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

If a long-term care insurance policy or certificate replaces another long-term care policy or certificate, the replacing carrier shall waive any time periods applicable to preexisting conditions and probationary periods in the new long-term care policy or certificate for similar …

(a) This section does not apply to life insurance policies, annuity contracts, or riders providing long-term care benefits only through acceleration of life or annuity benefits. Such life insurance policies, annuity contracts, or riders must have nonforfeiture benefits that compl…

(a) A long-term care insurance policy or certificate shall condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits shall not be more restrictive than r…

(a) For purposes of this section, the following definitions apply: 1. "Qualified long-term care services" means services that meet the requirements of Section 7702(c)(1) of the Internal Revenue Code of 1986, as amended, as follows: necessary diagnostic, preventive, therapeutic, c…

(a) This section implements, interprets and makes specific the provisions of N.J.S.A. 17B:27E-6e in prescribing a standard format and the content of an outline of coverage. 1. The outline of coverage shall be a freestanding document, using no smaller than 10-point type. 2. The ou…

(a) A long-term care insurance shopper's guide in the format developed by the National Association of Insurance Commissioners, or a guide developed or approved by the Commissioner, shall be provided to all prospective applicants of a long-term care insurance policy or certificate…

(a) No individual producer licensed on or after February 17, 2009 may sell, solicit or negotiate long-term care insurance unless the individual is licensed as an insurance producer for accident and health or sickness or life insurance pursuant to N.J.S.A. 17:22A-26 et seq. and ha…

(a) No long-term care insurance policy delivered or issued for delivery in this State shall use the terms set forth below, unless the terms are defined in the policy and the definitions are consistent with the following: 1. "Activities of daily living" means at least bathing, con…

(a) In order to qualify for New Jersey's Long-Term Care Partnership Program, a long-term care insurance policy shall satisfy the following requirements: 1. The policy shall cover an insured who was a New Jersey resident at the time coverage first became effective under that polic…

Long-term care insurance policies that are to be delivered or issued for delivery in this State, and certificates and riders for use with such policies, shall be submitted to the Department for review and approval prior to use pursuant to the procedures in N.J.A.C. 11:4-40. Notes…

In addition to any other penalties provided by the laws of this State, any carrier and any agent found to have violated any requirement of this State relating to the regulation of long-term care insurance or the marketing of such insurance shall be subject to a fine of up to thre…

(a) Renewability: The terms "guaranteed renewable" and "noncancellable" shall not be used in any individual long-term care insurance policy without further explanatory language in accordance with the disclosure requirements of N.J.A.C. 11:4-34.6 and 34.7. 1. A policy issued to an…

(a) Each carrier offering long-term care insurance shall, as a protection against unintentional lapse, comply with the following: 1. Notice before lapse or termination. i. No individual long-term care policy or group certificate shall be issued until the carrier has received from…

(a) Renewability: Individual long-term care insurance policies shall contain a renewability provision. 1. The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state that the coverage is guaranteed renewable or noncancella…

(a) This section applies to any long-term care policy or certificate issued on or after December 19, 2005. (b) Other than policies for which no applicable premium rate or rate schedule increases can be made, carriers shall provide all of the information listed in this subsection …

(a) This section applies to any long-term care insurance policy or certificate issued in this State on or after June 19, 2006. Carriers may opt to comply with this section prior to June 19, 2006. (b) A carrier shall provide the information listed below to the Commissioner at leas…

(a) Carriers must complete underwriting prior to issuing a policy or certificate and are prohibited from reunderwriting at the time of claim. (b) All applications for long-term care insurance policies or certificates except those that are guaranteed issue, that is, that are issue…

(a) The purpose of this subchapter is to implement N.J.S.A. 17B:30B-1 et seq., governing viatical settlements. (b) This subchapter applies to persons who enter into agreements with New Jersey residents to purchase their life insurance policies for less than the current death bene…

(a) Viatical settlement providers and viatical settlement brokers are prohibited from entering into viatical settlements with viators who are insured policyowners or certificateholders of individual or group life insurance policies containing accelerated death benefit provisions …

(a) On or before March 1 of each year, each viatical settlement provider licensed in this State shall make and file with the Commissioner a report of all viatical settlement transactions where the viator is a resident of this State and for all states in the aggregate containing t…

(a) With respect to policies containing a provision for double or additional indemnity for accidental death, the additional payment shall remain payable to the beneficiary last named by the viator prior to entering into the viatical settlement contract, or to such other beneficia…

(a) A viatical settlement provider, viatical settlement broker or viatical settlement representative shall not discriminate in the making or solicitation of viatical settlements on the basis of race, age, sex, national origin, creed, religion, occupation, marital or family status…

(a) If a viatical settlement provider enters into a viatical settlement that allows the viator to retain an interest in the policy, the viatical settlement contract shall contain the following provisions: 1. A provision that the viatical settlement provider will effect the transf…

Advertising related to the viatical settlement shall be truthful and not misleading by fact or implication. If the advertiser emphasizes the speed with which the viatication will occur, the advertising shall disclose the average time frame from completed application to the date o…

(a) A disclosure document containing the disclosures required in N.J.S.A. 17B:30B-8 and this subchapter shall be provided to the viator before or concurrent with taking an application for a viatical settlement contract. (b) The disclosure document shall contain the following lang…

(a) A viatical settlement provider, viatical settlement broker or viatical settlement representative shall not provide patient identifying information to any person, unless the insured and viator provide written consent to the release of the information. (b) A viatical settlement…

(a) A violation of the Act or these rules shall be considered an unfair practice pursuant to N.J.S.A. 17B:30-1 et seq. and shall be subject to the penalties contained in N.J.S.A. 17B:30-17. (b) Before an administrative penalty is imposed, the Department shall direct a notice by c…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Act" means an Act concerning life insurance viatical settlements approved September 22, 2005, N.J.S.A. N.J.S.A. 17B:30B-1 et seq. "Commis…

(a) The purpose of this subchapter is to implement N.J.S.A. 17B:30B-1 et seq., governing viatical settlements. (b) A viatical settlement license issued by the Commissioner shall be valid for a term of one year with a commencement date of July 1 and an expiration date of June 30 o…

(a) A first time applicant for a viatical settlement provider's license shall submit the following: 1. An Admission Application including the payment of a nonrefundable application fee of $ 1,000 by check or money order made payable to State of New Jersey--General Treasury; 2. A …

(a) A first time applicant for an individual viatical settlement broker's license or viatical settlement representative's license shall submit the following: 1. A properly executed and dated application requesting issuance of a viatical settlement broker's or representative's lic…

(a) The following shall apply to license renewal: 1. Where a current licensee seeks to renew a license, the licensee shall, at least 15 days before June 30, submit a properly completed renewal application signed, dated and certified to be correct by the licensee or a licensed off…

(a) Where it appears from an application, the attached documents or Department records that an applicant has not demonstrated the qualifications prescribed in the Act or this subchapter, the Department shall advise the applicant in writing that the license request is denied; shal…

(a) A person shall not act as a viatical settlement representative without first obtaining an appointment from a licensed viatical settlement provider or licensed viatical settlement broker. 1. The appointment shall be made on a form required by the Commissioner and accompanied b…

(a) A person shall not use a viatical settlement contract or provide to a viator a disclosure statement form in this State unless filed with and approved by the Commissioner. Contract filings shall include the methodology for determining the viatical settlement proceeds. A viatic…

(a) The purpose of this subchapter is to set forth standards and procedures whereby a carrier shall obtain approval from the Commissioner of its offering of health benefits plans utilizing selective contracting arrangements that promote health care cost containment while adequate…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Allowable expense" means the usual, customary and reasonable item of expense for a covered service when the item of expense is covered at…

(a) A selective contracting arrangement that involves direct contracting between the carrier and network providers or that involves a contract between the carrier and a PPO shall contain an adequate number of network providers by specialty to render the particular covered service…

(a) No carrier shall issue health benefits plans utilizing selective contracting arrangements unless the carrier has entered into such arrangements directly with network providers or has contracted with a licensed or certified ODS, an HMO, or a PPO for prescription drug benefits.…

(a) The approval of a selective contracting arrangement issued by the Department under this subchapter may be denied, suspended or revoked if the Commissioner determines that: 1. The selective contracting arrangement criteria set forth in this subchapter are not being met; 2. Pay…

Notes N.J. Admin. Code § 11:4-37.6 Recodified by R.2006 d.189, effective 5/15/2006. See: 37 N.J.R. 4510(a), 38 N.J.R. 2159(a). Former N.J.A.C. 11:4-37.6 recodified as N.J.A.C. 11:4-37.5; section was "Denial, suspension and revocation".

Notes N.J. Admin. Code § 11:4-37.7 Repealed by R.2006 d.189, effective 5/15/2006. See: 37 N.J.R. 4510(a), 38 N.J.R. 2159(a). Section was "Monitoring; auditing."

(a) Every carrier shall pay a $ 1,500 filing fee for filing each of the following with the Department: 1. A selective contracting arrangement approval application pursuant to N.J.A.C. 11:4-37.4; and 2. A triennial renewal application of a selective contracting arrangement pursuan…

Carriers failing to comply with the requirements of this subchapter may be subject to penalties authorized by law. Notes N.J. Admin. Code § 11:4-37.9 New Rule, R.1998 d.302, effective 6/15/1998. See: 30 New Jersey Register 267(a), 30 New Jersey Register 2214(a).

(a) Passbooks resembling those used for savings deposits in banks shall not be used in connection with policies to which this regulation applies which contain guaranteed annual endowment benefits. (b) No reference shall be made in any material used in connection with such policie…

The use of such books as described at N.J.A.C. 11:4-4.1(a) is determined to be an unfair method of competition and unfair or deceptive act or practice pursuant to N.J.S.A. 17B:30-18, and such books shall not be used in connection with policies to which this regulation applies. No…

(a) This practice shall be discontinued with respect to policies to which this regulation applies because it conflicts with N.J.S.A. 17B:25-5 which requires "that the policy constitute the entire contract between the parties". (b) The reference to such language as "deposits" in s…

If any provision of this regulation or the application thereof to any person or circumstance is held 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. Admin. Code § 11:4-4.4…

The effective date of this regulation shall be August 1, 1963. Notes N.J. Admin. Code § 11:4-4.5

(a) The purpose of this subchapter is to implement P.L. 1995, c.73 (the Life and Health Insurance and Health Maintenance Organization Form Approval Reform Act) by setting forth standards and procedures whereby all life insurance, health insurance, and annuity forms, and rates whe…