Title 17, Title 17: CORPORATIONS AND INSTITUTIONS FOR FINANCE AND INSURANCE

17:48E-11. Professional Advisory Committee a. There is created a Professional Advisory Committee which shall be elected by the directors in a manner provided by the bylaws, which shall advise and make recommendations to the board with respect to professional practice and health c…

17:48E-12 Eligible providers' services. 12. In any contract entered into by a health service corporation, which includes coverage for health care services provided by a physician, coverage shall be deemed to include health care services provided by a registered bio-analytic labor…

17:48E-13. Approval of forms 13. No health service corporation shall enter into any contract with a subscriber unless it has filed with the commissioner a copy of the contract or certificate and copies of all applications, riders, and endorsements for use in connection with the i…

17:48E-13.1. Health service corporation contract; compliance 11. No health service corporation contract subject to the provisions of P.L.1985, c.236 (C.17:48E-1 et seq.) or application for that contract, if a written application is required and is to be made a part of that contra…

17:48E-13.2. Filing of contract or related form 12. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), any contract subject to the provisions of P.L.1985, c.236 (C.17:48E-1 et seq.), including any application, ride…

17:48E-13.3. Contract forms; certification memorandum 13. a. Pursuant to the provisions of this section, a health service corporation authorized to do business in this State may file with the commissioner and use, in accordance with subsection d. of this section, any contract, en…

17:48E-14. Individual contract requirements In every individual contract made, issued or delivered in this State: a. All printed portions shall be plainly printed in type of which the face is not smaller than 10 point; b. There shall be a brief description of the contract on its …

17:48E-15. Classification permitted A health service corporation may classify subscribers whereby under specified circumstances a subscriber or covered dependents may pay a participating provider of health care services an amount in addition to that payable by the corporation for…

17:48E-15.1. Eligibility for enrollment in health service corporation 3. Notwithstanding any other provision of law to the contrary, a health service corporation shall not consider a person's eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or t…

17:48E-15.2. Health service corporation contract, exclusion, rates, terms based on genetic information prohibited 13. Every individual or group health service corporation contract providing hospital or medical expense benefits that is delivered, issued, executed or renewed in thi…

17:48E-16. Joint ventures a. A health service corporation of this State may, (1) with the participation of any other corporation licensed pursuant to Title 17 of the Revised Statutes, Title 17B of the New Jersey Statutes, or P.L. 1973, c. 337 (C. 26:2J-1 et seq.), or licensed pur…

17:48E-17. Expense limits; investments; administrative services 17. a. No health service corporation shall during any one year disburse more than 10% of the aggregate amount of the payments received from subscribers during that year as expenditures for the soliciting of subscribe…

17:48E-17.1. Two special contingent surplus accounts 5. a. Every health service corporation shall accumulate and maintain during each calendar year two separate special contingent surplus accounts, one for its individual contracts and one for its other activities. b. Every health…

17:48E-17.2. Special contingent surplus required for health service corporation 8. Notwithstanding the provisions of section 5 of P.L.1988, c.71 (C.17:48E-17.1) or any other provision of law to the contrary, on or after December 31, 1996 or the date on which the commissioner deem…

17:48E-17.3 Examination of annual regulatory filings; annual audit. 4. a. The commissioner shall, on an annual basis, examine a health service corporation's annual regulatory filings to determine whether the health service corporation's risk-based capital ratio is within 550% to …

17:48E-17.4 Health service corporation, aggregate benefits. 3. a. Beginning with the calendar year starting on January 1, 2020, and in each calendar year thereafter, a health service corporation providing health benefits plans to a large employer shall return, in the form of aggr…

17:48E-18. Annual contract, renewal; family coverage a. Every individual contract made by a health service corporation shall provide coverage for a specified period of not less than one year, and no contract shall be made providing for the inception of coverage at a date later th…

17:48E-19. Provisions of subscription certificates Every individual contract entered into between a health service corporation and a subscriber shall be in writing and a certificate stating the terms and conditions thereof shall be furnished to the subscriber to be kept by him. N…

17:48E-2. Establishment of health service corporation a. A health service corporation may be established: (1) By incorporating and obtaining a certificate of authority in accordance with the provisions of this act; or (2) By the merger of a hospital service corporation and a medi…

17:48E-20 Coverage for newborn child. 20. a. Family type individual contracts shall provide that the coverage applicable for children shall be payable with respect to a newly born child of the subscriber, or his or her spouse, from the moment of birth. Coverage for newly born chi…

17:48E-21. Coverage for former spouse Whenever, pursuant to the provisions of an individual contract issued by a health service corporation, the former spouse of a named subscriber under a contract is no longer entitled to coverage as an eligible dependent by reason of divorce, s…

17:48E-22 Coverage for child with intellectual disability, physical handicap. 22. Coverage of an unmarried child, covered prior to attainment of age 19 by an individual contract under which coverage terminates at a specified age, who is incapable of self-sustaining employment by …

17:48E-23. Group contracts a. A health service corporation may issue to a policyholder a group contract, covering at least two employees or members at the date of issue, if it conforms to the following description: (1) A contract issued to an employer or to the trustees of a fund…

17:48E-24. Provisions of group contract forms a. Every group contract entered into by a health service corporation with any policyholder shall be in writing and a contract form stating the terms and conditions thereof shall be furnished to the policyholder to be kept by him. No g…

17:48E-25. "Employee" coverage The group contract may provide that the term "employee" shall include as employees of a single employer the employees of one or more subsidiary corporations and the employees, individual proprietors and partners of affiliated corporations, proprieto…

17:48E-26. Experience rating a. A group contract, covering at least two employees or members, may provide for the adjustment of the rate of premium of insurance based on past or projected experience, and may include those claim costs and utilization trend factors which the health…

17:48E-27. Rate schedule filing 27. No health service corporation shall issue individual contracts until it has made an informational filing with the commissioner, pursuant to the provisions of this act, of a full schedule of rates which are to apply to those contracts. The rates…

17:48E-27.1. Individual contract rate changes 7. A health service corporation shall make an informational filing of any change in its rates for coverage under individual contracts which are not experience rated, along with supporting information as required pursuant to subsection…

17:48E-28 Group coverage for newborn child. 28. a. Family type group coverage shall provide that the coverage applicable for children shall be payable with respect to a newly born child of the subscriber, or his or her spouse, from the moment of birth. The coverage for newly born…

17:48E-29. Nongroup coverage for former spouse Whenever, pursuant to the provisions of a group contract issued by a health service corporation, the former spouse of an employee or member of a policyholder under a group contract is no longer entitled to coverage as an eligible dep…

17:48E-3 Health service corporations. 3. a. A health service corporation shall not be established as a corporation organized for pecuniary profit. Every health service corporation established pursuant to the provisions of P.L.1985, c.236 (C.17:48E-1 et seq.) shall be operated for…

17:48E-30 Group coverage for child with intellectual disability, physical handicap. 30. Coverage of an unmarried child, covered prior to attainment of age 19 by a group contract under which coverage terminates at a specified age, who is incapable of self-sustaining employment by …

17:48E-30.1 Coverage for certain dependents until age 31 by health service corporation. 3. a. As used in this section, "dependent" means a subscriber's child by blood or by law who: (1) is 30 years of age or younger; (2) is unmarried; (3) has no dependent of his own; (4) is a res…

17:48E-31. Family coverage after member's death Any group contract which contains provisions for the payment by the insurer of benefits for members of the family or dependents of a person in the insured group shall provide that, subject to payment of the appropriate premium, fami…

17:48E-32. Continuation of coverage for totally disabled A group contract or individual group certificate delivered or issued for delivery in this State which covers employees or members and their dependents for health services on an expense incurred or service basis, other than …

17:48E-32.1 Coverage provided by health service corporation for subscriber's child. 5. a. A health service corporation contract which provides hospital or medical expense benefits under which dependent coverage is available shall continue to make that coverage available for an ad…

17:48E-32.2. Requirements applicable to State Medicaid 6. A health service corporation shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible f…

17:48E-33. Second, third surgical opinions a. A health service corporation issuing a group or individual contract in accordance with this act, which provides payment for surgical services rendered to a person while confined in a hospital as an inpatient, shall make available bene…

17:48E-35. Reconstructive breast surgery benefits 35. Every subscription certificate and group and individual contract providing health service coverage, delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the commissioner on…

17:48E-35.1. Benefits for home treatment of hemophilia Every group or individual contract providing hospital expense benefits to any subscriber or other person covered thereunder for expenses incurred in connection with the treatment of routine bleeding episodes associated with h…

17:48E-35.10 Health service corporation contracts, child screening, blood lead, hearing loss; immunizations. 1. No health service corporation contract providing hospital or medical expense benefits for groups with greater than 50 persons shall be delivered, issued, executed, or r…

17:48E-35.11. Coverage for diabetes treatment by individual group health service corporation. 3. a. Every individual or group health service corporation contract providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant t…

17:48E-35.12. Health service corporation contract, Pap smear benefits 1. No health service corporation contract providing hospital or medical expense benefits for groups with greater than 50 persons shall be delivered, issued, executed or renewed in this State, or approved for is…

17:48E-35.13. Health service corporation contract, prostate cancer testing 1. No health service corporation contract providing hospital or medical expense benefits for groups with greater than 49 persons shall be delivered, issued, executed or renewed in this State, or approved f…

17:48E-35.14. Coverage for minimum inpatient care following mastectomy by individual, group health service corporation 3. a. Every individual or group health service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or rene…

17:48E-35.15 Applicability of Health Care Quality Act 27. Notwithstanding the provisions of P.L.1985, c.236 (C.17:48E-1 et seq.) to the contrary, no individual or group contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the …