New Jersey Administrative Code

Notes N.J. Admin. Code § 11:20-8.5 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. Amended by R.2003 d.91, effective 1/28/2003. See: 35 N.J.R. 73(a), 35 N.J.R. 1290(a). Rewrote the section. Amended by R.2006 d.15, effec…

In Part D of the Exhibit K Assessment Report, the Chief Financial Officer, or other duly authorized officer of the carrier, shall certify that the Exhibit K Assessment Report and all Exhibit K Part C Premium Data Worksheets filed with the IHC Board are accurate and complete and c…

Failure to file in a timely manner the Exhibit K Assessment Report and certification required by this subchapter shall result in the Board's using the premium set forth in the member's most recent Annual Statements filed with the Department as the premium base to calculate that m…

Notes N.J. Admin. Code § 11:20-8.8 New Rule, 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). In (b), inserted "gain" preceding "(loss)" in the first sentence; and…

Notes N.J. Admin. Code § 11:20-8.9 New Rule, 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. Amended by R.2006 d.15, effective 1/3/2006. See:…

(a) This chapter implements provisions of P.L. 1992, c.162 as amended (N.J.S.A. 17B:27A-17 et seq.), herein referred to as the Small Employer Health Benefits Act. This chapter establishes procedures and standards for carriers to meet their obligations under N.J.S.A. 17B:27A-17 et…

Words and terms contained in the Act, when used in this chapter, shall have the meanings as defined in the Act, unless the context clearly indicates otherwise, or as such words and terms are further defined by this chapter. "Act" means P.L. 1992, c.162, as adopted and subsequentl…

All written communications with the SEH Board shall be submitted to the SEH Board at the following address: New Jersey Small Employer Health Benefits Program Board 20 West State Street, 11th Floor PO Box 325 Trenton, New Jersey 08625-0325 Fax: (609) 633-2030 E-mail: ellen.derosa@…

Failure of a carrier to comply with any provision of this chapter shall result in the imposition of penalties as authorized by law, including, but not limited to, penalties set forth at N.J.S.A. 17B:27A-41 and 17B:27A-43. Notes N.J. Admin. Code § 11:21-1.4

If any provision of this chapter or the application thereof to any person or circumstance is found to be invalid for any reason, the remainder of the chapter and the application thereof to other persons or circumstances shall not be affected thereby. Notes N.J. Admin. Code § 11:2…

The mission of the New Jersey Small Employer Health Benefits Program Board is to administer the New Jersey Small Employer Health Benefits Program in a manner aimed at increasing access to coverage, protecting consumers, educating key stakeholders in the marketplace and other inte…

(a) This subchapter sets forth annual reporting requirements of market share data for the assessment of operational and administrative expenses of the SEH Program. (b) This subchapter shall apply to all carriers that are, or become, members of the SEH Program for any portion of a…

Notes N.J. Admin. Code § 11:21-10.2 Reserved by 48 N.J.R. 2360(a), effective 11/7/2016

(a) Every member of the SEH Program shall file the Market Share Report set forth as Exhibit CC in the Appendix to this chapter, incorporated herein by reference, on or before April 1. Every member shall complete Parts A, B, C and D of the Market Share Report. 1. Affiliated carrie…

(a) Every member's net earned premium for the preceding calendar year ending December 31 shall be set forth in Part C of the Market Share Report. 1. Net earned premium set forth in Part C of the Market Share Report shall include net earned premium resulting from health benefits p…

All reports shall be certified as accurate, complete and conforming with the requirements of this subchapter by the Chief Financial Officer or other duly authorized officer of the member. Notes N.J. Admin. Code § 11:21-10.5

Failure to comply with the reporting provisions of this subchapter shall result in the Board determining that the premium set forth in the member's most recent Annual Statement filed with the Department is the premium based upon which that member's market share allocation of asse…

(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-38 or to offer coverage or accept applications to a small employer, pursuant to N.J.S.A. 17B:27A-26. (b) Th…

Nothing in this subchapter shall be construed as limiting the Commissioner's authority to take such action with respect to insurers, health service corporations, medical service corporations, hospital service corporations or health maintenance organizations as may be authorized b…

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 pursuant to N.J.S.A. 17B:27A-43 and the SEH Program Plan of Operation as codified at N.J.A.C. 11:21-2, including, b…

(a) Words and terms defined at N.J.S.A. 17B:27A-17 and N.J.A.C. 11:21-1, 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, w…

(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-38 shall be submitted to the Department no later than 15 days following the due date of payment of the ass…

(a) When requesting relief from obligations pursuant to N.J.S.A. 17B:27A-26b or 17B:27A-38, 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. The form of rel…

(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., except for the following items, but only…

(a) When the Commissioner determines pursuant to N.J.S.A. 17B:27A-26b or 17B:27A-38 as applicable, that the member is or would be placed in a financially impaired condition through fulfillment of a coverage or assessment obligation or obligations, the Commissioner shall notify th…

(a) If the Commissioner denies a member's request for relief made pursuant to this subchapter, or if the member objects to the terms of the relief granted, the member may request a hearing on the Commissioner's determination within seven days from the date of receipt of such dete…

Members requesting relief pursuant to this subchapter shall concurrently provide notice of all such requests to the SEH Program through the Interim Administrator or Administrator, as appropriate. Members shall also provide notice to the SEH Program of all dispositions of such req…

(a) Any member HMO asserting that it is not required to offer coverage or accept applications pursuant to the requirements of the Act because it reasonably anticipates that it will not have the capacity in its network of providers within the service area to deliver service adequa…

(a) The purpose of this subchapter is to establish the requirements and procedures by which carriers may cease doing business in the small employer market in this State. Additionally, this subchapter establishes the requirements and procedures by which carriers may cease issuing …

Words and terms, when used in this subchapter, shall have the meanings set forth in the Act or at N.J.A.C. 11:21-1.2 unless defined below or unless the context clearly indicates otherwise: "Affiliate" or "affiliated company" means a carrier that directly or indirectly through one…

(a) No small employer carrier shall nonrenew except in accordance with N.J.S.A. 17B:27A-23a, c, d, f, h and i or refuse to issue any small employer health benefits plan unless the small employer carrier withdraws from the small employer market in New Jersey in accordance with the…

Any small employer carrier that ceases to do business pursuant to this subchapter shall be prohibited from writing new business in the New Jersey small employer market for a period of five years from the date of termination of the last health benefits plan nonrenewed under this s…

(a) No carrier shall cease to issue or nonrenew a standard small employer health benefits plan, plan option or copayment/deductible option required or permitted to be offered pursuant to N.J.A.C. 11:21-3 until the carrier submits a notice of intent to withdraw a plan, plan option…

Failure to comply with the requirements of this subchapter shall result in the imposition of penalties pursuant to N.J.S.A. 17B:27A-43 and any and all other penalties provided by law. Notes N.J. Admin. Code § 11:21-16.6 Recodified from N.J.A.C. 11:21-16.5 by R.2004 d. 108, effect…

Nothing in this subchapter shall be construed to contravene any rights of policyholders concerning cancellation requirements or obligations set forth in a policy or contract issued by a small employer carrier. Notes N.J. Admin. Code § 11:21-16.7 Recodified from N.J.A.C. 11:21-16.…

(a) A carrier may revoke its notice of intent to withdraw, filed with the Commissioner pursuant to N.J.A.C. 11:21-16.3, prior to the date that its withdrawal is complete, by submitting a statement to the Department at the address specified at N.J.A.C. 11:21-16.3(c) and to the Boa…

(a) Each small employer carrier which issues marketing and/or promotional materials in conjunction with the standard health benefits plans may attach its own name or identification to each of the plans, but shall also identify each of those standard health benefits plans by the a…

Small employer carriers shall maintain a complete file of all marketing and promotional material specific to the health benefits plans, which it disseminates to consumers, producers, or otherwise publicly disseminates. Small employer carriers shall retain each piece of promotiona…

(a) Each small employer carrier disseminating marketing and promotional material shall certify that its marketing and promotional material conforms with the requirements of this subchapter. The certification, set forth in Part 2 of Exhibit BB of the Appendix, incorporated herein …

Notes N.J. Admin. Code § 11:21-17.4 Reserved by 48 N.J.R. 2360(a), effective 11/7/2016

(a) A small employer carrier may select those insurance producers, as defined by N.J.S.A. 17:22A-2j, with whom it chooses to contract. No small employer carrier shall terminate or refuse to renew the contract of its insurance producers because of health status-related factors of …

This subchapter shall apply to all petitions made by interested persons for the promulgation, amendment or repeal of any rule by the Board, pursuant to N.J.S.A. 52:14B-4(f). Notes N.J. Admin. Code § 11:21-18.1

(a) Any person who wishes to petition the Board to promulgate, amend or repeal a rule shall submit to the Board, in writing, the following information: 1. Name and address of the petitioner; 2. The substance or nature of the rulemaking which is requested; 3. The reasons for the r…

(a) Upon receipt of a petition in compliance with N.J.A.C. 11:21-18.2 the Board shall, within 15 days, file 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 subst…

(a) The Program has been created pursuant to section 12 of P.L. 1992, c.162 (N.J.S.A. 17B:27A-28) as amended to assure the availability of the standardized health benefits plans to New Jersey small employers, their full-time employees and the dependents of those eligible employee…

(a) The Board shall maintain the books and records of the Program so that financial statements can be prepared to satisfy the Act. Further, these books shall satisfy any additional requirements of the Board and outside auditors. 1. The receipt and disbursement of cash by the Prog…

(a) The Board shall provide for the maintenance and retention of its official records in accordance with the Destruction of Public Records law (N.J.S.A. 47:3-15through 32) and all other applicable laws. (b) The Board's records shall include the following: 1. Minutes of all Board …

(a) The Program shall have an annual audit of its operations conducted by an independent certified public accountant approved by the Board. This audit shall encompass at least the following items: 1. The handling and accounting of assets and money for the Program; and 2. The annu…

Notes N.J. Admin. Code § 11:21-2.13 Reserved by 48 N.J.R. 2360(a), effective 11/7/2016

(a) A member or employee of the Board, including the Executive Director and staff, shall not be liable in an action for damages to any person for any action taken or recommendation made by him or her within the scope of his or her functions as a member or employee, if the action …