New Jersey Administrative Code

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 Repealed by R.2013 d.130, effective 10/1/2013 (operative January 1, 2014).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…

(a) The purpose of this subchapter is to establish the requirements and procedures by which carriers seeking to enter the individual plan market and carriers issuing plans in the individual plan market shall file individual policy or contract forms with the Commissioner and certi…

(a) Before marketing, issuing or renewing any of the standard policy forms, a member shall file with the Department, the Certification of Compliance set forth in the Appendix to this subchapter as Exhibit E, incorporated herein by reference. Each affiliated carrier must file a se…

(a) Before a member may offer or issue the basic and essential health care services plan policy form, the member shall submit the information set forth below to the Department at Department of Banking and Insurance, Life and Health, Basic and Essential Health Care Services Plan F…

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…

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…