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

(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…

Notes N.J. Admin. Code § 11:4-59.6 Repealed by R.2013 d.014, effective 2/4/2013 (operative August 4, 2013). See: 44 N.J.R. 1681(a), 45 N.J.R. 211(a). Section was "Insurer supervision procedures".

Notes N.J. Admin. Code § 11:4-59.7 Recodified to N.J.A.C. 11:4-59.5 by R.2013 d.014, effective 2/4/2013 (operative August 4, 2013). See: 44 N.J.R. 1681(a), 45 N.J.R. 211(a). Former N.J.A.C. 11:4-59.7, Penalties, recodified to N.J.A.C. 11:4-59.5.

(a) The purpose of this subchapter is to implement N.J.S.A. 17B:25-34 et seq., and 17B:30-1 et seq., to require producers to act in the best interest of the consumer when making a recommendation of an annuity and to require insurers to establish and maintain a system to supervise…

Words and terms as defined 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 in this subchapter. The following words and terms, when used in this subchapter, sha…

(a) In recommending to a consumer the purchase of an annuity, an insurance producer shall act in the best interest of the consumer pursuant to the circumstances known at the time the recommendation is made, without placing the producer's or the insurer's financial interest ahead …

(a) An insurance producer shall not solicit the sale of an annuity product unless the insurance producer has adequate knowledge of the product to recommend the annuity and the insurance producer is in compliance with the insurer's standards for product training. An insurance prod…

(a) Insurers, general agents, independent agencies, and insurance producers shall maintain or be able to make available to the Commissioner records of the information collected from the consumer and other information used in making the recommendations that were the basis for insu…

(a) An insurer shall be responsible for compliance with this subchapter. If a violation occurs, either because of the action or inaction of the insurer or its insurance producer, the Commissioner may order:1. An insurer to take reasonably appropriate corrective action for any con…

(a) This subchapter applies to all insurers authorized to write health insurance in this State. These standards apply to all individual and group health insurance coverages issued prior to January 1, 2017. Reserve standards for such coverages issued prior to January 1, 2017, incl…

(a) The following applies to the basis for contract reserves: 1. Minimum standards with respect to morbidity or other contingency are those set forth in N.J.A.C. 11:4-6.1 4 and 6.15. Valuation net premiums used under each contract shall have a structure consistent with the gross …

(a) Provided the contract reserve on all contracts to which an alternative method or basis is applied is not less in the aggregate than the amount determined according to the applicable standards specified in N.J.A.C. 11:4-6.1 0, an insurer may use any reasonable assumptions as t…

(a) Annually, an appropriate review shall be made of the insurer's prospective contract liabilities on contracts valued by tabular reserves, to determine the continuing adequacy and reasonableness of the tabular reserves giving consideration to future gross premiums. The insurer …

Increases to, or credits against, reserves carried, arising because of reinsurance assumed or reinsurance ceded, shall be determined in a manner consistent with these minimum reserve standards and with all applicable provisions of the reinsurance contracts which affect the insure…

(a) Minimum morbidity standards for valuation of specified individual contract health insurance benefits are as follows: 1. For disability income benefits due to accident or sickness use: i. When calculating contract reserves: (1) For contracts issued on or after January 1, 1965 …

(a) Minimum morbidity standards for valuation of specified group contract health insurance benefits are as follows:1. For disability income benefits due to accident or sickness use: i. When calculating contract reserves: (1) For contracts issued prior to January 1, 2001: The same…

(a) For contract reserves the maximum interest rate is: 1. For contracts issued prior to January 1, 1973: 3 1/2 percent. 2. For contracts issued on or after January 1, 1973 through December 31, 2000: A rate of interest not exceeding the maximum rate of interest specified in N.J.S…

The mortality basis used for all policies except long-term care individual policies and group certificates and for long-term care individual policies or group certificates issued before January 1, 2001 shall be according to a table (but without use of selection factors) permitted…

(a) Where an insurer calculates tabular reserves using the 1964 CDT, 85CIDA, 85CIDB or any other table based on exposures that include contracts on premium waiver as in-force contracts rather than a table based on "active lives," reserves shall be valued on the following basis: 1…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Annual-claim cost" means the net annual cost per unit of benefit before the addition of expenses, including claim settlement expenses, a…

(a) Claim reserves are required for all incurred but unpaid claims on all health insurance policies. (b) Appropriate claim expense reserves are required with respect to the estimated expense of settlement of all incurred but unpaid claims. (c) All claim reserves for prior valuati…

(a) The following applies to disability income: 1. The maximum interest rate for claim reserves is specified in N.J.A.C. 11:4-6.1 6. 2. Minimum standards with respect to morbidity are those specified in N.J.A.C. 11:4-6.1 4 and 6.15, except that, at the option of the insurer: i. F…

A generally accepted actuarial reserving method or other reasonable method, if the method is approved by the Commissioner prior to the statement date, or a combination of methods, may be used to estimate all claim liabilities. The methods used for estimating liabilities generally…