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

(a) No insurer shall make or permit any unfair discrimination between individuals of the same class and equal expectation of life in the rates charged, dividends or other benefits payable thereon, or in any other of the terms and conditions for any policy of life insurance or con…

The Department shall approve life insurance policy forms that provide conversion credits pursuant to N.J.S.A. 17B:30-14e. Notes N.J. Admin. Code § 11:4-48.4 Recodified from N.J.A.C. 11:4-48.6 and amended by R.2000 d.130, effective 3/20/2000. See: 31 New Jersey Register 3910(a), 3…

The Department shall not approve life insurance policy forms intended for sale to non-smokers. Insurers may decline or not offer insurance to smokers if underwriting considerations based on mortality risk exposure would result in such smokers being ineligible. Insurers shall not …

The Department shall not approve provisions in life insurance policy forms under which the level of premiums or benefits varies depending solely upon who retains the ownership rights of the policy. Notes N.J. Admin. Code § 11:4-48.6 Recodified from N.J.A.C. 11:4-48.8 by R.2000 d.…

A policy shall not provide credits for a surrender charge imposed under another contract for the reason that such credits unfairly discriminate among contractholders based on the source of funding. Notes N.J. Admin. Code § 11:4-48.7 Recodified from N.J.A.C. 11:4-48.9 by R.2000 d.…

(a) In addition to the discounts based solely on savings in expenses due to the method of premium collection as permitted by N.J.S.A. 17B:30-14d and the discounts based solely on the amount of insurance issued to a particular insured as permitted by N.J.S.A. 17B:30-14e, reduction…

Notes N.J. Admin. Code § 11:4-48.9 Recodified to N.J.A.C. 11:4-48.9 by R.2000 d.130, effective 3/20/2000. See: 31 New Jersey Register 3910(a), 32 New Jersey Register 1024(a). Recodified from N.J.A.C. 11:4-48.10 by R.2003 d.54, effective 2/3/2003. See: 34 New Jersey Register 3194(…

(a) The purpose of this subchapter is to implement P.L. 1995, c.331 by specifically setting forth the benefits required to be provided pursuant to P.L. 1995, c.331, and by identifying the particular health insurance policy or contract responsible for payment of such benefits. (b)…

The following words and terms, as used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Commissioner" means the Commissioner of the Department of Banking and Insurance. "Dental only policy or contract" means a policy or contra…

(a) The diabetes benefits set forth in this subsection shall be included in all health benefits plans. 1. All equipment and supplies for the treatment of diabetes if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist as follows: i. Blood gluc…

All group health insurance policies or contracts providing hospital or medical expense benefits, except for policies or contracts providing prescription drug benefits, may provide that the benefits required to be provided pursuant to this subchapter are excluded if the benefits a…

(a) In conformance with N.J.S.A. 30:7E-1 et seq., the purpose of this subchapter is to establish rules for the reimbursement of costs incurred in the provision of medical care, hospitalization, surgery, dental care and vision care to inmates that are covered by a health coverage …

The following words and terms, as used in this subchapter, shall have the following meanings, unless the text clearly indicates otherwise: "Confinement" means incarceration, detention or commitment to any institution. "Correctional medical services subcontractor" and "correctiona…

Inmates are liable for the cost of any medical care, surgery, medical service, nursing care, prescription drugs, nonprescription drugs, durable medical equipment, hospitalization, therapy treatment, dental care, vision care provided to them while in confinement. Notes N.J. Admin.…

Pursuant to N.J.S.A. 30:7E-2, the amount of inmate liability for medical care shall be the usual, customary and reasonable charges incurred for the inmate's medical care as determined by the State and county treasurers in accordance with the guidelines promulgated by the Commissi…

(a) In accordance with N.J.S.A. 30:7E-3, State and County Treasurers shall file a claim for reimbursement of the value of the usual, customary and reasonable charges incurred for an inmate's medical care upon any health coverage plan providing benefits to an inmate as an enrollee…

(a) Where the inmate is an enrollee, he or she shall provide a signed and completed assignment of benefits form in favor of the treasurer of the State or county institution, a claims form and a medical release. These forms shall be obtained from the inmate's plan. The assignment …

(a) The determination of primary coverage responsibility shall be governed by N.J.A.C. 11:4-28 to determine the priority of reimbursement in the event of multiple coverages of an inmate. (b) For the purpose of the coordination of benefits, the medical services provided by the ins…

Health coverage plans shall not contain any provision which would limit or restrict the ability of the State or county treasurers to seek reimbursement for the cost of medical services provided to inmates under N.J.S.A. 30:7E-1 et seq. Notes N.J. Admin. Code § 11:4-50.8

(a) The purpose of these rules is to provide life insurance policy illustrations that shall protect consumers and foster consumer education. These rules provide illustration formats, prescribe standards to be followed when illustrations are used, and specify the disclosures that …

In addition to any other penalties provided by the laws of this State, an insurer or producer that violates a requirement of these rules shall be guilty of a violation of N.J.A.C. 11:2-17. Notes N.J. Admin. Code § 11:4-52.10

(a) Until January 1, 1999, insurers may use the following language instead of the statement required by N.J.A.C. 11:4-52.5(d)1: "I have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be either highe…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Actuarial Standards Board" means the board established by the American Academy of Actuaries to develop and promulgate standards of actu…

(a) Each insurer marketing policies to which these rules are applicable shall notify the Commissioner whether a policy form is to be marketed with or without an illustration. 1. For policy forms filed after July 6, 1998, the identification shall be made at the time of filing. Any…

(a) An illustration used in the sale of a life insurance policy shall satisfy the applicable requirements of these rules, be clearly labeled "life insurance illustration" and contain the following basic information: 1. The name of the insurer; 2. The name and business address of …

(a) A basic illustration shall conform with the following requirements: 1. The illustration shall be labeled with the date on which it was prepared. 2. Each page, including any explanatory notes or pages, shall be numbered and show its relationship to the total number of pages in…

(a) A supplemental illustration may be provided so long as: 1. It is appended to, accompanied by or preceded by a basic illustration that complies with these rules; 2. The non-guaranteed elements shown are not more favorable to the policy owner than the corresponding elements bas…

(a) If a basic illustration is used by an insurance producer or other authorized representative of the insurer in the sale of a life insurance policy and the policy is applied for as illustrated, a copy of that illustration, signed in accordance with these rules, shall be submitt…

(a) In the case of a policy designated as one for which illustrations will be used, the insurer shall provide each policy owner with an annual report on the status of the policy that shall satisfy the requirements of N.J.A.C. 11:4-45. (b) Upon the request of the policy owner, the…

(a) The board of directors of each insurer shall appoint one or more illustration actuaries. (b) The illustration actuary shall certify that the disciplined current scale used in illustrations is in conformity with the Actuarial Standard of Practice for Compliance with the NAIC M…

(a) The purpose of this subchapter is to:1. Permit the sale of specified disease and critical illness coverage in New Jersey; 2. Provide for reasonable standardization of coverage and the simplification of terms and benefits of specified disease and critical illness policies; 3. …

The following words and terms, as used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Aggregate loss ratio" means the ratio of the accumulated value of past paid benefits (from the original effective date of the form to the …

(a) No carrier shall deliver or issue for delivery in this State any specified disease or critical illness policy unless its policy form, and its rates where required by N.J.S.A. 17B:26-1, have been approved by the Commissioner pursuant to the procedures set forth at N.J.A.C. 11:…

(a) Specified disease policies shall provide the following minimum benefits: 1. A fixed-sum benefit of at least $ 100.00 for each day of hospital confinement for at least 365 days; and 2. A fixed-sum benefit equal to at least one-half of the benefit for hospital confinement, for …

(a) The total benefit amounts available under the policy shall only be available in increments of $ 1,000. As long as the policy clearly indicates, in cases of clearly identifiable forms of diseases with significantly lower treatment costs, lesser amounts may be provided, but in …

(a) In order to assure that benefits are reasonable in relation to the premium charged, the minimum loss ratio for specified disease and critical illness policies shall be as follows: 1. For policies issued to groups other than associations, at least 75 percent; 2. For individual…

All advertisements shall comply with the standards set forth at N.J.A.C. 11:2-11 (the Department's Rules Governing Advertisement of Health Insurance) and any other disclosure and advertising rules which may be applicable to carriers. Notes N.J. Admin. Code § 11:4-53.7 Amended by …

(a) The purpose of this subchapter is to implement P.L. 2001, c. 236 by establishing uniform definitions of terms associated with infertility coverage and benefits that must be provided for infertility in this State. (b) This subchapter shall apply to the following: 1. All polici…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Artificial insemination" means the introduction of sperm into a woman's vagina or uterus by noncoital methods for the purpose of concept…

(a) A carrier shall not impose a separate copayment, coinsurance, deductible, dollar maximum, visit maximum or procedure maximum on any infertility treatment other than limiting infertility coverage to four completed egg retrievals per lifetime of the covered person. (b) A carrie…

(a) Infertility coverage shall include, but is not limited to, payment of benefits for the following services and procedures recognized by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists: 1. Artificial insemination with no…

(a) Following are the only permissible exclusions from the infertility benefit requirements of this subchapter:1. Reversal of voluntary sterilization. i. Coverage for infertility services provided to partners of persons who have successfully reversed sterilization may not be excl…

(a) A carrier shall exclude coverage for in vitro fertilization, embryo transfer, artificial insemination, zygote intrafallopian transfer, gamete intrafallopian transfer, and intracytoplasmic sperm injection at the request of a religious employer only if the required coverage is …

Forms previously filed or approved by the Commissioner pursuant to N.J.S.A. 17B:27-49 and 26:2J-43 that contain provisions not in compliance with this subchapter shall be deemed withdrawn and shall not be delivered, issued, executed or renewed. Notes N.J. Admin. Code § 11:4-54.7…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "ANSI identification number" means the American National Standards Institute (ANSI) International ID Number assigned to the administrato…

(a) Each carrier, multiple employer welfare arrangement, or other provider of a health benefits plan that provides pharmacy benefits shall issue, or cause to be issued, to the primary insured a card satisfying the requirements of N.J.S.A. 17B:30-35 et seq. and this section. At th…

(a) A carrier, multiple employer welfare arrangement, or health benefits provider shall provide each primary insured a new pharmacy identification card within 60 days of a health benefits plan becoming effective. (b) A card shall be issued to the primary insured within 60 days of…