26:2J-8. Evidence of coverage

8. Evidence of coverage. a. (1) Enrollees are entitled to receive evidence of coverage and evidence of the total amount of payment which the enrollee is obligated to prepay for health care services and, where applicable, for indemnity benefits. If an enrollee obtains coverage through an insurance policy or through a contract issued by a hospital or medical service corporation or health service corporation, whether by option or otherwise, the insurer or the hospital or medical service corporation or health service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage.

(2) No evidence of coverage, or amendment thereto, shall be issued or delivered to any person until a copy of the form of the evidence of coverage, or amendment thereto, has been filed with the commissioner or, where applicable, with the Commissioner of Insurance.

(3) An evidence of coverage shall contain:

(a) provisions or statements which are not unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation, or which are untrue, misleading or deceptive as defined in subsection a. of section 15 of P.L.1973, c.337 (C.26:2J-15); and

(b) a clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of:

(i) the health care services and where applicable the insurance or other benefits, if any, to which enrollees are entitled;

(ii) any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or co-payment feature;

(iii) where and in what manner information is available as to how services may be obtained;

(iv) a clear and understandable description of the health maintenance organization's method for resolving enrollee complaints; and

(v) the total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or non-contributory with respect to group certificates.

(4) Any subsequent change may be evidenced in a separate document issued to the enrollee.

b. (1) no schedule of charges for enrollee coverage for health care services, or amendment thereto, may be used by a health maintenance organization until a copy of such schedule, or amendment thereto, has been filed with the Commissioner of Insurance for informational purposes; provided, however, that the Commissioner of Insurance may bring an enforcement action pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) if the commissioner has reason to believe that the rates are excessive, inadequate or unfairly discriminatory.

(2) such charges may be established in accordance with actuarial principles for various categories of enrollees, provided that charges applicable to an enrollee shall not be individually determined based on the status of his health. However, the charges shall not be excessive, inadequate, or unfairly discriminatory. A certification, by a qualified actuary, to the appropriateness of the charges, based on reasonable assumptions, shall accompany the filing.

c. In accordance with the provisions of section 26 of P.L.1995, c.73 (C.26:2J-44), the commissioner or, where applicable, the Commissioner of Insurance shall approve any form if the requirements of subsection a. of this section are met. It shall be unlawful to issue such form until approved. A form that is disapproved may be resubmitted for approval in accordance with subsections b., c., and d. of section 25 of P.L.1995, c.73 (C.26:2J-43) and shall be subject to review in accordance with the procedure described in the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder. Any such form which is filed by the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith.

d. The commissioner or Commissioner of Insurance, where applicable, may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to subsection a. of this section.

L.1973,c.337,s.8; amended 1994,c.11,s.11; 1995,73,s.28.