services, including copayments, deductibles, and coinsurance, as applicable, and with respect to POS contracts, an explanation of the member's obligation to pay charges for out-of-network services that exceed what the HMO determines are usual, customary and reasonable;

5. A description of the grounds for termination of a member and group;

6. A description of the claims procedures for members for out-of-network services;

7. A complete description of the HMO's method for resolving member complaints or grievances, and the process for appealing a utilization management decision, including all time frames applicable to the processes for making and resolving the complaint, grievance or appeal;

8. A description of continuation of coverage for those individuals who are in a health care facility at the time of termination of the group contract;

9. A description of how coverage under the health benefits plan may be continued pursuant to applicable Federal or State law (COBRA and/or N.J.S.A. 17B:27A-27) in the event of both member termination and group termination;

10. A description of the extension of benefits for those members who become totally disabled; and

11. A description of the service area.

Notes

N.J. Admin. Code § 11:24-17.3