New Jersey Administrative Code

(a) This Plan may be amended by a majority vote of the entire Board, subject to approval of the Commissioner as provided hereinafter. A vote on an amendment may be taken at any meeting called, in whole or in part, for the purpose of considering a proposed amendment. Written notic…

Notes N.J. Admin. Code § 11:21-2.16 Recodified to N.J.A.C. 11:21-2.15 by R.1997 d.62, effective 2/3/1997. See: 28 New Jersey Register 4344(a), 29 New Jersey Register 428(a).

Notes N.J. Admin. Code § 11:21-2.17 Reserved by 48 N.J.R. 2360(a), effective 11/7/2016

The words and terms used in this Plan shall have the meanings set forth at N.J.S.A. 17B:27A-17 and N.J.A.C. 11:21-1.2 or as further defined below: "Administrator" or "Executive Director" means that person, persons, or entity selected by the Board to effectuate the administrative …

(a) The Board has the specific authority pursuant to the Act to: 1. Adopt rules and regulations to establish a voluntary risk pooling arrangement. 2. Enter into contracts as are necessary or proper to carry out the provisions and purposes of the Act; 3. Sue or be sued, including …

(a) The Board shall perform its function under this Plan, and in accordance with the Act. The Plan is intended to assure the fair, reasonable and equitable administration of the Program and shall constitute a public record and accordance with the Act. (b) The Plan does not, nor i…

(a) The Program shall exercise its powers through a Board. 1. The Board shall be made up of the Commissioner, the Commissioner of Health and Senior Services, or their designees (who shall serve ex officio) and 16 public members. The composition of the Board shall be as described …

(a) Appointments to Standing and other committees shall be approved by a majority of the Board present. A written record of the proceedings of each committee shall be maintained by the Executive Director. Committee members are responsible for providing staff support, but may reco…

(a) The Executive Director shall be selected by the Board. (b) The Executive Director shall perform the administrative functions required under the Act and the Plan. The Executive Director is responsible, along with the Board, for the fair, equitable and reasonable administration…

(a) Following approval of a final audited Program statement, the Board shall determine the final administrative expense total for the fiscal year, if any. 1. Each member's final assessment shall be reduced by any interim assessment paid by the member or credited to the member by …

Carriers shall submit statements, assessments and other reports as may be required by the Board pursuant to the Act and this chapter. Notes N.J. Admin. Code § 11:21-2.9 Amended by 48 N.J.R. 2360(a), effective 11/7/2016

(a) The purpose of this subchapter is to establish the procedures that the Board uses in providing notice of proposed rulemaking, receiving public comments regarding existing rules and proposed rulemaking, extending the public comment period, conducting a public hearing, and prov…

(a) Unless the Board proposes a rule pursuant to the special procedures set forth at N.J.S.A. 17B:27A-51, the Board shall provide for the following four types of public notice for rule proposals in accord with the New Jersey Administrative Procedure Act, N.J.S.A. 52:14B-1et seq.,…

(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 extend the time for submission of public comments on a proposed rulemaking, at its discre…

(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…

(a) The Board shall adopt an annual schedule of regular meetings to be held by it 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 of a…

(a) For the purpose of disseminating information about the SEH Program, including information about rulemaking and meeting dates, the Board shall maintain a mailing list of carriers and other interested parties. 1. The mailing list of members shall be based upon the member carrie…

(a) The standard health benefits plans established by the Board contain the benefits, limitations, exclusions and other terms set forth in exhibits in the Appendix to this chapter, which is incorporated herein by reference. 1. Plan B, "The Small Group Health Benefits Policy B," s…

(a) Members may offer riders that increase the coverage offered by Plans B, C, D, E, HMO, and HMO POS plan subject to the provisions set forth in (a)1 through 6 below. 1. Before a member may sell a rider that increases any benefits or increases the actuarial value of Plans B, C, …

(a) Members shall use the standard policy forms for Plans B, C, D, and E which are set forth in the Appendix to this chapter as Exhibits F, and W subject to the "Explanation of Brackets" set forth in Exhibit K of the Appendix, incorporated herein by reference. Members shall not m…

(a)No carrier shall issue any health benefits plan certificate or evidence of coverage to a small employer or the employees of a small employer or use any application form, employer or employee certification, waiver or enrollment form or make any amendments thereto until the carr…

Notes N.J. Admin. Code § 11:21-4.3 New Rule, R.1994 d.153, effective 2/28/1994. See: 26 N.J.R. 741(a), 26 N.J.R. 1352(a). Amended by R.2004 d.107, effective 3/15/2004 (operative October 1, 2004). See: 35 N.J.R. 5011(a), 36 N.J.R. 1594(a). In (a), deleted former 4, recodified form…

(a) Notwithstanding the requirements of N.J.A.C. 11:21-4.1, members may incorporate regulatory changes required to be made to the standard policy forms, standard HMO and HMO POS contracts, certificates, and evidences of coverage for Plans B, C, D, E, HMO, and HMO POS through the …

(a) All small employer carriers offering small employer health benefits plans with an effective date on or after January 1, 1994, shall use the standard application form approved by the Board and available on the Board's website at www.state.nj.us/dobi/division_insurance/ihcseh/s…

Small employer carriers shall require each small employer covered by a small employer health benefits plan issued by the small employer carrier to that small employer to complete each year the New Jersey Small Employer Certification form approved by the Board and available on the…

Notes N.J. Admin. Code § 11:21-6.3 Amended by R.1994 d.418, effective 7/15/1994. See: 26 New Jersey Register 2843(a), 26 New Jersey Register 3442(b). Amended by R.1997 d.62, effective 2/3/1997. See: 28 New Jersey Register 4344(a), 29 New Jersey Register 428(a). Inserted reference…

Any full-time employee who declines coverage under the small employer health benefits plan shall complete the employee waiver form approved by the Board and specified in Exhibit T of the Appendix to this chapter incorporated herein by reference. Notes N.J. Admin. Code § 11:21-6.4…

This subchapter sets forth the standards all carriers must meet in offering, issuing and renewing all health benefits plans to any small employer, the small employer's full-time employees, and the dependents of those full-time employees. Notes N.J. Admin. Code § 11:21-7.1 Amended…

A small employer carrier that does not embed pediatric dental benefits in the health benefits plans offered to small employers shall obtain a reasonable assurance that the small employer has purchased a stand-alone pediatric dental benefit plan from a carrier that offers a qualif…

(a) All health benefits plans that are issued or renewed on or after January 1, 1994, must be guaranteed renewable at the option of the policy or contract holder or small employer, except that a carrier may discontinue a health benefits plan pursuant to (b) below or nonrenew a he…

(a) A small employer carrier shall file with the Board, quarterly no later than 60 days after the end of the fiscal quarter, the following information reported with respect to standard health benefits plans: 1. The number of small employers, covered employees, and dependents that…

Notes N.J. Admin. Code § 11:21-7.13 Reserved by 48 N.J.R. 2360(a), effective 11/7/2016

(a) For health benefits plans issued or renewed on or after January 1, 2014, a carrier shall not differentiate premium rates charged to different small employers for the same health benefits plan except on the basis of age and geography in accordance with the following restrictio…

A small employer carrier shall not be required to modify the waiting period provision of a health benefits plan except as of an anniversary date of the plan, and upon the request of a small employer. Notes N.J. Admin. Code § 11:21-7.15 New Rule, R.2004 d.107, effective 3/15/2004.…

Members that offer small employer health benefits plan in this State shall offer and make a good faith effort to market individual health benefits plans pursuant to N.J.S.A. 17B:27A-2 et seq. and N.J.A.C. 11:20-24.6. Such requirement may be satisfied by the member or the member's…

(a) To determine whether an employer qualifies as a small employer, as defined in N.J.A.C. 11:21-1.2, a carrier shall evaluate whether an employer satisfies the requirements of the definition. (b) A small employer carrier shall add the number of full-time employees (where full-ti…

(a) A small employer carrier shall issue a health benefits plan to any small employer which requests it, pays the premiums therefor, and meets the contribution and participation requirements, if any, of the small employer carrier. All health benefits plans shall provide coverage …

(a) A small employer who purchases a health benefits plan pursuant to the Act shall not be permitted to purchase a health benefits plan with a greater actuarial value until the first anniversary date of the small employer's existing health benefits plan. (b) When a small employer…

(a) A small employer carrier shall require a minimum participation under the small employer's health benefits plan of 75 percent of full-time employees (where full-time means 25 or more hours per week for purposes of eligibility for coverage and participation requirements) who ar…

(a) A small employer carrier shall not require a minimum small employer contribution of more than 10 percent of the annual cost of the small employer's health benefits plan. This contribution requirement shall be applied by the small employer carrier uniformly among all health be…

(a) Each small employer shall designate a 30-day period each year as the employee open enrollment period. Such period shall begin no more than 90 days prior to the start of the plan year. (b) Employees and dependents who are eligible under the small employer's plan but who are la…

(a) The special enrollment period means a period of time that is no less than 30 days following the date of a triggering event listed in (b)1 through 5 below and no less than 60 days following a triggering event listed in (b)6 below during which: 1. Full-time employees and depend…

(a) A small employer carrier, prior to issuing a health benefits plan, may require the following: 1. A completed small employer standard application form including the small employer certification form in accordance with N.J.A.C. 11:21-6.1(a) and (b); 2. Complete employee enrollm…

(a) A small employer carrier shall provide a price quote to a small employer, directly or through an authorized third party, within 10 working days of receiving a request for a quote and such information as is reasonable and necessary to provide the quote. A small employer carrie…

(a) The purpose of this subchapter is to establish informational rate filing requirements and procedures applicable to health benefits plans, including riders or endorsements, issued, renewed, reinstated or continued pursuant to N.J.S.A. 17B:27A-17 et seq. (b) This subchapter app…

Words and terms, when used in this subchapter, shall have the meanings as defined at N.J.S.A. 17B:27A-17 or N.J.A.C. 11:21-1.2 unless defined below or the context clearly indicates otherwise. "Classification factor" means a factor used to vary rates based upon characteristics of …

(a) All carriers issuing policies, contracts or certificates under health benefit plans to small employers, including any standard or nonstandard rider option, prior to issuing any policy, contract or certificate under such plan, shall file with the Commissioner an informational …

(a) All carriers providing discounts to small employer purchasing alliances shall file an informational rate filing with the Commissioner prior to the date of providing such discounts, which shall include the following data: 1. A statement that the discount is based on reductions…

(a) Informational filings submitted pursuant to this subchapter shall be sent to the Department at the following address: Attention: SEH Informational Rate Filings Life and Health Division New Jersey Department of Banking and Insurance 20 West State Street PO Box 325 Trenton, NJ …

(a) Any carrier that quotes, bills or collects a premium to or from a small employer that is less than the rate shown in the carrier's informational SEH rate filing in effect at the time the premium is billed or collected shall: 1. Provide written notice to the small employer of …