The NJDPA — in consultation with our chief counsel, Dan Frier, Esq — submitted comments to the New Jersey Dept of Banking and Insurance on several new proposed regulations. Below is a brief outline of our comments, with full commentary in the attached document. We hope that this will help bolster network accountability for carriers across the state, and prevent harmful interruptions in patient-care during “in-plan exception” denial appeals.
I. Establish Specific Standards for Appealing “In-Plan Exceptions”
- Amend N.J.A.C. § 11:24-8.4 and N.J.A.C. § 11:24A-3.5 to require carriers and HMOs to maintain the status quo by providing interim coverage of treatment when faced with good faith appeals of “in-plan exception” denials unless and until such appeals are fully exhausted.
- Promulgate rules which ensure disclosure of relevant network adequacy documentation during appeals II. Defining What Constitutes a “Qualified, Accessible, and Available” Provider