New Jersey Administrative Code

The mission of the New Jersey Individual Health Coverage Program Board is to administer the New Jersey Individual Health Coverage Program in a manner aimed at increasing access to coverage, protecting consumers, educating key stakeholders and other interested persons, and promoti…

(a) This subchapter establishes the informational and procedural requirements for members requesting relief from obligations to pay assessments pursuant to N.J.S.A. 17B:27A-12 (including assessments for IHC Program losses and administrative expenses), or to offer coverage or acce…

Nothing in this subchapter shall be construed as limiting the Commissioner's authority to take such action with respect to insurers, health service corporations or health maintenance organizations as may be authorized by law, including, but not limited to, placing an insurer, hea…

Failure to comply with this subchapter, including all notice requirements set forth herein, may result in the denial of relief requested and imposition of penalties as authorized by law, including any actions that may be taken by the Board pursuant to N.J.S.A. 17B:27A-2 et seq. a…

(a) Words and terms defined at N.J.S.A. 17B:27A-2 and N.J.A.C. 11:20-1, when used in this subchapter, shall have the meanings as defined therein, unless more specifically defined in (b) below or unless the context clearly indicates otherwise. (b) The following words and terms, wh…

(a) Any member seeking relief may submit such request to the Department at any time, except that requests for relief from payment of assessments pursuant to N.J.S.A. 17B:27A-12a(3) shall be submitted to the Department no later than 15 days following the due date of payment of the…

(a) When requesting relief from obligations imposed pursuant to N.J.S.A. 17B:27A-4 or N.J.S.A. 17B:27A-12, the applicant shall provide with its request the following information in a clear, concise, and complete manner: 1. A cover letter stating: i. The name of the applicant; ii.…

(a) All data or information contained in the request for relief filed pursuant to this subchapter shall be confidential and shall not be subject to public disclosure or copying pursuant to the "Right to Know" law, N.J.S.A. 47:1A-1 et seq., or the common law right to know, except …

(a) When the Commissioner determines pursuant to N.J.S.A. 17B:27A-8 or N.J.S.A. 17B:27A-12a(3), as applicable, that the member does not have the financial reserves necessary to underwrite additional coverage or is or would be placed in a financially impaired condition through ful…

(a) A member may request a hearing on a determination by the Commissioner within 20 days from the date of receipt of such determination as expressly permitted by the chapter as follows: 1. A request for a hearing shall be in writing and shall include: i. The name, address, daytim…

Members requesting relief pursuant to this subchapter shall concurrently provide written notice of all such requests to the IHC Program through the Executive Director. Members shall also provide written notice to the IHC Program of all dispositions of such requests by the Commiss…

(a) Any member health maintenance organization (HMO) asserting that it is not required to offer coverage or accept applications pursuant to the requirements of the Act because it does not have the capacity to enroll additional members, pursuant to N.J.S.A. 17B:27A-8a, shall file …

This subchapter sets forth the standards for purchasing a standard health benefits plan or a standard health benefits plan with rider by a person who is covered under an individual plan or a group health benefits plan. Notes N.J. Admin. Code § 11:20-12.1 Amended by R.2013 d.130, …

Notes N.J. Admin. Code § 11:20-12.2 Amended by R.2009 d.45, effective 12/29/2008. See: 40 N.J.R. 6904(a), 41 N.J.R. 799(b). Added definition "Special open enrollment period". Amended by R.2011 d.163, effective 6/6/2011. See: 43 N.J.R. 131(a), 43 N.J.R. 1353(a). Deleted definition…

Notes N.J. Admin. Code § 11:20-12.3 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

(a) Except as stated in N.J.A.C. 11:20-12.5 with respect to the special enrollment period, a person who is covered under a standard health benefits plan, standard health benefits plan with rider, or group health benefits plan may only elect during the annual open enrollment perio…

Notes N.J. Admin. Code § 11:20-12.4A New Rule, R.2011 d.254, effective 9/13/2011 (operative November 1, 2011). See: 43 N.J.R. 1813(a), 43 N.J.R. 2668(a). Repealed by R.2013 d.130, effective 10/1/2013 (operative January 1, 2014). See: 45 N.J.R. 2310(a), 45 N.J.R. 2385(a). Section …

(a) A person covered under a standard health benefits plan or a standard individual health benefits plan with a rider or group health benefits plan may enroll for coverage under a different standard health benefits plan or standard individual health benefits plan with a rider dur…

(a) This subchapter provides for the quarterly submission of enrollment status reports by all members of the IHC Program, and sets forth the procedures for filing those reports. (b) This subchapter applies to all members of the IHC Program that issue or renew standard health bene…

(a) Words and terms defined at N.J.S.A. 17B:27A-2 and N.J.A.C. 11:20-1, when used in this subchapter, shall have the meanings as defined therein, unless more specifically defined in (b) below or unless the context clearly indicates otherwise. (b) The following words and terms, wh…

(a) Every member of the IHC Program issuing or renewing standard health benefits plans shall complete and file with the Board the enrollment status reports required by this subchapter. (b) Members shall file enrollment status reports on a quarterly basis reflecting the informatio…

(a) Members shall report the following information on a quarterly basis on the enrollment status report form separately for each of the standard health benefits plans, broken out into PPO or POS or EPO for Plans A/50, B, C, and D, the HMO plans reported by copay or coinsurance, a…

§ 11:20-17.5 - Reserved Notes N.J. Admin. Code § 11:20-17.5

(a) The purpose of this subchapter is to establish the requirements and procedures by which carriers issuing plans pursuant to the IHC Act may cease doing business in the individual plan market in this State. Additionally, this subchapter establishes the requirements and procedur…

Words and terms, when used in this subchapter, shall have the meanings set forth in the Act or at N.J.A.C. 11:20-1.2, unless defined below or unless the context clearly indicates otherwise: "Cease doing business" for purposes of this subchapter means market withdrawal. "Individua…

No carrier with in force individual plans shall cancel an individual plan, except in accordance with N.J.S.A. 17B:27A-6, or nonrenew an individual plan upon the plan's anniversary date, except in accordance with N.J.A.C. 11:20-18.5, 18.6, or 18.7. Notes N.J. Admin. Code § 11:20-1…

(a) No carrier with in force individual plans shall cease to offer and issue all of its individual plans to an eligible person unless the Commissioner has determined pursuant to N.J.S.A. 17B:27A-8b and N.J.A.C. 11:20-11 that the carrier does not have the financial resources neces…

(a) No carrier with in force individual plans, whether or not affiliated with other carriers doing business in the individual plan market in New Jersey, shall refuse to issue or refuse to renew an individual plan, except in accordance with N.J.S.A. 17B:27A-6, or in accordance wit…

(a) No carrier shall cease to issue or nonrenew an individual plan, plan option, or deductible/copayment option required or permitted to be offered by N.J.A.C. 11:20-3.1 until the carrier submits a notice of intent to withdraw a plan, plan option, or deductible/copayment option t…

A carrier that ceases to do business pursuant to N.J.A.C. 11:20-18.5 shall be prohibited from writing new individual plans and new small employer plans in New Jersey for a period of five years beginning on the termination date of the last standard individual health benefits plan …

(a) A carrier issuing all of the standard individual plans in the IHC market on and before January 4, 2009 that elects to offer at least three but not all of the standard individual plans after January 4, 2009, as permitted by N.J.S.A. 17B:27A-4b, that has in-force business in th…

Nothing in this subchapter shall be construed to contravene any rights of policy or contractholders concerning other obligations set forth in a policy or contract issued by a carrier. Notes N.J. Admin. Code § 11:20-18.9

This subchapter shall apply to all petitions to the Board by interested persons to adopt a new rule, or amend or repeal any existing rule by the Board, pursuant to N.J.S.A. 52:14B-4(f). Notes N.J. Admin. Code § 11:20-19.1 Amended by R.2006 d.15, effective 1/3/2006. See: 37 N.J.R.…

(a) Any person who wishes to petition the Board to adopt a new rule or amend or repeal any existing rule shall submit to the Board, in writing, the following information: 1. Name, address, phone, fax, and email address of the petitioner; 2. The substance or nature of the rulemaki…

(a) Upon receipt of a petition in compliance with N.J.A.C. 11:20-19.2, the Board shall file, within 15 days, a notice of petition with the Office of Administrative Law for publication in the New Jersey Register. The notice shall include: 1. The name of the petitioner; 2. The subs…

(a) The "IHC Program" created pursuant to the N.J.S.A. 17B:27A-2 to 16, as amended, has as its members all insurance companies, health service corporations, hospital service corporations, medical service corporations, and health maintenance organizations that issue or have in for…

(a) The Board shall establish the policy and contract forms and benefit levels (standard health benefits plans) to be made available by members. 1. In designing and amending the standard health benefits plans, the Board shall give consideration to the types of coverage currently …

Notes N.J. Admin. Code § 11:20-2.11 Repealed by R.1998 d.443, effective 8/7/1998. See: 30 New Jersey Register 2581(a), 30 New Jersey Register 3289(a). Section was "Assessment for 1992 total reimbursable net paid losses".

(a) Except as described in (a)4 below, every member shall be liable for a portion of the administrative expenses of the IHC Program. Within 90 days of approving a final audited statement of the IHC Program financial statements and the conclusion of all appeals of assessments for …

Notes N.J. Admin. Code § 11:20-2.13 Amended by R.1998 d.443, effective 8/7/1998. See: 30 N.J.R. 2581(a), 30 N.J.R. 3289(a). Substituted "Executive Director at the address listed in N.J.A.C. 11:20-2.1(h)" for "Interim Administrator (or Administrator)". Amended by R.2006 d.15, effe…

If a member determined liable for an assessment fails to pay the full amount of the assessment and applicable interest, if any, within 60 days of the date of the invoice, and has neither submitted notice that it is seeking a deferral from the Commissioner, nor requested a hearing…

(a) A member seeking to challenge the amount of an assessment must do so within 20 days of receiving the notice of the assessment pursuant to the procedures for appeals set forth at N.J.A.C. 11:20-20.2. (b) If the Board determines that the nature or extent of errors or conduct by…

(a) The participation in the IHC Program as a member, the establishment of rates, forms or procedures, or any other joint or collective action required by the Act shall not be the basis of any legal action, criminal or civil liability, or penalty against the IHC Program, member o…

Notes N.J. Admin. Code § 11:20-2.17 New Rule, R.1994 d.165, effective 3/1/1994. See: 26 N.J.R. 1200(a), 26 N.J.R. 1507(b). Amended by R.1998 d.443, effective 8/7/1998. See: 30 N.J.R. 2581(a), 30 N.J.R. 3289(a). Rewrote the section. The expiration date of N.J.A.C. 11:20-2.17 was e…

If the total amount of a member's assessment invoice would be less than $ 5.00, the member shall not be liable for that amount and that amount shall be reapportioned pursuant to N.J.A.C. 11:20-2.12. This provision shall apply to an invoice for administrative expenses issued pursu…

(a) Words and terms defined at N.J.S.A. 17B:27A-2 as amended, and N.J.A.C. 11:20-1, when used in this subchapter, shall have the meanings as defined therein, unless more specifically defined in (b) below or unless the context clearly indicates otherwise. (b) The following words a…

(a) The IHC Program shall have the general powers and authority granted under the laws of this State to insurance companies, health service corporations and health maintenance organizations licensed or approved to transact business in this State, except that the IHC Program shall…

The Plan of Operation and amendments thereto shall become effective upon approval by the Commissioner and submission of final action to the Office of Administrative Law for publication. The Commissioner may amend the Plan of Operation by providing written notice to the Board of a…

(a) The Board shall consist of nine Directors, including the Commissioner or his or her designee, who shall sit ex officio. 1. Four Directors shall be appointed by the Governor, with the advice and consent of the Senate. i. One of the Governor's appointees shall be a representati…

(a) The Board shall make appointments to standing and other committees from among Directors. Each of the standing committees shall include no more than four Directors, but the Chair may appoint additional Directors as needed subject to ratification by the Board at the next subseq…