New Jersey § 52:14-17

§ 52:14-17.

(A) The contract or contracts purchased by the commission pursuant to subsection b.

of section 4 of P.L.1961, c. 49 ( C.52:14-17.28 ) shall provide separate coverages or policies as follows: (1) Basic benefits which shall include: (a) Hospital benefits, including outpatient; (b) Surgical benefits; (c) Inpatient medical benefits; (d) Obstetrical benefits; and (e) Services rendered by an extended care facility or by a home health agency and

for specified medical care visits by a physician during an eligible period of such

services, without regard to whether the patient has been hospitalized, to the extent

and subject to the conditions and limitations agreed to by the commission and the

carrier or carriers. Basic benefits shall be substantially equivalent to those available on a group remittance

basis to employees of the State and their dependents under the subscription contracts

of the New Jersey “Blue Cross” and “Blue Shield” Plans. Such basic benefits shall include benefits for: (i) Additional days of inpatient medical service; (ii) Surgery elsewhere than in a hospital; (iii) X-ray, radioactive isotope therapy and pathology services; (iv) Physical therapy services; (v) Radium or radon therapy services; and the extended basic benefits shall be subject to the same conditions and limitations,

applicable to such benefits, as are set forth in “Extended Outpatient Hospital Benefits

Rider,” Form 1500, 71(9-66), and in “Extended Benefit Rider” (as amended), Form MS

7050J(9-66) issued by the New Jersey “Blue Cross” and “Blue Shield” Plans, respectively,

and as the same may be amended or superseded, subject to filing by the Commissioner

of Banking and Insurance; and (2) Major medical expense benefits which shall provide benefit payments for reasonable

and necessary eligible medical expenses for hospitalization, surgery, medical treatment

and other related services and supplies to the extent they are not covered by basic

benefits. The commission may, by regulation, determine what types of services and supplies shall

be included as “eligible medical services” under the major medical expense benefits

coverage as well as those which shall be excluded from or limited under such coverage.

Benefit payments for major medical expense benefits shall be equal to a percentage

of the reasonable charges for eligible medical services incurred by a covered employee

or an employee's covered dependent, during a calendar year as exceed a deductible

for such calendar year of $100.00 subject to the maximums hereinafter provided and

to the other terms and conditions authorized by this act. The percentage shall be 80 percent of the first $2,000.00 of charges for eligible medical services incurred subsequent

to satisfaction of the deductible and 100 percent thereafter. There shall be a separate deductible for each calendar year for (a) each enrolled

employee and (b) all enrolled dependents of such employee. Not more than $1,000,000.00 shall be paid for major medical expense benefits with

respect to any one person for the entire period of such person's coverage under the

plan, whether continuous or interrupted except that this maximum may be reapplied

to a covered person in amounts not to exceed $2,000.00 a year. Maximums of $10,000.00 per calendar year and $20,000.00 for the entire period of the

person's coverage under the plan shall apply to eligible expenses incurred because

of mental illness or functional nervous disorders, and such may be reapplied to a

covered person, except as provided in P.L.1999, c. 441 ( C.52:14-17.29d et al.). The same provisions shall apply for retired employees and their dependents. Under the conditions agreed upon by the commission and the carriers as set forth in

the contract, the deductible for a calendar year may be satisfied in whole or in part

by eligible charges incurred during the last three months of the prior calendar year. Any service determined by regulation of the commission to be an “eligible medical

service” under the major medical expense benefits coverage which is performed by a

duly licensed practicing psychologist within the lawful scope of psychologist practice shall be recognized for reimbursement under the same conditions as would

apply were such service performed by a physician. (B) The contract or contracts purchased by the commission pursuant to subsection c.

of section 4 of P.L.1961, c. 49 ( C.52:14-17.28 ) shall include coverage for services and benefits that are at a level that is equal

to or exceeds the level of services and benefits set forth in this subsection, provided

that such services and benefits shall include only those that are eligible medical

services and not those deemed experimental, investigative or otherwise not eligible

medical services. The determination of whether services or benefits are eligible medical services shall

be made by the commission consistent with the best interests of the State and participating

employers, employees, and dependents. The following list of services is not intended to be exclusive or to require that

any limits or exclusions be exceeded. Covered services shall include: (1) Physician services, including: (a) Inpatient services, including: (i) medical care including consultations; (ii) surgical services and services related thereto; and (iii) obstetrical services including normal delivery, cesarean section, and abortion. (b) Outpatient/out-of-hospital services, including: (i) office visits for covered services and care; (ii) allergy testing and related diagnostic/therapy services; (iii) dialysis center care; (iv) maternity care; (v) well child care; (vi) child immunizations/lead screening; (vii) routine adult physicals including pap, mammography, and prostate examinations;

and (viii) annual routine obstetrical/gynecological exam. (2) Hospital services, both inpatient and outpatient, including: (a) room and board; (b) intensive care and other required levels of care; (c) semi-private room; (d) therapy and diagnostic services; (e) surgical services or facilities and treatment related thereto; (f) nursing care; (g) necessary supplies, medicines, and equipment for care; and (h) maternity care and related services. (3) Other facility and services, including: (a) approved treatment centers for medical emergency/accidental injury; (b) approved surgical center; (c) hospice; (d) chemotherapy; (e) diagnostic x-ray and lab tests; (f) ambulance; (g) durable medical equipment; (h) prosthetic devices; (i) foot orthotics; (j) diabetic supplies and education; and (k) oxygen and oxygen administration. (4) All services for which coverage is required pursuant to P.L.1961, c. 49 ( C.52:14-17.25 et seq. ), as amended and supplemented. Benefits under the contract or contracts purchased as authorized by the State Health

Benefits Program shall include those for mental health services subject to limits

and exclusions consistent with the provisions of the New Jersey State Health Benefits

Program Act. (C) The contract or contracts purchased by the commission pursuant to subsection c.

of section 4 of P.L.1961, c. 49 ( C.52:14-17.28 ) shall include the following provisions regarding reimbursements and payments: (1) In the successor plan, the co-payment for doctor's office visits shall be $10

per visit with a maximum out-of-pocket of $400 per individual and $1,000 per family

for in-network services for each calendar year. The out-of-network deductible shall be $100 per individual and $250 per family for

each calendar year, and the participant shall receive reimbursement for out-of-network

charges at the rate of 80 percent of reasonable and customary charges, provided that the out-of-pocket maximum shall

not exceed $2,000 per individual and $5,000 per family for each calendar year. (2) In the State managed care plan that is required to be included in a contract entered

into pursuant to subsection c. of section 4 of P.L.1961, c. 49 ( C.52:14-17.28 ), the co-payment for doctor's office visits shall be $15 per visit. The participant shall receive reimbursement for out-of-network charges at the rate

of 70% of reasonable and customary charges. The in-network and out-of-network limits, exclusions, maximums, and deductibles shall

be substantially equivalent to those in the NJ PLUS plan in effect on June 30, 2007,

with adjustments to that plan pursuant to a binding collective negotiations agreement

or pursuant to action by the commission, in its sole discretion, to apply such adjustments

to State employees for whom there is no majority representative for collective negotiations

purposes. (3) “ Reasonable and customary charges ” means charges based upon the 90th percentile of the usual, customary, and reasonable

(UCR) fee schedule determined by the Health Insurance Association of America or a

similar nationally recognized database of prevailing health care charges. (D) Benefits under the contract or contracts purchased as authorized by this act may

be subject to such limitations, exclusions, or waiting periods as the commission finds

to be necessary or desirable to avoid inequity, unnecessary utilization, duplication

of services or benefits otherwise available, including coverage afforded under the

laws of the United States, such as the federal Medicare program, or for other reasons. Benefits under the contract or contracts purchased as authorized by this act shall

include those for the treatment of alcohol use disorder where such treatment is prescribed by a physician and shall also include treatment

while confined in or as an outpatient of a licensed hospital or residential treatment

program which meets minimum standards of care equivalent to those prescribed by the

Joint Commission on Hospital Accreditation. No benefits shall be provided beyond those stipulated in the contracts held by the

State Health Benefits Commission. (E) The rates charged for any contract purchased under the authority of this act shall

reasonably and equitably reflect the cost of the benefits provided based on principles

which in the judgment of the commission are actuarially sound. The rates charged shall be determined by the carrier on accepted group rating principles

with due regard to the experience, both past and contemplated, under the contract.

The commission shall have the right to particularize subgroups for experience purposes

and rates. No increase in rates shall be retroactive. (F) The initial term of any contract purchased by the commission under the authority

of this act shall be for such period to which the commission and the carrier may agree,

but permission may be made for automatic renewal in the absence of notice of termination

by the commission. Subsequent terms for which any contract may be renewed as herein provided shall each

be limited to a period not to exceed one year. (G) A contract purchased by the commission pursuant to subsection b. of section 4

of P.L.1961, c. 49 ( C.52:14-17.28 ) shall contain a provision that if basic benefits or major medical expense benefits

of an employee or of an eligible dependent under the contract, after having been in

effect for at least one month in the case of basic benefits or at least three months

in the case of major medical expense benefits, is terminated, other than by voluntary

cancellation of enrollment, there shall be a 31-day period following the effective

date of termination during which such employee or dependent may exercise the option

to convert, without evidence of good health, to converted coverage issued by the carriers

on a direct payment basis. Such converted coverage shall include benefits of the type classified as “basic benefits”

or “major medical expense benefits” in subsection (A) hereof and shall be equivalent

to the benefits which had been provided when the person was covered as an employee.

The provision shall further stipulate that the employee or dependent exercising the

option to convert shall pay the full periodic charges for the converted coverage which

shall be subject to such terms and conditions as are normally prescribed by the carrier

for this type of coverage. (H) The commission may purchase a contract or contracts to provide drug prescription

and other health care benefits or authorize the purchase of a contract or contracts

to provide drug prescription and other health care benefits as may be required to

implement a duly executed collective negotiations agreement or as may be required

to implement a determination by a public employer to provide such benefit or benefits

to employees not included in collective negotiations units. (I) The commission shall take action as necessary, in cooperation with the School

Employees' Health Benefits Commission established pursuant to section 33 of P.L.2007, c. 103 ( C.52:14-17.46.3 ), to effectuate the purposes of the School Employees' Health Benefits Program Act

as provided in sections 31 through 41 of P.L.2007, c. 103 ( C.52:14-17.46.1 through C.52:14-17.46.11 ) and to enable the School Employees' Health Benefits Commission to begin providing

coverage to participants pursuant to the School Employees' Health Benefits Program

Act as of July 1, 2008. (J) Beginning January 1, 2012, the State Health Benefits Plan Design Committee shall

provide to employees the option to select one of at least three levels of coverage

each for family, individual, individual and spouse, and individual and dependent,

or equivalent categories, for each plan offered by the program differentiated by out

of pocket costs to employees including co-payments and deductibles. Notwithstanding any other provision of law to the contrary, the committee shall have

the sole discretion to set the amounts for maximums, co-pays, deductibles, and other

such participant costs for all plans in the program. The committee shall also provide for a high deductible health plan that conforms with Internal Revenue Code Section 223 . There shall be appropriated annually for each State fiscal year, through the annual

appropriations act, such amounts as shall be necessary as funding by the State as

an employer, or as otherwise required, with regard to employees or retirees who have

enrolled in a high deductible health plan that conforms with Internal Revenue Code Section 223 .