New Jersey Admin Code-Title 11-Chapter 24A-Subchapter 4. Provisions Applicable to Carriers Offering One or More Health Benefits Plans That Are Managed Care Plans

Termination

(a) A carrier shall give a health care professional written notice at least 90-days prior to termination of the provider’s contract, specifying the health care professional’s right to a hearing before a panel appointed by the carrier.

1. The carrier shall set forth in writing the reasons for the termination if requested by the health care professional and the reason is not otherwise stated in the written notice of termination.

(b) A carrier shall not be required to provide 90 days prior written notice and the opportunity for a hearing for terminations of health care professionals based on: nonrenewal of the contract, a determination of fraud, breach of contract by the health care professional, or the opinion of the carrier’s medical director that the health care professional represents an imminent danger to a covered person or the public health, safety, and welfare.

1. A carrier that terminates a contract based on a determination of fraud shall report the fraud, with the basis of the determination of fraud, to the appropriate administrative agency.

2. A carrier that terminates a contract based on a determination that the health care professional represents an imminent danger to the patient or the public health, safety, and welfare shall report the determination to the appropriate State licensing board.

(c) With respect to contracts and policies in which covered persons are required to select a PCP and there is a gatekeeper system, carriers shall provide written notification to each covered person within at least 30 business days prior to the termination or withdrawal from the carrier’s provider network of a covered person’s PCP and any other physician or provider from which the covered person is currently receiving a course of treatment.

1. The 30-day prior notice to covered persons may be waived in cases of immediate termination of a health care professional for: breach of contract by the health care professional, a determination of fraud of the health care professional, or where the carrier’s medical director is of the opinion that the health care professional is an imminent danger to one or more covered persons or public health, safety or welfare.

2. In those instances in which the 30-day prior notice requirement may be waived, the carrier shall provide notice to covered persons as expeditiously as possible, and in no event later than 30 days following termination of the health care professional.

3. The carrier shall honor referrals made by a terminated PCP if the referral is made prior to the date of the PCP’s termination, or after the date of termination if continued care is required in accordance with (d) below).

Continuity of Care Post-Contract

(d) The carrier shall assure continued provision of covered services by a terminated health care professional at the in-network benefit level for up to four months in cases where it is medically necessary for the covered person to continue treatment with the terminated provider except as set forth below. Nothing in this subsection shall be construed to limit the applicability of N.J.S.A. 17:48E-10.

1. In cases of the pregnancy of a covered person, medical necessity shall be deemed to have been demonstrated and coverage of services by the terminated health care professional shall continue to the postpartum evaluation of the covered person, up to six weeks after delivery.

2. In the case of care post-operative care, coverage of services by the terminated health care professional shall continue for a period up to six months.

3. In the case of oncological treatment, coverage of services by the terminated health care professional shall continue for a period up to one year.

4. In the case of psychiatric treatment, coverage of services by the terminated health care professional shall continue for a period of up to one year.

5. The carrier is not required to continue coverage in those instances in which the health care professional has been terminated based upon: the opinion of the carrier’s medical director that the provider is an imminent danger to one or more covered persons or the public health, safety and welfare, a determination of fraud, or a breach of contract by the provider or the health care professional is the subject of disciplinary action by the State Board of Medical Examiners.

6. The determination as to the medical necessity of a covered person’s continued treatment with a terminated health care professional shall be subject to the appeal procedures set forth at N.J.A.C. 11:24A-4.1 2.

Continuity of Care Post-Contract

7. Notwithstanding (d) above, when termination is by the health care professional, the contract shall include a provision requiring the health care professional to continue to provide services at the contracted price to covered persons who are patients of the health care professional immediately prior to the date of termination for 30 days following the date of termination, but for the remainder of the four-month period only in cases where it is medically necessary for the covered person to continue treatment with the terminated health care professional, except as (d)1 through 4 above may apply.

(e) The carrier shall establish policies regarding the termination of providers other than health care professionals.

(f) The carrier shall establish a policy and procedure, reviewable upon request by the Department, addressing the following:

1. Methods by which the termination policy shall be made known to providers upon initial participation and on renewal; and

2. Methods by which the termination policy regarding providers shall be made known to covered persons at the time of enrollment and on a periodic basis.

See https://regulations.justia.com/states/new-jersey/title-11/chapter-24a/subchapter-4/