26:2S-4 Disclosure of terms and conditions in writing to subscriber.
4. A carrier shall disclose in writing to a subscriber, in a manner consistent with the "Life and Health Insurance Policy Language Simplification Act," P.L.1979, c.167 (C.17B:17-17 et seq.), the terms and conditions of its health benefits plan, and shall promptly provide the subscriber with written notification of any change in the terms and conditions prior to the effective date of the change. The carrier shall provide the required information at the time of enrollment and upon request thereafter.
a. The information required to be disclosed pursuant to this section shall include a description of:
(1) covered services and benefits to which the subscriber or other covered person is entitled;
(2) restrictions or limitations on covered services and benefits, including, but not limited to, physical and occupational therapy services, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, radiological examinations and behavioral health care services;
(3) financial responsibility of the covered person, including copayments and deductibles;
(4) prior authorization and any other review requirements with respect to accessing covered services;
(5) where and in what manner covered services may be obtained;
(6) changes in covered services or benefits, including any addition, reduction or elimination of specific services or benefits;
(7) the covered person's right to appeal and the procedure for initiating an appeal of a utilization management decision made by or on behalf of the carrier with respect to the denial, reduction or termination of a health care benefit or the denial of payment for a health care service;
(8) the procedure to initiate an appeal through the Independent Health Care Appeals Program established pursuant to this act; and
(9) such other information as the commissioner shall require.
b. The carrier shall file the information required pursuant to this section with the department.
c. In the case of a carrier that owns, wholly or in part, or contracts with a managed behavioral health care organization, the information required to be disclosed pursuant to this section shall include the following:
(1) the specific behavioral health care services covered and the specific exclusions that apply to the subscriber or other covered person;
(2) the covered person's responsibilities for obtaining behavioral health care services;
(3) the reimbursement methodology that the carrier and managed behavioral health care organization use to reimburse health care providers for behavioral health care services; and
(4) if the carrier offers a managed care plan that provides for both in-network and out-of-network benefits, the procedure that a covered person must utilize when attempting to obtain behavioral health care services from a health care provider who is not included in the network of providers used by the carrier or managed behavioral health care organization.
L.1997,c.192,s.4; amended 2005, c.172, s.2.