reglab/housing_qa huggingface dataset:
NJ Rev Stat § 17B:27A-7.26 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-7.26 - Individual health benefits plan to meet essential health benefits requirements.

17B:27A-7.26 Individual health benefits plan to meet essential health benefits requirements.  1. a. An individual health benefits plan subject to P.L.1992, c.161 (C.17B:27A-2 et seq.) shall provide coverage under every plan delivered, issued, executed or renewed in this State, on or after the effective date of this act, that meets the essential health benefits requirements provided by this section. b. Pursuant to section 3 of P.L.2019, c.354 (C.17B:27A-60), the commissioner shall define essential health benefits to include at least the following general categories and the items and services covered within the categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services, including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care. c. An individual health benefits plan shall provide for a level of coverage that is designed to provide benefits that are actuarially equivalent to: (1) 60 percent of the full actuarial value of the benefits provided under the plan; (2) 70 percent of the full actuarial value of the benefits provided under the plan; or (3) 80 percent of the full actuarial value of the benefits provided under the plan. d. The level of coverage of a plan shall be determined on the basis that the essential health benefits described in subsection b. of this section are provided to a standard population, and without regard to the actual population to which the plan may provide benefits. e. The commissioner shall develop guidelines to provide for a de minimis variation in the actuarial calculations used in determining the level of coverage of a plan to account for differences in actuarial estimates. L.2019, c.354, s.1.
NJ Rev Stat § 17B:27A-7.27 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-7.27 - Individual health benefits plan to cover preventive services.

17B:27A-7.27 Individual health benefits plan to cover preventive services.  6. a. An individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage, without requiring any cost sharing, for the following preventive services: (1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; (2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;  (3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and (4) with respect to women, any additional preventive care and screenings not described in paragraph (1) as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. b. (1) Except as provided in paragraph (2) of this subsection, nothing in this section shall: (a) require a plan which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or (b) preclude a plan which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider. (2) If a plan does not have in its network a provider who can provide an item or service described in subsection a. of this section, the plan shall cover the item or service when performed by an out-of-network provider, and shall not impose cost sharing with respect to that item or service. c. (1) A plan shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued. (2) (a) Except as provided in subparagraph (b) of this paragraph, a plan that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year.  (b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section. d. This section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium. L.2019, c.360, s.6.
NJ Rev Stat § 17B:27A-7.28 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-7.28 - Individual health benefits plan to provide coverage for certain prescription drugs.

17B:27A-7.28 Individual health benefits plan to provide coverage for certain prescription drugs.  6. a. Notwithstanding any other provision of law to the contrary, a carrier that offers an individual health benefits plan that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), shall ensure that: at least 25 percent of all plans, or at least one plan if the carrier offers less than four plans, offered by the carrier in each rating area and in each of the bronze, silver, gold, and platinum levels of coverage, in the individual market pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), shall conform with the following:  (1) (a) a health benefits plan that provides a silver, gold, or platinum level of coverage, as defined in 45 C.F.R. s.156.140, shall limit a covered person's cost-sharing, including any copayment or coinsurance, for prescription drugs, including specialty drugs, to no more than $150 per month for each prescription drug for up to a 30-day supply of any single drug; (b) a health benefits plan that provides a bronze level of coverage, as defined in 45 C.F.R. s.156.140, shall ensure that any required covered person's cost-sharing, including any copayment or coinsurance, does not exceed $250 per month for each prescription drug for up to a 30-day supply of any single drug;  (c) a health benefits plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall be exempt from the requirements of subparagraphs (a) and (b) of this paragraph; (2) except as provided in paragraph (3) of this subsection, the limits described in paragraph (1) of this subsection shall apply at any point in the benefit design, including before and after any applicable deductible is reached; and (3) for prescription drug benefits offered in conjunction with a high-deductible health plan, the plan shall not provide prescription drug benefits until the expenditures applicable to the deductible under the plan have met the amount of the minimum annual deductibles in effect for self-only and family coverage under section 223(c)(2)(A)(i) of the federal Internal Revenue Code (26 U.S.C. s.223(c)(2)(A)(i)) for self-only and family coverage, respectively. Once the foregoing expenditure amount has been met under the plan, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in paragraph (1) of this subsection. b. The provisions of this section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium. L.2019, c.471, s.6.
NJ Rev Stat § 17B:27A-7.29 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-7.29 - Individual health benefits plan to cover adolescent depression screenings.

17B:27A-7.29 Individual health benefits plan to cover adolescent depression screenings.  6. An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), on or after the effective date of this act, shall provide coverage for expenses incurred in screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service. The benefits shall be provided to the same extent as for any other condition under the health benefits plan, except that the carrier shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium. L.2021, c.73, s.6.
NJ Rev Stat § 17B:27A-8 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-8 - Offering of certain coverage not required

17B:27A-8. Offering of certain coverage not required  7. a. A health maintenance organization shall not be required to offer coverage to or accept an applicant pursuant to this act if: (1) the eligible individual does not live, reside, or work within the health maintenance organization's approved service area; and (2) the carrier has demonstrated to the commissioner that the carrier will not have the capacity to deliver services adequately to additional eligible persons because of its obligations to existing group contract holders and enrollees and individual enrollees and it applies this paragraph uniformly to individuals without regard to any health status-related factor of such individuals and without regard to whether the individuals are eligible persons. Upon denying individual health benefits coverage pursuant to this paragraph, a carrier may not offer such coverage in the individual market for a period of 180 days after the date the coverage is denied. If the health maintenance organization does not have the capacity in its facilities for additional individual enrollees, it also shall not offer coverage to or accept any new group enrollees. b. A carrier shall not be required to offer coverage or accept applications pursuant to this act if the commissioner determines that the carrier does not have the financial reserves necessary to underwrite additional coverage. Upon denying individual health benefits coverage pursuant to this subsection, a carrier may not offer such coverage in the individual market for a period of 180 days after the date the coverage is denied or until the carrier has demonstrated to the commissioner that the carrier has sufficient financial reserves to underwrite additional coverage, whichever is later. L.1992,c.161,s.7; amended 1997, c.146, s.5.
NJ Rev Stat § 17B:27A-10.1 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-10.1 - Short title.

17B:27A-10.1 Short title.  1. This act shall be known and may be cited as the "New Jersey Health Insurance Premium Security Act." L.2018, c.24, s.1.
NJ Rev Stat § 17B:27A-10.2 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-10.2 - Purpose of act.

17B:27A-10.2 Purpose of act.  2. It is the intent of the Legislature to stabilize or reduce premiums in the individual health insurance market by providing reinsurance payments to health insurance carriers with respect to claims for eligible individuals. The Commissioner of Banking and Insurance, and the board of directors of the New Jersey Individual Health Coverage Program, are authorized to apply for, accept and receive federal funds to implement and sustain market stabilization programs. Preliminary planning, analysis, and implementation to effectuate the purposes of this act shall continue under the direction of the commissioner and the board.  L.2018, c.24, s.2.
NJ Rev Stat § 17B:27A-10.3 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-10.3 - Definitions relative to health insurance premiums.

17B:27A-10.3 Definitions relative to health insurance premiums.  3. For the purposes of this act: "Affiliated carrier" means the same as defined in N.J.A.C.11:20-1.2. "Affordable Care Act" or "PPACA" means the federal Patient Protection and Affordable Care Act, Pub.L.111-148, as amended by the federal "Health Care and Education Reconciliation Act of 2010," Pub.L.111-152, and any federal rules and regulations adopted pursuant thereto. "Attachment point" means an amount as provided in subsection h. of section 4 of this act. "Benefit year" means the calendar year for which an eligible carrier provides coverage through an individual health benefits plan. "Board" means the board of directors of the New Jersey Individual Health Coverage Program established pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.). "Carrier" means any entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefits plan, including a sickness and accident insurance company, a health maintenance organization, a hospital, medical or health service corporation, or any other entity providing a health benefits plan. For purposes of this act, carriers that are affiliated carriers shall be treated as one carrier. "Paid claim" means a claim by a covered person for payment of benefits under a health benefits plan for which the financial obligation for the payment of the claim under the contract rests upon and has been paid by the carrier, excluding claims adjustment expenses. "Coinsurance rate" means the rate as provided in subsection i. of section 4 of this act.  "Commissioner" means the Commissioner of Banking and Insurance. "Department" means the Department of Banking and Insurance. "Eligible carrier" means a carrier that offers individual health benefits plans in the State. "Fund" means the New Jersey Health Insurance Premium Security Fund created pursuant to section 10 of this act. "Health benefits plan" means the same as that term is defined in section 1 of P.L.1992, c.161 (C.17B:27A-2). "Payment parameters" means the attachment point, reinsurance cap, and coinsurance rate for the plan. "Plan" means the Health Insurance Premium Security Plan established pursuant to section 4 of this act. "Reinsurance cap" means the threshold amount as provided in subsection j. of section 4 of this act. "Reinsurance payment" means an amount paid by the board to an eligible carrier under the plan. L.2018, c.24, s.3.
NJ Rev Stat § 17B:27A-10.4 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-10.4 - Health Insurance Premium Security Plan.

17B:27A-10.4 Health Insurance Premium Security Plan.  4. a. There is hereby established, and the board in consultation with the commissioner shall administer, the Health Insurance Premium Security Plan. b. The board or commissioner may apply for any available federal funding for the plan. All funds received pursuant to an application for federal funding, assessed by the board pursuant to this act, or otherwise dedicated to the fund shall be remitted to the State Treasurer and deposited in the fund. c. The commissioner, in consultation with the board, shall collect data from carriers necessary to determine the reinsurance payment parameters and shall share this data with the board.  d. For each applicable benefit year, the board shall notify carriers, the commissioner, and the State Treasurer of the reinsurance payments to be made for the applicable benefit year no later than June 30 of the year following the applicable benefit year. e. On a quarterly basis during the applicable benefit year, the board shall provide each eligible carrier and the commissioner with the calculation of total reinsurance payment requests. f. By November 1 of the year following the applicable benefit year, the State Treasurer shall disburse all applicable reinsurance payments to an eligible carrier. g. The board, subject to the disapproval of the commissioner pursuant to section 5 of this act, shall design and adjust the payment parameters to ensure the payment parameters: (1) will stabilize or reduce premium rates in the individual market by achieving between a 10% and 20% reduction in what indicated premium rates would be for the applicable benefit year without the plan; (2) will encourage increased participation in the individual market; (3) mitigate the impact high-risk individuals have on premium rates in the individual market; (4) take into account any federal funding available for the plan; (5) take into account the total amount available to fund the plan; and (6) encourage cost savings mechanisms related to the management of health care services. h. The attachment point for the plan is the threshold amount for paid claims by an eligible carrier for an enrolled individual's covered benefits in a benefit year, beyond which the paid claims are eligible for reinsurance payments. The attachment point shall be set by the board, but shall not exceed the reinsurance cap. i. The coinsurance rate for the plan is the rate at which the board will reimburse an eligible carrier for paid claims for an enrolled individual's covered benefits in a benefit year above the attachment point and below the reinsurance cap. The coinsurance rate shall be set by the board. j. The reinsurance cap is the amount for paid claims of an eligible carrier for an enrolled individual's covered benefits, above which the paid claims for benefits are no longer eligible for reinsurance payments. The reinsurance cap shall be set by the board. L.2018, c.24, s.4.
NJ Rev Stat § 17B:27A-10.5 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-10.5 - Payment parameters.

17B:27A-10.5 Payment parameters.  5. The board shall propose to the commissioner the payment parameters for the next benefit year by April 30 of the year before the applicable benefit year. The commissioner shall have 15 days to review the payment parameters. If the commissioner takes no affirmative action to disapprove the payment parameters within that time the proposed payment parameters are final and effective. L.2018, c.24, s.5.
NJ Rev Stat § 17B:27A-10.6 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-10.6 - Calculation of reinsurance payment.

17B:27A-10.6 Calculation of reinsurance payment.  6. a. Each reinsurance payment shall be calculated with respect to an eligible carrier's paid claims for an individual enrollee's covered benefits in the applicable benefit year. If the paid claims do not exceed the attachment point, a reinsurance payment shall not be made. If the paid claims exceed the attachment point, the reinsurance payment shall be calculated as the product of the coinsurance rate and the lesser of: (1) the paid claims minus the attachment point; or (2) the reinsurance cap minus the attachment point. b. The board shall ensure that reinsurance payments made to eligible carriers do not exceed the total amount paid by the eligible carrier for any eligible claim. "Total amount paid" means the amount paid by the eligible carrier based upon the allowed amount less any deductible, coinsurance, or co-payment, as of the time the data are submitted or made accessible under section 7 of this act. L.2018, c.24, s.6.
NJ Rev Stat § 17B:27A-10.7 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-10.7 - Requests for reinsurance payments.

17B:27A-10.7 Requests for reinsurance payments.  7. a. An eligible carrier shall submit a request to the board for reinsurance payments when the eligible carrier's total amount paid for an enrollee meets the criteria for reinsurance payments. b. An eligible carrier shall make requests for reinsurance payments in accordance with any requirements established by the board. c. An eligible carrier shall calculate the premium amount the carrier would have charged for the applicable benefit year if the plan was not in effect and submit this information as part of its rate filing. d. An eligible carrier shall maintain documents and records, whether paper, electronic, or in other media, sufficient to substantiate the requests for reinsurance payments made pursuant to this section for a period of at least six years. An eligible carrier shall also make those documents and records available upon request from the commissioner for purposes of verification, investigation, audit, or other review of reinsurance payment requests. e. (1) At least once every five years the board shall engage an independent audit firm to audit eligible carriers that receive reinsurance payments to assess compliance with the requirements of this act. The eligible carrier shall cooperate with an audit. If an audit results in a proposed finding of material weakness or significant deficiency with respect to compliance with any requirement of this act or overpayment of reinsurance payments in the audited benefit years, the eligible carrier may respond to the draft audit report within 30 days of the draft audit report's issuance. (2) Within 30 days of the issuance of the final audit report, if the final audit results in a finding of material weakness or significant deficiency with respect to compliance with any requirement of this act or overpayment of reinsurance payments in the audited benefit years, the eligible carrier shall: (a) provide a written corrective action plan to the board for approval, that includes recoupment of any reinsurance overpayments; (b) upon board approval, implement the corrective action plan described; and (c) provide the board with documentation of the corrective actions taken. L.2018, c.24, s.7.
NJ Rev Stat § 17B:27A-10.8 (2021)
2021 New Jersey Revised Statutes|Title 17B - Insurance|Section 17B:27A-10.8 - Accounting for each benefit year.

17B:27A-10.8 Accounting for each benefit year.  8. The board shall keep an accounting for each benefit year, including but not limited to, the following: a. funds appropriated for reinsurance payments and administrative and operational expenses; b. requests for reinsurance payments received from eligible carriers; c. reinsurance payments made to eligible carriers; and d. administrative and operational expenses incurred for the plan. L.2018, c.24, s.8.