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:

  1. Incorporate the revised text in the standard plans;
  2. Use the Compliance and Variability Rider (N.J.A.C. 11:21 Appendix Exhibit DD) to amend the standard plans to conform with the adopted amendments; or
  3. A combination of incorporating the revised text in the standard plans and use of the Compliance and Variability Rider.

 

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 Personís 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

  1. insulin needles and syringes an glucose test strips and lancets;
  2. colostomy bags, belts and irrigators; and
  3. as stated in the Policy for food and food products for inherited metabolic diseases.

 

 

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 Employeeís 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 [Memberís] 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;

  1. insulin needles and insulin syringes and glucose test strips and lancets;
  2. colostomy bags, belts, and irrigators; and
  3. as stated in the Contract for food and food products for inherited metabolic diseases.

 

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 [Memberís] 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 [Memberís] 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;

  1. insulin needles and insulin syringes and glucose test strips and lancets;
  2. colostomy bags, belts, and irrigators; and
  3. as stated in the Contract for food and food products for inherited metabolic diseases.

 

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.