17:48D-9 - Evidence of coverage - New Jersey Statutes

17:48D-9  Evidence of coverage.

9. a. An enrollee shall be entitled to receive evidence of coverage or a certificate indicating specifically the nature and extent of coverage, and evidence of the total amount or percentage of payment, if any, which the enrollee is obligated to pay for dental services.  If an individual enrollee obtains coverage through an insurance policy or through a contract issued by a medical or dental service corporation, whether by option or otherwise, the insurer or medical or dental service corporation shall issue the evidence of coverage.  Otherwise, the dental plan organization shall issue the evidence of coverage.

b.No evidence of coverage or amendment thereto shall be issued or delivered to any person until a copy of the form of evidence of coverage or amendment thereto has been filed with the commissioner.

c.Evidence of coverage shall contain a clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:

(1)The dental services and the insurance or other benefits, if any, to which covered persons are entitled;

(2)Any limitations on the services, kind of services, benefits, or kind of benefits to be provided, including any charge, deductible or co-payment feature;

(3)Where and in what manner information is available as to how services may be obtained;  and

(4)A clear and understandable description of the dental plan organization's method for resolving covered persons' complaints.

d.Any subsequent change in the evidence of coverage or the amount or percentage of payment which the enrollee is obligated to pay, shall be evidenced in a separate document issued to the enrollee.

L.1979,c.478,s.9; amended 2005, c.38, s.6.