N.J. Admin. Code § 12:21-2.4

Current through Register Vol. 57, No. 1, January 6, 2025

Section 12:21-2.4 - Choice of health care provider

(a) A care recipient whose care giver is covered under a private plan shall have the right to choose his or her own health care provider. The care giver shall, if requested by the private plan insurer, have the care recipient submit to an examination by a licensed medical practitioner designated by the private plan insurer. The examinations shall not be more frequent than once a week, shall be made without cost to the care giver or care recipient and shall be held at a reasonable time and place. Refusal by the care recipient to submit to an examination shall disqualify the care giver from all benefits for the period of family leave in question, except from benefits already paid.

(b) Where a care recipient has utilized a health care provider, and that health care provider has examined the care recipient and has diagnosed him or her with a serious health condition, the insurer paying benefits may only deny benefits to the care giver during that period so certified where:

1. The insurer paying benefits has contacted the care recipient's health care provider and has reached a mutual agreement therewith as to a change in the period of either the care recipient's serious health condition or care required by the care giver;

2. A licensed medical practitioner designated by the insurer paying benefits has examined the care recipient and has determined that the care recipient either no longer has a serious health condition or requires care by the care giver. Where such a determination has been made, benefits shall not be paid beyond the date of the examination;

3. A care recipient refuses to submit to or fails to attend an examination conducted by a licensed medical practitioner designated by the insurer paying benefits, in which case the care giver shall be disqualified from receiving all benefits for the period of family leave in question, except as to benefits already paid; or

4. The insurer paying benefits has obtained credible factual evidence showing that the care recipient is performing activities that demonstrate a serious health condition does not exist. In such instances, benefits shall not be paid beyond the date that such factual evidence is obtained.

N.J. Admin. Code § 12:21-2.4