Title 26, HEALTH AND VITAL STATISTICS

26:2J-12. Complaint system a. (1) Every health maintenance organization shall establish and maintain a complaint system to provide reasonable procedures for the resolution of written complaints initiated by enrollees concerning health care services. (2) Each health maintenance or…

26:2J-13. Investments With the exception of investments made in accordance with section 5 a. (1) and (3) hereof, the investable funds of a health maintenance organization shall be only in securities or other investments permitted by the laws of this State for the investment of as…

26:2J-14. Protection against insolvency Each health maintenance organization shall deposit cash or a form of guaranty or security in such amount as will assure that the obligations to the enrollees will be performed in such amount and for such time as prescribed by the commission…

26:2J-15. Prohibited practices for health maintenance organization 15. a. No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of …

26:2J-15.1. Health care services contract, exclusion, rates, terms based on genetic information prohibited 16. Every contract for health care services that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issu…

26:2J-16. Regulation of agents The commissioner may, after notice and hearing, promulgate such reasonable rules and regulations, which have been approved by the Commissioner of Insurance, as are necessary to provide for the certification of agents. An agent as used herein means a…

26:2J-17. Powers of insurers and hospital and medical service corporations a. An insurance company licensed in this State, or a hospital or medical service corporation authorized to do business in this State, may either directly or through a subsidiary or affiliate organize and o…

26:2J-18. Examinations a. Not less frequently than once every 3 years the commissioner may make an examination concerning the quality of health care services and other affairs of the health maintenance organization and providers with whom such organization has contracts, agreemen…

26:2J-18.1 Examination of HMO by Commissioner of Banking and Insurance. 20. The Commissioner of Banking and Insurance may conduct an examination of a health maintenance organization in accordance with the procedures provided in P.L.1993, c.236 (C.17:23-20 et seq.) as often as he …

26:2J-18.2 Definitions relative to risk based capital requirements for HMOs. 1. As used in sections 1 through 5 of P.L.2005, c.65 (C.26:2J-18.2 et seq.): "Commissioner" means the Commissioner Banking and Insurance. "Health maintenance organization" means an entity authorized to t…

26:2J-18.3 Increase of capital, surplus; methods, procedures. 2. The commissioner may increase the amount of capital or surplus required of a health maintenance organization, or subsequently revise or redetermine that increase, using appropriate methods and procedures established…

26:2J-18.4 Factors in determining change in capital, surplus. 3. In determining any increase, revision or redetermination in the capital or surplus of a health maintenance organization pursuant to the provisions of section 2 of P.L.2005, c.65 (C.26:2J-18.3) the commissioner shall…

26:2J-18.5 Noncompliance, penalties. 4. The commissioner may suspend or revoke the authority to do business in this State of any health maintenance organization that does not comply with the provisions of P.L.2005, c.65 (C.26:2J-18.2 et al.). L.2005,c.65,s.4.

26:2J-18.6 Regulations. 5. The commissioner may promulgate regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to effectuate the purposes of P.L.2005, c.65 (C.26:2J-18.2 et al.). L.2005,c.65,s.5.

26:2J-19. Suspension or revocation of certificate of authority a. The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this act if he finds that any of the following conditions exist: (1) The health maintenance orga…

26:2J-2. Definitions a. "Commissioner" means the State Commissioner of Health. b. "Basic health care services" means those services, including but not limited to emergency care, inpatient hospital and physician care, and outpatient medical services, designated by regulations prom…

26:2J-21. Regulation The commissioner may, upon notice and hearing, promulgate reasonable rules and regulations, as are necessary or proper to carry out the provisions of this act. Where applicable, such rules and regulations shall be promulgated after consultation with the Commi…

26:2J-22. Administrative procedures a. When the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, he shall notify the health m…

26:2J-23 Fees. 23. Every health maintenance organization subject to this act shall pay to the commissioner the following fees: a. for filing an application for a certificate of authority or amendment thereto, $100.00; b. for filing each annual report, $10.00; and c. for the purpo…

26:2J-24 Administrative penalty; enforcement 24. a. The commissioner may, in lieu of suspension or revocation of a certificate of authority under section 18 hereof, levy an administrative penalty in an amount not less than $250 nor more than $10,000 for each day that the health m…

26:2J-25 Statutory construction and relationship to other laws. 25. Statutory construction and relationship to other laws. a. Except as otherwise provided in this act, provisions of the insurance law and provisions of hospital, medical or health service corporation laws shall not…

26:2J-26 Filings and reports as public documents. 26. Filings and reports as public documents. All applications, filings and reports required under this act shall be treated as public documents and, except for any examination being conducted pursuant to section 20 of P.L.1997, c.…

26:2J-27. Confidentiality of medical information Any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant obtained from such enrollee or from any provider by any health maintenance organization shall be held in confidence and shall no…

26:2J-28. Commissioner of health's authority to contract The commissioner or where applicable the Commissioner of Insurance, in carrying out his obligations under sections 4 a. (2), and 18 a. hereof, may contract with qualified persons to make recommendations concerning the deter…

26:2J-29. Enrollment of State employees Any employee of the State or any subdivision of the State or any institution supported in whole or in part by the State may elect to enroll in a health maintenance organization and have all deductions from his salary or wages and all contri…

26:2J-3. Establishment of health maintenance organizations a. Notwithstanding any law of this State to the contrary, any person may apply to the commissioner for and obtain a certificate of authority to establish and operate a health maintenance organization in compliance with th…

26:2J-30. Severability If any section, term, or provision of this act shall be adjudged invalid for any reason, such judgment shall not affect, impair, or invalidate any other section, term, or provision of this act, but the remaining sections, terms, and provisions shall be and …

26:2J-31. Definitions 1. As used in this act: "Applicant" means any individual who seeks enrollment with a health maintenance organization for the purpose of obtaining medicare supplement health care services. "Commissioner" means the Commissioner of Insurance. "Department" means…

26:2J-32. Applicability of act 2. Except as otherwise specifically provided: a. This act shall apply to all medicare supplement health care services provided pursuant to a medicare supplement contract or evidence of coverage delivered or issued for delivery in this State. b. This…

26:2J-33. Avoidance of duplication of benefits, regulations 3. a. No medicare supplement contract or evidence of coverage shall provide for health care services which duplicate any benefits provided by medicare. b. The commissioner shall promulgate regulations to establish specif…

26:2J-34. Coverage for preexisting condition 4. Notwithstanding any other provision of law to the contrary, a medicare supplement contract or evidence of coverage shall not deny medicare supplement health care services for losses incurred more than six months from the effective d…

26:2J-35. Regulations 5. The commissioner shall promulgate regulations to effectuate and enforce the provisions of this act and any regulations which are necessary to conform medicare supplement health care services provided under a medicare supplement contract or evidence of cov…

26:2J-36. Authorization for health maintenance organization to offer, provide medicare supplement health care services 6. No health maintenance organization shall offer or provide medicare supplement health care services in this State without authorization by the commissioner. Th…

26:2J-37. Submission of underlying plan; rate filings 7. a. No health maintenance organization authorized pursuant to section 6 of this act shall deliver or issue for delivery in this State any medicare supplement contract or evidence of coverage or any application or notificatio…

26:2J-38. Outline of coverage delivered to applicant 8. a. In order to provide for full and fair disclosure in the sale of medicare supplement contracts or evidences of coverage, no medicare supplement contract or evidence of coverage shall be delivered or issued for delivery in …

26:2J-39. 30-day return provision, refunds 9. Notice shall be prominently printed on the first page of each medicare supplement contract and evidence of coverage stating in substance that the applicant shall have the right to return the contract or evidence of coverage within 30 …

26:2J-4. Issuance of certificate of authority a. (1) Upon receipt of an application for issuance of a certificate of authority the commissioner shall forthwith transmit copies of such application and accompanying documents to the Commissioner of Insurance. The approval of the Com…

26:2J-4.1. Health maintenance organization to pay benefits for treatment of Wilm's tumor Notwithstanding any provision of law to the contrary, every health maintenance organization for which a certificate of authority to establish and operate a health maintenance organization in …

26:2J-4.10 Health maintenance organization, child screening, blood lead, hearing loss; immunizations. 4. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insuran…

26:2J-4.11. Coverage, diabetes treatment by HMO contracts. 6. a. Every contract for health care services that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State on or after the …

26:2J-4.12 HMO contracts, Pap smear benefits. 5. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the…

26:2J-4.13. HMO certificate of authority, prostate cancer testing 5. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Health on or after the effective date of this act unles…

26:2J-4.14 HMO to provide benefits for reconstructive breast surgery. 6. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Ban…

26:2J-4.15 Coverage for minimum inpatient care following mastectomy by HMO. 8. a. Every enrollee agreement that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved f…

26:2J-4.16 Applicability of Health Care Quality Act 28. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on o…

26:2J-4.17 Coverage for treatment of inherited metabolic diseases by health maintenance organization. 8. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued o…