New Jersey Administrative Code

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…

The purpose of this subchapter is to implement the loss ratio and refund reporting requirements of N.J.S.A. 17B:27A-19.3 and 25. Notes N.J. Admin. Code § 11:21-7A.1 Amended by R.1998 d.427, effective 8/17/1998. See: 30 New Jersey Register 282(a), 30 New Jersey Register 3057(a). S…

The following terms, when used in this subchapter, shall have the following meanings: "Closed nonstandard health benefits plan" means a closed nonstandard health benefits plan as defined at N.J.A.C. 11:21-11.2. "Open nonstandard health benefits plan" means an open nonstandard hea…

(a) Each carrier having standard health benefits plan policy forms, open or closed nonstandard health benefits plan policy forms or HMO plans in force at any time during the preceding calendar year shall file with the Department an annual loss ratio report on the form appearing a…

(a) A loss ratio report filed pursuant to N.J.A.C. 11:21-7A.3 shall include the following information:1. The reporting carrier's name and address; 2. The carrier's earned premiums, before dividends or credits applicable to prior years, and claims for the preceding calendar year, …

(a) If the preceding calendar year loss ratio for any of the classifications listed in N.J.A.C. 11:21-7A.3(a) is less than 80 percent, the carrier shall include within the loss ratio report a plan to be approved by the Department for the distribution of all dividends and credits …

(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 …

(a) All data or information filed with the Department pursuant to N.J.A.C. 11:21-9.3(a) are public records and may be disclosed in accordance with N.J.S.A. 47:1A-1 et seq., except that actuarial memoranda which contain confidential and proprietary information pursuant to N.J.A.C.…

Failure to comply with the provisions of this subchapter may result in the imposition of fines or other penalties provided by N.J.S.A. 17B:27A-43. Notes N.J. Admin. Code § 11:21-9.8 Recodified from N.J.A.C. 11:21-9.6 by R.2002 d.342, effective 11/4/2002. See: 34 New Jersey Regist…

(a) This chapter implements N.J.S.A. 17B:30-26 through 34, which sets standards for the payment of claims relating to health benefit plans and dental plans. (b) This chapter applies to any insurance company, health service corporation, medical service corporation, hospital servic…

(a) Every health carrier or its agent shall establish an internal appeals mechanism to resolve payment disputes between health carriers or their agents and health care providers, but not including appeals related to medical necessity made pursuant to N.J.A.C. 11:24-8.5, 8.6, and …

(a) Every dental plan organization and dental service corporation shall establish an internal appeals mechanism to resolve disputes between dental carriers or their agents and participating health care providers relating to payment of claims for services or supplies covered by a …

(a) Every dental plan organization and dental service corporation shall offer an independent, external alternative payment dispute resolution (ADR) mechanism to participating health care providers to review adverse decisions of its internal appeals process. 1. The ADR mechanism s…

(a) Any dispute regarding the determination of an internal appeal conducted pursuant to a health carrier's or its agent's internal appeal mechanism established pursuant to P.L. 2005, c. 352, and described at N.J.A.C. 11:22-1.10, may be referred to arbitration, except for the foll…

(a) A carrier or ODS shall report to the Department on a quarterly and annual basis on the timeliness of claims payments and on the reasons for denial and late payment of claims in a format set forth by bulletin or similar means and/or on the Department's website. Due dates for t…

(a) Upon review of the reports required by N.J.A.C. 11:22-1.14, the Commissioner may require that the carrier, ODS, or the agent of a carrier or ODS, at its own expense: 1. Implement a plan of remedial action; and/or 2. Have the claims processing procedures of the carrier or its …

(a) Every carrier shall provide an explanation of benefits, within 30 days if the claim is filed electronically or 40 days if a claim is submitted in writing, to covered persons in response to the filing of a claim by a provider or a covered person under a health benefits plan. (…

(a) The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "ADR" or "alternative dispute resolution" means any procedure, other than litigation, used in the conciliatory resolution of a dispute,…

(a) A carrier or its agent shall acknowledge receipt of all claims. The acknowledgement shall include the date the carrier or its agent received the claim. 1. If a claim is submitted by electronic means, the claim shall be acknowledged electronically no later than two working day…

(a) A health carrier or its agent shall provide in a clear and conspicuous manner through a publicly accessible internet website information concerning the submission and processing of claims including, but not limited to, where applicable: 1. A list of the material, documents, o…