New Jersey Administrative Code

Preexisting conditions shall not be excluded from coverage; carriers shall not limit coverage in any way based upon a preexisting condition. Notes N.J. Admin. Code § 11:4-13.3 Amended by 51 N.J.R. 618(a), effective 5/6/2019

(a) Carriers offering student health plans shall adhere to the following requirements for the filing of rates and forms: 1. Each carrier shall submit separate rate and policy form filings in System for Electronic Rate and Form Filing (SERFF) for each student health plan offered, …

These rules apply to individual and group health insurance policies which provide coverage for the costs of daily room and board while confined in a hospital or skilled nursing facility. They do not apply to hospital indemnity policies which provide additional income while the in…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Home health care" means those nursing and other home health care services rendered to a person in his place of residence, under the foll…

(a) Minimum coverage rules are as follows:1. The policy may require no more than three continuous days of hospitalization or skilled nursing facility care prior to provision of home health care benefits. 2. The home health care services listed in paragraphs 1 through 7 of the def…

(a) This subchapter does not impose an obligation to pay benefits for physician's services in connection with home health care except for those benefits required under paragraph 9 of the definition of home health care services. (b) Home health care services including those of hom…

These rules shall be effective on December 15, 1977. Notes N.J. Admin. Code § 11:4-14.5

Notes N.J. Admin. Code § 11:4-15.1 Reserved by 51 N.J.R. 618(a), effective 5/6/2019

Notes N.J. Admin. Code § 11:4-15.2 Reserved by 51 N.J.R. 618(a), effective 5/6/2019

Notes N.J. Admin. Code § 11:4-15.3 Reserved by 51 N.J.R. 618(a), effective 5/6/2019

The purpose of this regulation is to implement N.J.S.A. 17B:26-45 so as to provide reasonable standardization and simplification of language, terms and coverages to facilitate understanding and comparisons; elimination of provisions which may be misleading or unreasonably confusi…

If any provision of the regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby. Notes N.J. Admi…

If after notice and hearing the commissioner finds that a person has violated this regulation, a penalty, in addition to any other penalty, not exceeding $ 2,000 for each violation may be imposed and shall be collected and enforced pursuant to N.J.S.A. 2A:58-1 et seq. Notes N.J. …

This regulation shall apply to all individual health insurance policies delivered or issued for delivery in this State on or after the effective date hereof except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege or to credit he…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Health benefits plan" means a hospital and medical expense insurance policy, health service corporation contract, hospital service corp…

This regulation shall be effective after it has been accepted by the Legislature. Acceptance by the Legislature will occur 60 days after the regulation has been submitted to the Legislature, unless the Legislature passes a concurrent resolution stating in substance that the Legis…

(a) Except as provided hereafter, no health insurance policy delivered or issued for delivery in this State shall contain definitions respecting the matters set forth below unless such definitions comply with the requirements of this section. 1. "Accident", "accidental injury", "…

(a) No policy except a short term, nonrenewable trip policy shall provide coverage solely for specifically identified kind(s) of accident(s); however a policy may provide increased benefits for specifically identified accident(s) for any accident only coverage specified in sectio…

(a) The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections. No individual health insurance policy shall be delivered or issued for delivery in this State that does not meet the required minimum standards for t…

(a) This section sets forth the minimum standards that are prescribed for individual health insurance policies that are health benefits plans. (b) All individual health benefits plans shall comply with N.J.A.C. 11:20. (c) No individual benefits plan shall be delivered or issued f…

(a) Application forms shall not include provisions, statements or questions that: 1. Pertain to race, creed, color, national origin or ancestry of the proposed insured, except for hospital-medical insurance application forms for the purpose of collecting demographic data. No appl…

(a) General disclosure requirements are as follows: 1. Each individual policy of health insurance shall include a renewal, continuation, or nonrenewal provision. The language or specifications of such provision must be consistent with the type of contract issued. Such provision s…

(a) General rules include:1. Within 120 days after the effective date of this regulation, each issuer shall submit a list of all individual health insurance forms currently filed which meet the requirements contained herein. An executive officer of the company shall certify that …

The purpose of this rule is to eliminate unfair and deceptive practices in the promotion, solicitation, and sale of individual health insurance. Notes N.J. Admin. Code § 11:4-17.1

This regulation shall apply to all individual health insurance policies delivered or issued for delivery in this state on or after the effective date hereof except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege or to credit he…

The following words and terms, when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise. "Duplicative coverage" means a transaction wherein health insurance is to be purchased and it is known or should be known to the licensee …

(a) No person shall engage in any unfair, deceptive, misleading, or unreasonably confusing practice in the promotion, solicitation or sale of individual health insurance. (b) The following acts and practices shall be deemed prima facie evidence of a violation of this regulation a…

(a) All licensees involved in the sale of individual health insurance, other than health benefits plans, shall diligently inquire of each applicant as to the existence of any health insurance on any proposed insured. The licensee shall obtain either in the application or in a sep…

(a)N.J.S.A. 17B:30-13.2 requires the maintenance of complaint records. The following requirements prescribed the minimum information to be maintained in order to comply with the statute. 1. The minimum information required to be contained in a person's complaint record is set for…

(a) Any person who, after notice and hearing, is determined by the Commissioner to be in violation of this regulation shall be liable to a penalty not exceeding $ 2,000 for each violation. In addition to, or in lieu thereof, the Commissioner may revoke or suspend the license or c…

If any provision of the regulation or the application thereof to any person or circumstance shall be held invalid for any reason, the remainder of this regulation and the application of such provision to other persons or circumstances shall not be affected thereby. Notes N.J. Adm…

This regulation shall be effective after it has been accepted by the Legislature. Acceptance by the Legislature will occur 60 days after the regulation has been submitted to the Legislature, unless the Legislature passes a concurrent resolution stating in substance that the Legis…

The purpose of this subchapter is to record the policies and practices which the commissioner has traditionally applied to assure that individual health insurance benefits are reasonable in relation to the premiums charged, as required by N.J.S.A. 17B:26-1h, and to further expand…

All policies of insurance previously filed with the Commissioner which are not in compliance with this subchapter as of the operative date shall be deemed to be withdrawn from filing and disapproved. No new policy of insurance shall be delivered or issued for delivery in this Sta…

This subchapter shall apply to all individual health insurance policies delivered or issued for delivery in this State, except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege, it shall not apply to credit health insurance as de…

(a) The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. 1. Terms related to policy renewability are: i. "Collectively renewable insurance" means all insurance which is made available on any…

(a) Each insurer shall include with each submission of new or revised rates the following information and material:1. An actuarial memorandum which shall include the following: i. The anticipated loss ratio; ii. The specific formulas and methodology used in calculating gross prem…

(a) For new forms, the benefits provided are presumed reasonable in relation to the premiums charged if the anticipated loss ratio meets the following standards: 1. For over 65 coverage, the ratio is at least 65 percent; 2. For accident only coverage, the ratio is at least 50 per…

(a) Each insurer shall maintain records of premiums, claims, and reserves on each policy form as required for the accident and health policy experience exhibit. (b) If the incurred/earned loss ratios for a particular policy form, based on a substantial volume of reasonably mature…

(a) Each insurer shall maintain on file with the department an up-to-date rate manual for all individual health insurance policies, riders, and endorsements currently available for sale in New Jersey. Such manual shall include: 1. Name of the insurer on each page; 2. Table of con…

If any provisions of this regulation or the application thereof to any person or circumstance shall be held invalid, the invalidity shall not affect the provisions or application of this regulation which can be given effect without the invalid provision or application, and for th…

If, after notice and hearing the commissioner finds that a person has violated this regulation a penalty, in addition to any other penalty, not exceeding $ 2,000 for each violation may be imposed and shall be collected and enforced pursuant to N.J.S.A. 2A:58-1 et seq. Notes N.J. …

The purpose of this subchapter is to prevent the exclusion of pregnancy-related surgery and sterilization procedures from certain second surgical opinion programs and to make maternity coverage available to insureds. Notes N.J. Admin. Code § 11:4-19.1

This subchapter shall apply to all group and individual health insurance policies as well as hospital and medical service corporation contracts delivered or issued for delivery in this State, except that this subchapter does not apply to individual or group health benefits plans,…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Health benefits plan" means a hospital and medical expense insurance policy, health service corporation contract, hospital service corp…

Every health insurer and medical service corporation offering individual and group policies in this State, with the exception of hospital service corporations, shall include in its programs for second surgical opinions, coverage for pregnancy-related surgery and sterilization pro…

(a) Each insurer issuing plans that are not health benefits plans shall make available benefits coverage for maternity care without regard to the marital status of its policyholders, subscribers, or other persons thereunder covered for expenses incurred in pregnancy and childbirt…