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

17:48D-9 Evidence of coverage. 9. a. An enrollee shall be entitled to receive evidence of coverage or a certificate indicating specifically the nature and extent of coverage, and evidence of the total amount or percentage of payment, if any, which the enrollee is obligated to pay…

17:48D-9.1. Alternative dental coverage; original coverage restricted to limited number of providers Each employer or other organization which employs or has 25 or more employees or members during the full preceding calendar year and which contributes to a dental plan organizatio…

17:48D-9.2. Employer contribution An employer or other organization shall be required to pay for or contribute towards the provision of alternative coverage an amount equal to the premium or cost which it pays or contributes to the dental plan organization contract which limits t…

17:48D-9.3. Rules and regulations Within 120 days of the effective date of this act, the Commissioner of the Department of Insurance shall promulgate rules and regulations necessary to effectuate the purpose of this act, including procedures for notice to covered persons, employe…

17:48D-9.4 Dental plan organization to receive, transmit transactions electronically. 9. a. Within 180 days of the adoption of a timetable for implementation pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a dental plan organization, or a subsidiary that processes health …

17:48D-9.5 Dental plan organization to offer coverage for domestic partner. 56. Every dental plan organization contract that is delivered, issued, executed or renewed in this State pursuant to P.L.1979, c.478 (C.17:48D-1 et seq.) or approved for issuance or renewal in this State …

17:48D-9.6 Payment of out-of-network benefits by dental plan organization. 2. a. (1) Except as provided in subsection e. of this section, a dental plan organization that makes a dental benefit payment to an enrollee for services rendered by an out-of-network dentist shall issue t…

17:48E-1 Definitions. 1. As used in this act: a. "Commissioner" means the Commissioner of Banking and Insurance. b. "Board" and "board of directors" means the board of directors of the health service corporation. c. "Elective surgical procedure" means any nonemergency surgical pr…

17:48E-10. Agreements with service providers a. A health service corporation may enter into agreements with providers of health care services whereby the providers become participating providers of health care services of that health service plan. Copies of agreements proposed to…

17:48E-10.1 Health service corporation to receive, transmit transactions electronically; standards. 4. a. Within 180 days of the adoption of a timetable for implementation pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health service corporation or its agent or a subsi…

17:48E-10.2 Payment of out-of-network dental benefits by health service corporation. 3. a. (1) Except as provided in subsection e. of this section, a health service corporation that makes a dental benefit payment to a covered person for services rendered by an out-of-network dent…

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 …