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

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 Code § 11:4-59.6 Repealed by R.2013 d.014, effective 2/4/2013 (operative August 4, 2013).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) 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…

(a) Unearned premium reserves are required for all contracts with respect to the period of coverage for which premiums, other than premiums paid in advance, have been paid beyond the date of valuation. (b) If premiums due and unpaid are carried as an asset, such premiums shall be…

(a) The minimum unearned premium reserve with respect to any contract is the pro rata unearned modal premium that applies to the premium period beyond the valuation date, with such premium determined on the basis of: 1. The valuation net modal premium on the contract reserve basi…

The insurer may employ suitable approximations and estimates; including, but not limited to, groupings, averages and aggregate estimation in computing premium reserves. Such approximations or estimates shall be tested periodically to determine their continuing adequacy and reliab…

(a) Contract reserves are required, unless otherwise specified in N.J.A.C. 11:4-6.9(b), for: 1. All individual and group contracts with which level premiums are used; or 2. All individual and group contracts with respect to which, due to the gross premium pricing structure at iss…

(a) The purpose of this subchapter is to establish limitations, consistent with N.J.S.A. 17B:25-36 and the Unfair Trade Practices Act, N.J.S.A. 17B:30-1 et seq., on the use of certifications, professional designations, or forms of advertising by insurance producers, representativ…

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 New Jersey Department of Banking and Insurance. "Department" means the New Jersey Department …

(a) Consistent with the unfair trade practices set forth in N.J.S.A. 17B:30-1 et seq., an insurance producer, or an agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer in accordance with N.J.S.A. 17:44B-32, or an ins…

Failure to comply with this subchapter may result in the imposition of penalties as authorized by law, including penalties authorized pursuant to N.J.S.A. 17:22A-45 and 17B:30-17. Notes N.J. Admin. Code § 11:4-60.4

(a) The purpose of this subchapter is to set forth the disclosure and filing requirements for retained asset accounts, and disclosure requirements for all settlement options related to life insurance policies issued in this State. (b) This subchapter shall apply to all insurers a…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance. "Department" means the New Jersey Departmen…

(a) All insurers offering RAAs in this State shall, prior to the issuance of a group policy which provides for the payment of claims through an RAA or on which the opening of an RAA is an option, and prior to the transfer of a death benefit on an individual or group policy to an …

Failure to comply with the provisions of this subchapter shall result in the imposition of penalties as may be authorized by law. Notes N.J. Admin. Code § 11:4-61.4

(a) This subchapter sets forth the requirements for contracts between a pharmacy benefits manager and a contracted pharmacy pursuant to N.J.S.A. 17B:27F-1 et seq., and requires pharmacy benefits managers to certify that new or existing contracts, upon renewal, comply with the req…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health mai…

(a) Upon execution or renewal of each contract, a pharmacy benefits manager shall, with respect to contracts between a pharmacy benefits manager and a contracted pharmacy: 1. Include in the contract the sources utilized to determine multiple source generic drug pricing, including…

(a) All contracts between a pharmacy benefits manager and a contracted pharmacy shall include a process to appeal, investigate, and resolve disputes regarding multiple source generic drug pricing. The contract provision establishing the process shall include the following: 1. The…

(a) All pharmacy benefits managers shall file a certification with the Department in the form of N.J.A.C. 11:4-62 Appendix Exhibit A, which is incorporated herein by reference, attesting that all pharmacy benefits contracts executed or renewed between the pharmacy benefits manage…

(a) Failure to comply with the terms of this subchapter shall result in the imposition of penalties as authorized by law. (b) A pharmacy benefits manager that fails to file a certificate of compliance as required by N.J.A.C. 11:4-62.5 may, after notice and opportunity for a heari…

(a) The purpose of this subchapter is to establish standards and procedures whereby insurers may apply to the Commissioner to obtain approval to charge additional premium for any risk in which the developed manual premium does not adequately reflect the additional hazard being in…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance. "Department" means the New Jersey Departmen…

(a) Applications shall be filed with the Commissioner within 20 work days after the insured has signed it or within 20 work days of the inception date of the policy, whichever is earlier. All applications shall be made by filing the appropriate application form included in the Ap…

(a) Premium charges in excess of those produced by the rating system approved for the submitting company shall be reasonable and adequate and not unfairly discriminatory, and shall be proportionate to the additional hazard, subject to the following provisions on business for whic…

(a) The Commissioner shall approve applications complying with the requirements contained in N.J.A.C. 11:4-7.1 through 7.4 on a current basis, and shall provide notice of such approval to the submitting carrier. (b) The Commissioner shall disapprove applications that fail to comp…

(a)N.J.S.A. 17B:17-13.1 provides that qualified organizations as defined therein may enter into annuity agreements under conditions which are different from those which are applicable to organizations which are deemed to be insurers. This subchapter protects the interest of indiv…

If any provision of this subchapter or the application thereof to any person or circumstance is held invalid, the invalidity shall not affect the provisions or applications of this subchapter which can be given effect without the invalid provision or application, and for this pur…

Failure to comply with the provisions of this subchapter will subject any special permit holder to the penalties provided by N.J.S.A. 17B:17-13.1d and any other penalties available to the Commissioner. Notes N.J. Admin. Code § 11:4-8.11 Amended by R.1985 d.94, effective 3/18/1985…

The following words and terms, when 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. "Deferred annuity" means an annuity where the first ann…

(a) A qualified organization proposing to enter into an annuity agreement pursuant to N.J.S.A. 17B:17-13.1 shall first apply to the Commissioner for approval as a special permit holder. The application shall be in a form prescribed by the Commissioner. An application shall includ…

(a) An application for a special permit shall include a copy of each form of agreement that the applicant proposes to issue to annuitants. If a special permit holder intends to change or replace an existing agreement, or add a new form of agreement, the special permit holder shal…

(a) The original consideration for periodic payments payable to the holder of a charitable annuity may not be less than the net single premium, computed according to interest and mortality assumptions permitted by N.J.S.A. 17B:19-1 et seq. for guaranteed periodic payments, plus a…

(a) Each special permit holder shall have and maintain segregated assets at least equal to the sum of: 1. The reserves on its outstanding agreements calculated in accordance with the provisions of N.J.S.A. 17B:19; and 2. A surplus equal to $ 100,000 or to ten per cent of the amou…

(a) The segregated assets held by a special permit holder shall be invested pursuant to the standards set forth at N.J.S.A. 3B:20-11.1 et seq. An application for a special permit shall include the applicant's plan of operation for the segregated account. The plan of operation sha…

(a) As of December 31 of the calendar year in which a special permit is issued, and as of December 31 of each succeeding calendar year, the holder of a special permit shall submit a report to the Commissioner. Such report shall be submitted to the Commissioner within 120 days fol…

Forms previously filed or approved by the Commissioner pursuant to N.J.S.A. 17B:17-13.1 that are not in compliance with this subchapter shall be refiled with the annual report for calendar year 2004 or the first fiscal year ending after December 31, 2004. Notes N.J. Admin. Code §…