N.J.A.C. 11:4 — ACTUARIAL SERVICES (Subchapter 1 to 62)

(a) This subchapter sets forth procedures and requirements with respect to the New Jersey Insolvent Health Maintenance Organization Assistance Association established pursuant to N.J.S.A. 17B:32B-1 et seq. (b) This subchapter shall apply to all member organizations of the Associa…

Failure to comply with this subchapter may result in the denial of relief requested and imposition of penalties as authorized by law. Notes N.J. Admin. Code § 11:4-1.10

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Applicant" means the member organization seeking an exemption, abatement or deferral of its obligation to pay assessments pursuant to s…

(a) Pursuant to N.J.S.A. 17B:32B-1 et seq., the Association is created to administer the Fund established pursuant to N.J.S.A. 17B:32B-6 for purposes of providing payment for eligible claims under a covered health maintenance organization contract on an equitable basis to any cov…

(a) In accordance with N.J.S.A. 17B:32B-9e, the Association shall exempt, abate or defer, in whole or in part, the assessment of a member organization if, in the opinion of the Commissioner, payment of the assessment would endanger the ability of the member organization to fulfil…

(a) Any member organization seeking relief shall submit such request to the Department as set forth in (f) below no later than 15 days following the due date of payment of the assessment. (b) All requests shall be accompanied by a statement averring a need for relief from the obl…

(a) When requesting relief, the applicant shall provide with its request the following information in a clear, concise and complete manner: 1. A cover letter stating: i. The name of the applicant; ii. The form of relief and, if for less than the full amount, specific amount/perce…

(a) All data or information contained in the request for relief filed pursuant to this subchapter shall be confidential and shall not be subject to public disclosure or copying pursuant to the "Right to Know" law, N.J.S.A. 47:1A-1 et seq., except for the following items, but only…

(a) When the Commissioner determines pursuant to N.J.S.A. 17B:32B-9e that payment of the assessment would endanger the ability of the member organization to fulfill its contractual obligations or, based on indicia that relate to the ability to pay the assessment by the member org…

(a) In determining its schedule of charges or rates filed with the Commissioner pursuant to N.J.S.A. 26:2J-8b, or filed in accordance with any other law requiring such filing, no member organization shall include the amount paid or to be paid as assessments under N.J.S.A. 17B:32B…

(a) The purpose of this subchapter is to require insurers to deliver information to purchasers of life insurance that will improve the buyer's ability to select the most appropriate plan of life insurance for the buyer's needs and improve the buyer's understanding of the basic fe…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Annuity" means a contract not included within the definition of life insurance as set forth at N.J.S.A. 17B:17-3, or health insurance a…

(a) The generally applicable requirements are as follows: 1. The insurer shall provide a Buyer's Guide to all prospective purchasers, prior to accepting the applicant's initial premium or premium deposit. However, if the policy for which application is made contains an unconditio…

(a) Each insurer shall maintain, at its home office or principal office, a complete file containing one copy of each document authorized and used by the insurer pursuant to this subchapter for a period of three years following the date of its last authorized use unless otherwise …

Failure of an insurer, its producer, or other authorized representative or agent to provide or deliver to a buyer a Buyer's Guide, an in force illustration, a policy summary or policy data, or any other information required by this subchapter to be provided or delivered to buyers…

If any provisions of this subchapter are held invalid, the remainder shall not be affected. Notes N.J. Admin. Code § 11:4-11.6

This subchapter shall become operative on July 6, 2008. Notes N.J. Admin. Code § 11:4-11.7

(a) The purpose is to avoid any link or implication of association between a school or university and an insurance company soliciting life insurance unless specific endorsement by the school has been made. (b) Student life insurance is life insurance offered to a person because h…

(a) This rule prohibits certain provisions of group student health insurance policies and certificates which are unjust, unfair, inequitable, misleading, contrary to law or contrary to public policy of this State. (b) The rule shall apply to all student health insurance policies …

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Carrier" means any entity subject to the insurance laws and rules of this State, or subject to the jurisdiction of the Commissioner, tha…

Preexisting conditions shall not be excluded from coverage; carriers shall not limit coverage in any way based upon a preexisting condition. Notes N.J. Admin. Code § 11:4-13.3 Amended by 51 N.J.R. 618(a), effective 5/6/2019

(a) Carriers offering student health plans shall adhere to the following requirements for the filing of rates and forms: 1. Each carrier shall submit separate rate and policy form filings in System for Electronic Rate and Form Filing (SERFF) for each student health plan offered, …

These rules apply to individual and group health insurance policies which provide coverage for the costs of daily room and board while confined in a hospital or skilled nursing facility. They do not apply to hospital indemnity policies which provide additional income while the in…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Home health care" means those nursing and other home health care services rendered to a person in his place of residence, under the foll…

(a) Minimum coverage rules are as follows:1. The policy may require no more than three continuous days of hospitalization or skilled nursing facility care prior to provision of home health care benefits. 2. The home health care services listed in paragraphs 1 through 7 of the def…

(a) This subchapter does not impose an obligation to pay benefits for physician's services in connection with home health care except for those benefits required under paragraph 9 of the definition of home health care services. (b) Home health care services including those of hom…

These rules shall be effective on December 15, 1977. Notes N.J. Admin. Code § 11:4-14.5

Notes N.J. Admin. Code § 11:4-15.1 Reserved by 51 N.J.R. 618(a), effective 5/6/2019

Notes N.J. Admin. Code § 11:4-15.2 Reserved by 51 N.J.R. 618(a), effective 5/6/2019

Notes N.J. Admin. Code § 11:4-15.3 Reserved by 51 N.J.R. 618(a), effective 5/6/2019

The purpose of this regulation is to implement N.J.S.A. 17B:26-45 so as to provide reasonable standardization and simplification of language, terms and coverages to facilitate understanding and comparisons; elimination of provisions which may be misleading or unreasonably confusi…

If any provision of the regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby. Notes N.J. Admi…

If after notice and hearing the commissioner finds that a person has violated this regulation, a penalty, in addition to any other penalty, not exceeding $ 2,000 for each violation may be imposed and shall be collected and enforced pursuant to N.J.S.A. 2A:58-1 et seq. Notes N.J. …

This regulation shall apply to all individual health insurance policies delivered or issued for delivery in this State on or after the effective date hereof except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege or to credit he…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Health benefits plan" means a hospital and medical expense insurance policy, health service corporation contract, hospital service corp…

This regulation shall be effective after it has been accepted by the Legislature. Acceptance by the Legislature will occur 60 days after the regulation has been submitted to the Legislature, unless the Legislature passes a concurrent resolution stating in substance that the Legis…

(a) Except as provided hereafter, no health insurance policy delivered or issued for delivery in this State shall contain definitions respecting the matters set forth below unless such definitions comply with the requirements of this section. 1. "Accident", "accidental injury", "…

(a) No policy except a short term, nonrenewable trip policy shall provide coverage solely for specifically identified kind(s) of accident(s); however a policy may provide increased benefits for specifically identified accident(s) for any accident only coverage specified in sectio…

(a) The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections. No individual health insurance policy shall be delivered or issued for delivery in this State that does not meet the required minimum standards for t…

(a) This section sets forth the minimum standards that are prescribed for individual health insurance policies that are health benefits plans. (b) All individual health benefits plans shall comply with N.J.A.C. 11:20. (c) No individual benefits plan shall be delivered or issued f…

(a) Application forms shall not include provisions, statements or questions that: 1. Pertain to race, creed, color, national origin or ancestry of the proposed insured, except for hospital-medical insurance application forms for the purpose of collecting demographic data. No appl…

(a) General disclosure requirements are as follows: 1. Each individual policy of health insurance shall include a renewal, continuation, or nonrenewal provision. The language or specifications of such provision must be consistent with the type of contract issued. Such provision s…

(a) General rules include:1. Within 120 days after the effective date of this regulation, each issuer shall submit a list of all individual health insurance forms currently filed which meet the requirements contained herein. An executive officer of the company shall certify that …

The purpose of this rule is to eliminate unfair and deceptive practices in the promotion, solicitation, and sale of individual health insurance. Notes N.J. Admin. Code § 11:4-17.1

This regulation shall apply to all individual health insurance policies delivered or issued for delivery in this state on or after the effective date hereof except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege or to credit he…

The following words and terms, when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise. "Duplicative coverage" means a transaction wherein health insurance is to be purchased and it is known or should be known to the licensee …

(a) No person shall engage in any unfair, deceptive, misleading, or unreasonably confusing practice in the promotion, solicitation or sale of individual health insurance. (b) The following acts and practices shall be deemed prima facie evidence of a violation of this regulation a…

(a) All licensees involved in the sale of individual health insurance, other than health benefits plans, shall diligently inquire of each applicant as to the existence of any health insurance on any proposed insured. The licensee shall obtain either in the application or in a sep…

(a)N.J.S.A. 17B:30-13.2 requires the maintenance of complaint records. The following requirements prescribed the minimum information to be maintained in order to comply with the statute. 1. The minimum information required to be contained in a person's complaint record is set for…

(a) Any person who, after notice and hearing, is determined by the Commissioner to be in violation of this regulation shall be liable to a penalty not exceeding $ 2,000 for each violation. In addition to, or in lieu thereof, the Commissioner may revoke or suspend the license or c…