The following words and terms, as used in this chapter, shall
have the following meanings, unless the context clearly indicates
otherwise.
"Act" means
P.L.
1999, c. 409; as
codified, N.J.S.A. 17:48H-1 et seq., enacted January
18, 2000, and any subsequent amendments.
"Affiliate" means a person that directly, or indirectly
through one or more intermediaries, controls, is controlled by, or is under
common control with, an organized delivery system.
"Basic organizational documents" means the articles of
incorporation, articles of association, partnership agreement, management
agreement, trust agreement, or other applicable documents as appropriate to the
form of business entity involved, and all amendments to such documents.
"Business subject to the Act" means activities performed by
an ODS in accordance with a contract with a carrier related to the provision of
health care services under one or more health benefits plans.
"Carrier" means an insurer authorized to transact the
business of health insurance as defined at
N.J.S.A. 17B:17-4, a hospital service
corporation authorized to transact business in accordance with
N.J.S.A. 17:48-1 et seq., a medical service
corporation authorized to transact business in accordance with
N.J.S.A. 17:48A-1 et seq., a health
services corporation authorized to transact business in accordance with
N.J.S.A. 17:48E-1 et seq., or a health
maintenance organization authorized to transact business pursuant to
N.J.S.A. 26:2J-1 et seq.
"Case management" means the identification and tracking of
the medical condition and medical needs of a carrier's covered person in
consultation with health care providers in order to assist in the provision of
coordination of health care services and continuity of care.
"Certified organized delivery system" or "CODS" means an ODS
that is compensated on a basis that entails no assumption of financial risk, or
the assumption of a de minimus financial risk, as established by
N.J.A.C.
11:22-4, so as not to require the ODS to
become licensed under the Act, but rather, to become certified in accordance
with the Act.
"Contract" means, in reference to a contract between an ODS
and a carrier or an ODS and a health care provider or other subcontractor
engaged in the provision of delivering or allocating health care services, the
document representing the core agreement between the parties and all
appendixes, amendments, addenda, codicils, manuals or other documents
collateral thereto, whether or not specifically incorporated within the
contract.
"Control" means, when referring to an ownership interest in
or by an organized delivery system or an affiliate, ownership existing in any
natural or other legal person through voting securities, contract or otherwise,
such that the person has the authority to direct or cause the direction of the
management and/or policies of the organized delivery system that is the subject
of certification or licensing, or of an affiliate of such organized delivery
system.
"Department" means the Department of Banking and
Insurance.
"Financial risk" means financial risk as that term is defined
by the Department in accordance with
N.J.A.C.
11:22-4.
"Health benefits plan" means a contract or policy that pays
or provides coverage for hospital or medical services, or payment for expenses
therefor, and which is delivered or issued for delivery in this State by or
through a carrier. The term "health benefits plan" includes Medicare supplement
coverage, risk contracts with Medicare to the extent not otherwise prohibited
by Federal law, and any other policy or contract not specifically excluded by
statute or this definition. The term "health benefits plan" specifically
excludes the following policies or contracts: accident only, credit,
disability, long-term care, CHAMPUS supplement coverage, coverage arising out
of a workers' compensation or similar law, automobile medical payment
insurance, personal injury protection insurance issued pursuant to
N.J.S.A. 39:6A-1 et seq., or hospital
confinement indemnity coverage.
"Licensed organized delivery system" or "LODS" means an ODS
that is compensated on a basis that entails the assumption of financial risk by
the ODS, other than a de minimus financial risk, as
established by
N.J.A.C.
11:22-3, and that is therefore required to
become licensed in accordance with the Act.
"Licensed or otherwise authorized" means licensed or
certified by a jurisdiction having legal authority pursuant to statute to issue
licenses or certification for the performance of medical, dental or other
health care services. The term "licensed or otherwise authorized" shall not
include: licensing or certification of an organized delivery system or a
similar organization by another state; or, authorization by the Secretary of
the State of New Jersey or similar entity in another state, to form a
particular type of business structure, whether or not for the performance of,
or delivery of, health care services.
"Managed care plan" means a health benefits plan that
integrates the financing and delivery of appropriate health care services to
covered persons by arrangement with participating providers, who are selected
to participate on the basis of explicit standards, to furnish a comprehensive
set of health care services and financial incentives for covered persons to use
the participating providers and procedures provided for in the plan.
"Management agreement" means the contract between a carrier
and a CODS or LODS, except as noted at
N.J.A.C. 11:24B-4.1.
"Organized delivery system" or "ODS" means an entity with
defined governance that contracts with a carrier to provide or arrange for the
provision of one or more types of health care services to covered persons under
a carrier's health benefits plan(s), whether under the base policy or a rider
thereto, or that provides services that effect the delivery of one or more
types of health care services, the quality or quantity of one or more types of
health care services delivered, or the payment of benefits under a carrier's
health benefits plan for one or more types of health care services received.
The term "ODS" does not include a health care professional licensed or
authorized to render professional services pursuant to Title 45 of the New
Jersey Statutes, or similar laws in the jurisdiction in which the health care
professional renders services; or, a health care facility licensed or
authorized in accordance with Title 26 or Title 45 of the New Jersey Statutes,
or similar laws in the jurisdiction in which the health care facility provides
services.
"Participating provider" means a provider that, under
contract or other arrangement acceptable to the Department with the carrier,
the carrier's contractor or subcontractor, has agreed to provide health care
services or supplies to covered persons in the carrier's managed care plan(s)
for a predetermined fee or set of fees.
"Primary care provider" or "PCP" means an individual
participating provider who supervises, coordinates and provides initial and
basic care to members and maintains continuity of care for the members.
"Provider" means a physician, other health care professional,
health care facility or any other person who is licensed or otherwise
authorized to provide health care services within the scope of his or her
license or authorization in the state or jurisdiction in which the health care
services are rendered.
"Provider agreement" means the contract between a CODS or
LODS and a provider, or between two or more ODSs.
"Utilization management" or "UM" means a system for reviewing
the appropriate and efficient allocation of health care services under a health
benefits plan according to specified guidelines, in order to recommend or
determine whether, or to what extent, a health care service given or proposed
to be given to a covered person should or will be reimbursed, covered, paid
for, or otherwise provided under the health benefits plan. The system may
include: preadmission certification, the application of practice guidelines,
continued stay review, discharge planning, preauthorization of ambulatory care
procedures, and retrospective review.
