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

(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…

If a card has not been issued, or if the information on a card does not reflect the insured's current coverage, the carrier, multiple employer welfare arrangement or other health benefits provider shall provide the primary insured with a telephone number that can be used to obtai…

(a) Every carrier, multiple employer welfare arrangement or other health benefits provider issuing a card pursuant to this subchapter shall make an informational filing of the form of the card with the Department of Banking and Insurance within 30 days after issuing or causing th…

This subchapter shall apply to policies or contracts issued and/or renewed after December 15, 2004. Notes N.J. Admin. Code § 11:4-55.6

(a) This subchapter implements N.J.S.A. 17B:27C-1 et seq. by establishing rules for the registration, regulation and reporting of self-funded and partially self-funded multiple employer welfare arrangements (self-funded MEWAs). This subchapter also implements N.J.S.A. 17B:27A-49 …

(a) The Commissioner may, upon reasonable notice, conduct an examination of a registered self-funded MEWA as often as he or she deems necessary in order to protect the interests of enrollees, members, providers and the residents of this State. A registered self-funded MEWA shall …

(a) A carrier shall notify the Department by December 31 of each year of all health insurance contracts, health maintenance organization contracts, stop-loss contracts and administrative services only (ASO) contracts it issued, renewed, or had in force at any time during the 12-m…

(a) Persons failing to comply with any of the requirements of this subchapter shall be subject to revocation or suspension of a certificate of registration and/or a penalty of not more than $ 1,000 for a first offense, and not more that $ 5,000 for each subsequent offense pursuan…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Administrator" means a person, partnership, corporation or other legal entity engaged by a self-funded MEWA, as defined in this section, …

(a) By September 5, 2004, a self-funded MEWA operating in this State prior to June 7, 2004, shall file an application for initial registration with the Commissioner. A self-funded MEWA that was not operating in this State prior to June 7, 2004, shall not commence operations in th…

(a) An application for subsequent annual registration following the initial registration shall be filed annually. The application shall be due on the same date as the annual financial statements filed pursuant to N.J.A.C. 11:4-56.9(a). The application for the subsequent annual re…

(a) No self-funded MEWA, and no association that obtains health coverage from a self-funded MEWA, shall refuse to provide coverage or deny membership in the MEWA or association to any employer, employee or dependent based on any of the following characteristics of the employer, e…

(a) Prior to issuing benefit plans to small employers, a self-funded MEWA shall prepare, maintain and make available to the Department upon request, an exhibit showing the methodology for calculating assessments for small employer members. The exhibit shall contain: 1. A plan sch…

A registered self-funded MEWA shall not modify any information or document furnished pursuant to this subchapter unless the MEWA files with the Commissioner a notice of the change or modification, together with any additional information to explain the change or modification, at …

(a) A self-funded MEWA shall establish and maintain a separate trust account with respect to that segment of its operations that provides for self-funded health benefits plans. The trust account shall reflect the income, disbursements, assets and liabilities associated with provi…

(a) A self-funded MEWA shall file with the Commissioner an annual report for the separate trust account established pursuant to N.J.A.C. 11:4-56.8 no later than May 15 of each calendar year, or four months and 15 days after the end of each fiscal year of the self-funded MEWA for …

(a) The purpose of this subchapter is to implement P.L. 1999, c. 106 by specifying that certain exclusions may not be applied to treatment of biologically-based mental illness, and that benefit limits in health insurance policies and health maintenance organization contracts may …

The following words and terms, as used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Benefit limit" means any restriction, condition, or limitation (including, but not limited to, visit limits, dollar limits and preauthoriz…

(a) Notwithstanding the applicability of such exclusions to persons with physical illness, carriers shall not apply any exclusion in a health insurance policy or health maintenance organization contract to deny benefits for services or supplies that are medically necessary for th…

Forms that have been filed by the Commissioner containing provisions not in compliance with this subchapter shall be deemed withdrawn as of July 1, 2005. Notes N.J. Admin. Code § 11:4-57.4

(a) The purpose of this subchapter is to prohibit the use of discretionary clauses in all life, health and long-term care insurance policies and contracts, and all annuity contracts, to assure that all benefits provided under the policy or contract are contractually guaranteed, a…

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 or health insurance, as set forth in this section, under …

No individual or group health insurance policy or contract, individual or group life insurance policy or contract, individual or group long-term care insurance policy or contract, or annuity contract, delivered or issued for delivery in this State may contain a provision purporti…

As of January 1, 2008, forms previously filed, approved or acknowledged by the Commissioner 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 § 11:4-58.4

(a) The purpose of this subchapter is to prescribe disclosure requirements to be utilized in connection with the sale, solicitation or negotiation of annuities directly to consumers, as required by N.J.S.A. 17B:25-34 et seq. (b) This subchapter shall apply to any annuity, both im…

Words and terms as defined in the Act at N.J.S.A. 17B:25-35, when used in this subchapter, shall have the meanings as defined in the Act, unless the context clearly indicates otherwise or as further defined by this subchapter. The following words and terms, when used in this subc…

(a) Pursuant to N.J.S.A. 17B:25-37d, an insurance producer, agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer pursuant to N.J.S.A. 17:44B-32, or an insurer shall provide a consumer who applies for an annuity a copy…

(a) Pursuant to N.J.S.A. 17B:25-37d, an insurance producer, agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer pursuant to N.J.S.A. 17:44B-32, or an insurer shall provide to a consumer who applies for an annuity a c…

Failure to comply with this subchapter may result in the imposition of penalties as authorized by law, including penalties as authorized pursuant to N.J.S.A. 17B:25-42. Notes N.J. Admin. Code § 11:4-59.5 Recodified from N.J.A.C. 11:4-59.7 by R.2013 d.014, effective 2/4/2013 (oper…