The New Jersey Department of Banking and Insurance (DOBI) published proposed rules on Sept. 5, which may be welcomed by consumers and consumer advocates, perhaps not so much by the health insurance industry. (This publication follows the department's Aug. 21 publication of long-awaited proposed rules pertaining to New Jersey's Health Claims Authorization, Processing and Payment Act, N.J.S.A. 17B-30-48 et seq.)

The proposed rules that are the subject of this commentary pertain to three scenarios: (1) out-of-pocket expenses incurred by insureds when using “out-of-network” providers due to medical necessity; (2) deadlines to which health plans must adhere when insureds win their medical necessity appeals; and (3) explanation of benefits (EOBs) that must be provided to insureds and what must—and must not—be included in them.

Out-of-Network Services

According DOBI, these proposed rules are intended to reinforce existing rights of insureds to obtain out-of-network benefits and increase transparency and accountability with respect to network adequacy of health plans. (See 49 N.J.R. 2880(a)).