New Jersey Administrative Code

This subchapter shall apply to all appeals from Board determinations and requests for hearing as expressly provided pursuant to this chapter. Notes N.J. Admin. Code § 11:20-20.1 Amended by R.2006 d.15, effective 1/3/2006. See: 37 New Jersey Register 2994(a), 38 New Jersey Registe…

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

Notes N.J. Admin. Code § 11:20-22.1 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

Notes N.J. Admin. Code § 11:20-22.2 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

Notes N.J. Admin. Code § 11:20-22.3 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

Notes N.J. Admin. Code § 11:20-22.4 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

Notes N.J. Admin. Code § 11:20-22.5 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

Notes N.J. Admin. Code § 11:20-22.6 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

Notes N.J. Admin. Code § 11:20-22.7 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

(a) The purpose of N.J.A.C. 11:20-23.2 through 23.5 is to establish the procedures that the Board uses in rulemaking made pursuant to the New Jersey Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. The purpose of N.J.A.C. 11:20-23.6 is to establish procedures for public no…

(a) The Board shall provide the following types of public notice for rule proposals pursuant to the New Jersey Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq., and the Office of Administrative Law Rules for Agency Rulemaking, N.J.A.C. 1:30: 1. The rule proposal shall be f…

(a) The Board, pursuant to the New Jersey Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq., and the Office of Administrative Law Rules for Agency Rulemaking, N.J.A.C. 1:30, may extend the time for submission of public comments on a proposed rulemaking, at its discretion, w…

(a) The Board, in accordance with the New Jersey Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq., and the Office of Administrative Law Rules for Agency Rulemaking, N.J.A.C. 1:30, may conduct a public hearing on a proposed rulemaking, at its discretion, without the need fo…

The Board shall provide notice of new rules, amendments, repeals, or adoptions by posting these rules on its website at www.dobi.nj.gov and to the news media maintaining a press office in the State House complex. Notes N.J. Admin. Code § 11:20-23.5 Amended by 48 N.J.R. 2153(a), e…

(a) The Board shall adopt an annual schedule of regular meetings to be held during the following calendar year. (b) The Board may schedule meetings in addition to those set forth in the annual schedule. (c) The Board shall provide public notice for all meetings by: 1. Posting a n…

(a) For the purpose of disseminating information about the IHC Program, including, but not limited to, information about meeting dates and rulemaking made pursuant to either the New Jersey Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. or N.J.S.A. 17B:27A-16.1, the Board…

(a) This subchapter sets forth the standards all carriers must meet in offering and issuing standard health benefits plans and standard health benefits plans with riders to eligible persons off the Marketplace in New Jersey. (b) This subchapter sets forth requirements with which …

(a) The policyholder of a standard health benefits plan or a standard health benefits plans with rider shall be a resident, as defined at N.J.A.C. 11:20-1.2. A carrier may require reasonable proof of residency. A dependent of the policyholder may be a nonresident of New Jersey, b…

(a) A special enrollment period begins on the date of the triggering event and continues for 60 days. With respect to a loss of coverage the special enrollment period also includes the 60 days prior to the loss of coverage. During this period, an eligible person may apply for cov…

(a) A carrier may offer a credit card or debit card payment option or an automatic checking withdrawal option to individuals for the monthly or quarterly payment of premiums. In the event that a carrier elects to offer an automatic checking withdrawal option, the carrier shall of…

(a) A carrier, prior to issuing an individual health benefits plan, may require the following: 1. A completed individual application form; 2. Proof of the applicant's residency; 3. If a person is applying during a special enrollment period, evidence of the triggering event; 4. If…

Notes N.J. Admin. Code § 11:20-24.5 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

(a) In order for the Board to determine whether a member that is a small employer carrier as defined in N.J.S.A. 17B:27A-17 has offered and made a good faith effort to market the standard health benefits plans pursuant to N.J.S.A. 17B:27A-19a, every small employer carrier shall s…

Notes N.J. Admin. Code § 11:20-24.7 New Rule, R.2009 d.45, effective 12/29/2008. See: 40 N.J.R. 6904(a), 41 N.J.R. 799(b). 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 was "Conversion of in force con…

(a) The standard individual health benefits plans established by the Board contain the benefits, limitations and exclusions set forth in the Appendix to this chapter as follows: 1. Plan A/50, Appendix Exhibit A with pages identified as unique to Plan A/50; 2. Plan B, Appendix Exh…

(a) The standard plans set forth in Appendix Exhibits A and B include sample schedule page text. The sample schedule pages highlight some covered services. Carriers may include additional covered services on the schedule. Features included on one sample schedule page may be inclu…

(a) Members may incorporate regulatory changes required to be made to the standard policy forms, standard HMO contract, and standard riders through the use of the Compliance and Variability Rider as set forth as Exhibit D of the Appendix, incorporated herein by reference, if the …

Notes N.J. Admin. Code § 11:20-3.4 New Rule, by R.2006 d.119, effective 2/24/2006 (operative July 1, 2006). See: 38 N.J.R. 1306(a), 38 N.J.R. 1459(a). Former N.J.A.C. 11:20-3.4, recodified as N.J.A.C. 11:20-3.5. Amended by R.2009 d.45, effective 12/29/2008. See: 40 N.J.R. 6904(a)…

Notes N.J. Admin. Code § 11:20-3.5 Reserved by 48 N.J.R. 2153(a), effective 10/17/2016

(a) Members may offer riders that revise the coverage offered by Plans A/50, B, C, D, and HMO, subject to the provisions set forth in (a)1 through 8 below. 1. Before a member may sell a rider or amendment thereof that increases any benefits or increases the actuarial value of Pla…

(a) If the IHC Board promulgates rules withdrawing a plan, plan option, or deductible/copayment option, a carrier shall cease issuing that plan, plan option, or deductible/copayment option within the timeframe established by the IHC Board by regulation. (b) If the IHC Board promu…

The purpose of this subchapter is to establish informational rate filing requirements and procedures for members issuing or renewing individual health benefits plans pursuant to section 3 of the Act (N.J.S.A. 17B:27A-4) as well as the basic and essential health care services plan…

Words and terms, when used in this subchapter, shall have the meanings defined by the Act, N.J.A.C. 11:20-1.2, or as further defined below, unless the context clearly indicates otherwise. "Informational filing" means a submission by a carrier of rate manuals which specify the pla…

(a) All members issuing standard health benefits plans on a new contract or policy form and the basic and essential health care services plan shall make, prior to issuing any standard health benefits plan (or rider for a standard health benefits plan), or basic and essential heal…

(a) A member shall file one copy of the informational rate filing with the Department pursuant to N.J.A.C. 11:20-6.3(a) or (b) at the following address: New Jersey Dept. of Banking and Insurance Life & Health Actuarial: IHC Rate Filings PO Box 325 20 West State Street Trenton, NJ…

(a) A carrier shall not differentiate premium rates charged to different individuals except on the basis of age (in the case of standard plans and riders) and age, gender, and geography (in the case of basic and essential plans and riders) in accordance with the following restric…

The purpose of this subchapter is to implement the loss ratio and refund reporting requirements of the Act. Notes N.J. Admin. Code § 11:20-7.1

Words and terms, when used in this subchapter, shall have the meanings defined by the Act, N.J.A.C. 11:20-1.2, or as further defined below, unless the context clearly indicates otherwise. "Claims paid" means a dollar amount determined in accordance with statutory annual statement…

(a) Each member that had a standard health benefits plan or a basic and essential health care services plan in force during the preceding calendar year shall file with the Commissioner an annual Loss Ratio Report on the form appearing as Exhibit J in the Appendix to this chapter,…

(a) A Loss Ratio Report form set forth at Appendix Exhibit J shall be completed by August 15 of each year by each member and shall include the following information with respect to standard health benefits plans and basic and essential health care services plans: 1. The reporting…

(a) If the loss ratio determined in N.J.A.C. 11:20-7.4 is less than 80 percent, the member shall include with the Report a plan to be approved by the Commissioner for a refund to policy and contractholders of an amount equal to the difference between 80 percent of reported premiu…

(a) Any loss ratio refund issued by a carrier to a policy or contractholder pursuant to this subchapter which remains unclaimed by that policy or contractholder shall be deemed abandoned two years from the date upon which the Commissioner approves the refund plan as set forth in …

Within 30 days of issuing refunds to all policy or contractholders for a specific calendar year, any carrier required to provide a loss ratio refund pursuant this subchapter shall provide a certification to the Commissioner at the address in N.J.A.C. 11:20-6.4(a), stating the fol…

(a) This subchapter sets forth reporting and certification requirements for premium data of Program members and other carriers with reportable accident and health premium in New Jersey. (b) This subchapter shall apply to all carriers with reportable accident and health premium in…

(a) Every carrier with reportable accident and health premium in New Jersey shall file the N.J.A.C. 11:20 Appendix Exhibit K Assessment Report form and a copy of the N.J.A.C. 11:20 Appendix Exhibit K Part C Premium Data Worksheet, which are set forth as N.J.A.C. 11:20 Appendix Ex…

(a) In Part C of the N.J.A.C. 11:20 Appendix Exhibit K Assessment Report, each member shall set forth its total net earned premium from plans issued, continued, or renewed for all affiliated carriers during the preceding two-year calculation period through the 2017-2018 calculati…

Notes N.J. Admin. Code § 11:20-8.4 Amended by R.1994 d.177, effective 3/10/1994. See: 26 N.J.R. 1294(a), 26 N.J.R. 1509(a). 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. Repeal and New Rule, R.2003 d.91, effective 1/2…