NEW JERSEY
SMALL EMPLOYER HEALTH BENEFITS PROGRAM
20 West State Street, 10th Floor
PO Box 325
Trenton, NJ 08625
Phone: 609-633-1882
Fax: 609-633-2030
ADVISORY BULLETIN
98-SEH-08
September 29, 1998
To: SEH Program Member Carriers
From: Ellen F. DeRosa, Deputy Executive Director
Re: Amendments to the Standard Health Benefits Plans
Coincident with the adoption of the readoption with amendments of N.J.A.C. 11:21, the Small Employer Health ("SEH") Benefits Program Board adopted several changes to the standard health benefits plans, Plans A, B, C, D, E, HMO and HMO-POS. A copy of the adoption text, as filed with the Office of Administrative Law, is enclosed. The effective date of the amendments to the policy forms is the date of filing with the Office of Administrative Law, which is September 24, 1998.
Carriers may modify the text of the standard plans to comply with these amendments in one of the following ways:
Thus, either by means of incorporation into the standard plans or use of the Compliance and Variability rider:
Carriers that elect to use the Compliance and Variability Rider must use the attached text to address the changes to the standard plans. The introductory and concluding text on the rider must be consistent with N.J.A.C. 11:21 Exhibit DD.
To the extent that these forms changes necessitate a rate filing, please make the appropriate rate filing pursuant to N.J.A.C. 11:21-9.
If you have any questions, feel free to contact me.
Rider Text to be included on the Compliance and Variability Rider (Exhibit DD) to amend Standard Small Employer Health Benefits Plans A, B, C, D and E
Section: DEFINITIONS
Subsection: Creditable Coverage
The first paragraph of the Definition of Creditable Coverage is deleted and replaced with the following:
Creditable Coverage means, with respect to an Employee [or Dependent], coverage of the Employee [or Dependent] under any of the following: a Group Health Plan; a group or individual Health Benefits Plan; Part A or Part B of Title XVIII of the federal Social Security Act (Medicare); Title XIX of the federal Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928 of Title XIX of the federal Social Security Act (the program for distribution of pediatric vaccines); chapter 55 of Title 10, United States Code (medical and dental care for members and certain former members of the uniformed services and their dependents); a medical care program of the Indian Health Service or of a tribal organization; a state health benefits risk pool; a health plan offered under chapter 89 of Title 5, United States Code; a public health plan as defined by federal regulation; a health benefits plan under section 5(e) of the "Peace Corps Act"; or coverage under any other type of plan as set forth by the Commissioner of Banking and Insurance by regulation.
Section: HEALTH BENEFITS INSURANCE
Subsection: Covered Charges
The following provision addressing coverage for food and food products for inherited metabolic diseases is added to the Covered Charges subsection immediately following the provision addressing Nutritional Counseling
Food and Food Products for Inherited Metabolic Diseases
[Carrier] covers charges incurred for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods (enteral formula) and low protein modified food products as determined to be medically necessary by the Covered Person’s Practitioner.
For the purpose of this benefit:
"inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated by law;
"low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Practitioner for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and
"medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under the direction of a Practitioner.
Section: EXCLUSIONS
Subsection: Non-prescription drugs
The Non-prescription drugs item is deleted and replaced with the following:
Non-prescription drugs or supplies, except
Rider Text to be included on the Compliance and Variability Rider (Exhibit DD) to amend Standard Small Employer Health Benefits Plans HMO
Section: DEFINITIONS
Subsection: Creditable Coverage
The first paragraph of the Definition of Creditable Coverage is deleted and replaced with the following:
Creditable Coverage means, with respect to an Employee [or Dependent], coverage of the Employee [or Dependent] under any of the following: a Group Health Plan; a group or individual Health Benefits Plan; Part A or Part B of Title XVIII of the federal Social Security Act (Medicare); Title XIX of the federal Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928 of Title XIX of the federal Social Security Act (the program for distribution of pediatric vaccines); chapter 55 of Title 10, United States Code (medical and dental care for members and certain former members of the uniformed services and their dependents); a medical care program of the Indian Health Service or of a tribal organization; a state health benefits risk pool; a health plan offered under chapter 89 of Title 5, United States Code; a public health plan as defined by federal regulation; a health benefits plan under section 5(e) of the "Peace Corps Act"; or coverage under any other type of plan as set forth by the Commissioner of Banking and Insurance by regulation.
[Section: DEPENDENT COVERAGE
Subsection: Eligible Dependents for Dependent Health Benefits
The Exception which immediately follows the list which identifies who may be considered an Employee’s Eligible Dependents is deleted and replaced with the following.
Exception: Any dependent spouse who does not reside in the Service Area is not an eligible Dependent.]
[Note to Carriers: The above Dependent Coverage section should only be included by Carriers that require a dependent spouse to reside within the service area.]
Section: COVERED SERVICES & SUPPLIES
Subsection: OUTPATIENT SERVICES
The following supplies are added to the Outpatient Services section.
Food and Food Products for Inherited Metabolic Diseases: We cover charges incurred for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods (enteral formula) and low protein modified food products as determined to be medically necessary by a [Member’s] Practitioner.
For the purpose of this benefit:
"inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated by law;
"low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Practitioner for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and
"medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under the direction of a Practitioner.
Section: NON-COVERED SERVICES AND SUPPLIES
Subsection: Non-prescription drugs
The Non-prescription drugs item is deleted and replaced with the following:
Non-prescription drugs or supplies, except;
Section: MEDICARE AS SECONDARY PAYOR
Subsection: Medicare Eligibility by Reason of Disability
The fist paragraph of the When A [Member] Becomes Eligible For Medicare provision is deleted and replaced with the following.
When a [Member] becomes eligible for Medicare by reason of disability, the Contract is the primary plan. Medicare is the secondary plan.
Rider Text to be included on the Compliance and Variability Rider (Exhibit DD) to amend Standard Small Employer Health Benefits Plans HMO-POS
Section: DEFINITIONS
Subsection: Creditable Coverage
The first paragraph of the Definition of Creditable Coverage is deleted and replaced with the following:
Creditable Coverage means, with respect to an Employee [or Dependent], coverage of the Employee [or Dependent] under any of the following: a Group Health Plan; a group or individual Health Benefits Plan; Part A or Part B of Title XVIII of the federal Social Security Act (Medicare); Title XIX of the federal Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928 of Title XIX of the federal Social Security Act (the program for distribution of pediatric vaccines); chapter 55 of Title 10, United States Code (medical and dental care for members and certain former members of the uniformed services and their dependents); a medical care program of the Indian Health Service or of a tribal organization; a state health benefits risk pool; a health plan offered under chapter 89 of Title 5, United States Code; a public health plan as defined by federal regulation; a health benefits plan under section 5(e) of the "Peace Corps Act"; or coverage under any other type of plan as set forth by the Commissioner of Banking and Insurance by regulation.
Section: COVERED SERVICES & SUPPLIES
Subsection: OUTPATIENT SERVICES
The following supplies are added to the Outpatient Services section.
Food and Food Products for Inherited Metabolic Diseases: We cover charges incurred for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods (enteral formula) and low protein modified food products as determined to be medically necessary by a [Member’s] Practitioner.
For the purpose of this benefit:
"inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated by law;
"low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Practitioner for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and
"medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under the direction of a Practitioner.
Section: [NON-NETWORK] BENEFIT PROVISION APPLICABLE TO [NON-NETWORK] BENEFITS
Section: COVERED CHARGES APPLICABLE TO [NON-NETWORK] BENEFITS
The following provision addressing coverage for food and food products for inherited metabolic diseases is added to the Covered Charges subsection immediately following the provision addressing Nutritional Counseling
Food and Food Products for Inherited Metabolic Diseases
We cover charges incurred for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods (enteral formula) and low protein modified food products as determined to be medically necessary by the [Member’s] Practitioner.
For the purpose of this benefit:
"inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated by law;
"low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Practitioner for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and
"medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under the direction of a Practitioner.
Section: NON-COVERED SERVICES AND SUPPLIES AND NON-COVERED CHARGES
Section: Non-prescription drugs
The Non-prescription drugs item is deleted and replaced with the following:
Non-prescription drugs or supplies, except;
Section: MEDICARE AS SECONDARY PAYOR
Subsection: Medicare Eligibility by Reason of Disability
The fist paragraph of the When A [Member] Becomes Eligible For Medicare provision is deleted and replaced with the following.
When a [Member] becomes eligible for Medicare by reason of disability, the Contract is the primary plan. Medicare is the secondary plan.