reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-20 - Maintenance of insurance to cover insolvency.

17:48F-20 Maintenance of insurance to cover insolvency.
20. The commissioner may require, in connection with the plan for insolvency required pursuant to subsection p. of section 3 of this act, that a prepaid prescription service organization maintain insurance to cover the expenses to be paid for continued benefits following a determination of insolvency, or make other arrangements to ensure that benefits are continued for the period determined in the insolvency plan.
L.1997,c.380,s.20.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-21 - Rehabilitation, liquidation, conservation of prepaid prescription service organization.

17:48F-21 Rehabilitation, liquidation, conservation of prepaid prescription service organization.
21. Any rehabilitation, liquidation or conservation of a prepaid prescription service organization shall be subject to the provisions of N.J.S.17B:32-1 et seq. and shall be conducted under the supervision of the commissioner; except that the commissioner shall have the authority to regulate any prepaid prescription service organization doing business in this State as a domestic insurer. The commissioner may apply for an order directing him to rehabilitate, liquidate, reorganize or conserve an organization upon any one or more applicable grounds as stated for insurers in N.J.S.17B:32-1 et seq. or any other provision of Title 17B of the New Jersey Statutes or when in his opinion the organization fails to satisfy the requirements for the issuance of a certificate of authority relating to solvency or the requirements for solvency protection as set forth in this act.
L.1997,c.380,s.21.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-22 - Order of rehabilitation.

17:48F-22 Order of rehabilitation.
22. If an order of rehabilitation issued pursuant to this act directs or provides for the continued operation of the prepaid prescription service organization, including the receipt of payments from, and the provision of prescription services to enrollees, the order may authorize the rehabilitator to make the payments necessary for continued operation, including those expenses necessary for the conduct of the rehabilitation.
L.1997,c.380,s.22.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-23 - Providers enjoined from billing enrollees, beneficiaries under order of rehabilitation.

17:48F-23 Providers enjoined from billing enrollees, beneficiaries under order of rehabilitation.
23. In the event that an order of rehabilitation or liquidation is granted, the order may enjoin providers from billing enrollees and their beneficiaries for health care services provided. In the course of a rehabilitation proceeding, the court may allow reformation of enrollee and provider contracts, or other restructuring of outstanding liabilities, or transfer of the business to another prepaid prescription service organization. A primary goal of the restructuring or transfer shall be the provision of uninterrupted services to enrollees of the organization. In the course of a rehabilitation proceeding, a plan for settling the claims of general creditors shall not be deemed to be inequitable or to constitute preferential treatment if the amount of reimbursement for an outstanding claim depends, in part, on the estimated increase or decrease in future or prior claims of the creditor.
L.1997,c.380,s.23.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-24 - Inapplicability of C.17B:32A-1 et seq.

17:48F-24 Inapplicability of C.17B:32A-1 et seq.
24. A prepaid prescription service organization shall not be subject to the "New Jersey Life and Health Insurance Guaranty Association Act," P.L.1991, c.208 (C.17B:32A-1 et seq.), and the New Jersey Life and Health Insurance Guaranty Association established pursuant to that act shall not provide protection to any individuals entitled to receive prescription services from a prepaid prescription service organization.
L.1997,c.380,s.24.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-25 - Application, examination fees.

17:48F-25 Application, examination fees.
25. A prepaid prescription service organization subject to the provisions of this act shall pay to the commissioner such application fees and examination fees for applying for a certificate of authority as established by regulation by the commissioner.
L.1997,c.380,s.25.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-26 - Violations; penalties.

17:48F-26 Violations; penalties.
26. a. The commissioner may, upon notice and hearing, levy an administrative penalty in an amount not less than $1,000 nor more than $30,000 for each violation, per contract or enrollee. Penalties imposed by the commissioner pursuant to this section may be in lieu of, or in addition to, suspension or revocation of a certificate of authority pursuant to this act. A penalty may be recovered in a summary proceeding pursuant to "the penalty enforcement law," N.J.S.2A:58-1 et seq.
b. If the commissioner believes that any violation of this act has occurred or is threatened, the commissioner may give notice to the prepaid prescription service organization, its representatives, or any other persons who appear to be involved in the alleged violation. The commissioner may arrange a conference with the alleged violators or their authorized representatives to ascertain the facts relating to the alleged violation. In the event that it appears that a violation has occurred or is threatened, the commissioner may implement the necessary measures to correct or prevent the violation. Appeals under this section shall be conducted pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).
L.1997,c.380,s.26.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-27 - Cease and desist order; injunctive relief.

17:48F-27 Cease and desist order; injunctive relief.
27. a. The commissioner may issue an order directing a prepaid prescription service organization to cease and desist from engaging in any act or practice which is in violation of the provisions of this act. The order shall be subject to review pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).
b. In the event of noncompliance with a cease and desist order issued pursuant to subsection a. of this section, or if the commissioner elects not to issue a cease and desist order in the case of a violation of any provision of this act, the commissioner may institute a proceeding to obtain injunctive relief, in accordance with the applicable procedures provided in the Rules of Court.
L.1997,c.380,s.27.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-28 - Confidentiality of data, information.

17:48F-28 Confidentiality of data, information.
28. Any data or information relating to the diagnosis, treatment or health of an enrollee or prospective enrollee obtained by a prepaid prescription service organization from the contract holder, enrollee, prospective enrollee or any provider shall be confidential and shall not be disclosed to any person except:
a. To the extent that it may be necessary to carry out the purposes of this act;
b. Upon the express consent of the enrollee or prospective enrollee;
c. Pursuant to statute or court order for the production of evidence or the discovery thereof; or
d. In the event of a claim or litigation between an enrollee or a prospective enrollee and the organization wherein such data or information is relevant. An organization shall be entitled to claim any statutory privilege against disclosure which the provider who furnished the information to the organization is entitled to claim.
L.1997,c.380,s.28.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48F-29 - Rules, regulations.

17:48F-29 Rules, regulations.
29. The commissioner shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), to effectuate the purposes of this act.
L.1997,c.380,s.29.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48G-1 - Definitions relative to dental decision regulation.

17:48G-1 Definitions relative to dental decision regulation.
1. As used in this act:
"Adverse dental decision" means a dental decision by an insurer or a third party administrator, or any other person acting on its behalf to deny, reduce, or fail to provide payment, in whole or in part, for a covered service based upon a dental decision.
"Board" means the New Jersey State Board of Dentistry.
"Dental decision" means a decision which is based upon a dental diagnosis or a dental judgment related to dental services performed or to be performed in the State of New Jersey, including, but not limited to, any decision relating to: the quality or appropriateness of dental services rendered or proposed to be rendered by a dentist; reasonable necessity for or customary performance of a dental service; or diagnosis or prognosis of a dental condition.
"Insurer" means an insurance company, health service corporation, hospital service corporation, medical service corporation, dental service corporation, dental plan organization or health maintenance organization authorized to issue dental contracts or plans in this State.
"Third party administrator" means "third party administrator" as defined by section 1 of P.L.2001, c.267 (C.17B:27B-1).
L.2007, c.259, s.1.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48G-2 - Dental decisions made by insurer.

17:48G-2 Dental decisions made by insurer.
2. a. An insurer may make dental decisions in connection with the processing or payment of dental claims or otherwise in the course of its dental benefit administration activity. Dental decisions made by an insurer shall be consistent with the following:
(1) an initial adverse dental decision shall be made by a dentist duly licensed in this or another state;
(2) if a treating dentist questions the adverse dental decision and specifies in writing the basis of the disagreement with the adverse dental decision, the insurer, within 30 days shall:
(a) designate a reviewing dentist who is duly licensed in this State or who has been issued a limited registration certificate pursuant to section 4 of this act; and
(b) notify the treating dentist in writing promptly of the name and address where the reviewing dentist can be contacted and the telephone number which can be used to contact the reviewing dentist;
(3) if an agreement is not reached within a reasonable period of time, not to exceed 30 days from the insurer's notice issued pursuant to subparagraph (b) of paragraph (2) of this subsection, the insurer shall make its decision and communicate the results of the reviewing dentist's dental decision to the treating dentist.
b. Within 14 days of a written request by the treating dentist, or the patient or the patient's authorized representative, for the basis of an adverse dental decision by a reviewing dentist, provided to the treating dentist pursuant to paragraph (3) of subsection a. of this section, the insurer shall send a written notice containing the full name, address and telephone number of the reviewing dentist and a narrative statement specifically identifying the basis for the decision.
L.2007, c.259, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48G-3 - Dental decisions made by third party administrator.

17:48G-3 Dental decisions made by third party administrator.
3. a. A third party administrator may make dental decisions in connection with the processing or payment of dental claims or otherwise in the course of its dental benefit administration activity. Dental decisions made by a third party administrator shall be consistent with all of the following:
(1) an initial adverse dental decision shall be made by a dentist duly licensed in this or another state;
(2) if a treating dentist questions the adverse dental decision and specifies in writing the basis of the disagreement with the adverse dental decision, the third party administrator within 30 days shall:
(a) designate a reviewing dentist who is duly licensed in this State or who has been issued a limited registration certificate pursuant to section 4 of this act; and
(b) notify the treating dentist in writing promptly of the name and business address where the reviewing dentist can be contacted and telephone number which can be used to contact the reviewing dentist;
(3) if an agreement is not reached within a reasonable period of time, not to exceed 30 days from the third party administrator's notice issued pursuant to subparagraph (b) of paragraph (2) of this subsection, the third party administrator shall make its decision and communicate the results of the reviewing dentist's dental decision to the treating dentist.
b. Within 14 days of a written request by the treating dentist, or the patient or the patient's authorized representative, for the basis of an adverse dental decision by a reviewing dentist, provided to the treating dentist pursuant to paragraph (3) of subsection a. of this section, the third party administrator shall send a written notice containing the full name, address and telephone number of the reviewing dentist and a narrative statement specifically identifying the basis for the decision.
L.2007, c.259, s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48G-4 - Inapplicability of act relative to certain decisions of insurers, third party administrators.

17:48G-4 Inapplicability of act relative to certain decisions of insurers, third party administrators.
7. This act shall not be construed:
a. To regulate insurers' or third party administrators' making any decision, including, but not limited to, a decision concerning benefit or insurance coverage, that does not involve the making of a dental decision;
b. To regulate insurers' or third party administrators' use of a protocol for denying or limiting benefit payments for dental services where the protocol:
(1) has been approved for use by a dentist who is duly licensed in this State or who has been issued a limited registration certificate pursuant to section 4 of this act; and
(2) does not involve evaluation of an individual patient's dental care or condition; or
c. To regulate the application of contract limitations and exclusions, the credentialing of dentists or the conduct of retrospective fraud reviews.
L.2007, c.259, s.7.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48G-5 - Applicability of act to dental decisions.

17:48G-5 Applicability of act to dental decisions.
8. This act shall be construed to apply only to insurers and third party administrators or persons acting on their behalf who make dental decisions.
L.2007, c.259, s.8.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48G-6 - Construction of act relative to board.

17:48G-6 Construction of act relative to board.
9. Nothing in this act shall be construed to confer jurisdiction upon the board to make any dental benefit coverage determinations or to direct any insurer, benefit plan, administrator or other payor to make any payment or otherwise to regulate the conduct of an insurer or third party administrator.
L.2007, c.259, s.9.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-2 - Certification, licensure, required

17:48H-2. Certification, licensure, required
2. a. Beginning one year after the enactment of this act, no person, corporation, partnership, or other entity shall operate an organized delivery system in this State without obtaining certification or licensure pursuant to this act.
b. Any person, corporation, partnership, or other entity offering health care services to a carrier in a manner substantially provided for in this act shall be subject to the provisions of this act unless the entity is otherwise regulated under P.L.1973, c. 337 (C.26:2J-1 et seq.), Title 17 of the Revised Statutes, Title 17B of the New Jersey Statutes or P.L.1970, c.102 (C.18A:64G-1 et seq.).
L.1999,c.409,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-3 - Application for certification.

17:48H-3 Application for certification.
3. a. An organized delivery system which is not subject to licensure requirements pursuant to this act shall submit an application for certification to the Commissioner of Banking and Insurance. The organized delivery system may continue to operate during the pendency of its application, but in no case longer than 12 months after the date of submission of the application to the Department of Banking and Insurance, unless the commissioner, by regulation, extends the 12-month limitation. In the event the application is denied, the applicant shall be treated as an organized delivery system whose certification has been revoked pursuant to sections 7 and 8 of this act.
Notwithstanding the obligations imposed by this act regarding certification requirements, nothing in this subsection shall operate to impair any contract in force on the effective date of this act, but this act shall apply to any contract renewed on or after the effective date of this act.
b. The certification shall be valid for a period of three years.
c. A certified organized delivery system shall not directly issue health benefits plans.
L.1999, c.409, s.3; amended 2012, c.17, s.39.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-5 - Review of application.

17:48H-5 Review of application.
5. Following receipt of an application for certification, the Commissioner of Banking and Insurance shall review it and notify the applicant of any deficiencies contained therein.
a. The Commissioner of Banking and Insurance shall issue a certification to an organized delivery system if the commissioner finds that the system meets the standards provided for in this act, including, but not limited to:
(1) All of the material required by section 4 of this act has been filed;
(2) The persons responsible for conducting the applicant's affairs are competent, trustworthy, and possess good reputations, and have had appropriate experience, training, and education;
(3) The persons who are to perform the health care services are properly qualified;
(4) The organized delivery system has demonstrated the ability to assure that health care services will be provided in a manner which will assure the availability and accessibility of the services;
(5) The standard forms of provider agreements to be used by the organized delivery system are acceptable; and
(6) The organized delivery system's contracts to provide services do not entail or will not result in the assumption of financial risk by the system.
b. The commissioner may deny an application for certification if the applicant fails to meet any of the standards provided in this act or on any other reasonable grounds. If certification is denied, the commissioner shall notify the applicant and shall set forth the reasons for the denial in writing. The applicant may request a hearing by notice to the commissioner within 30 days of receiving the notice of denial. Upon such denial, the applicant shall submit to the commissioner a plan for bringing the organized delivery system into compliance or providing for the closing down of its business.
L.1999, c.409, s.5; amended 2012, c.17, s.41.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-6 - Notice of change, modification.

17:48H-6 Notice of change, modification.
6. a. A certified organized delivery system, unless otherwise provided for in this act, shall not materially modify any matter or document furnished to the Commissioner of Banking and Insurance pursuant to section 4 of this act unless the organized delivery system files with the commissioner, at least 60 days prior to use or adoption of the change, a notice of the change or modification, together with that information required by the commissioner to explain the change or modification. If the commissioner fails to affirmatively approve or disapprove the change or modification within 60 days of submission of the notice, the notice of modification shall be deemed approved. The commissioner may extend the 60-day review period for not more than 30 additional days by giving written notice of the extension before the expiration of the 60-day period. If a change or modification is disapproved, the commissioner shall notify the system in writing and specify the reason for the disapproval.
b. Prior to entering into any contract with a carrier, a certified organized delivery system shall file with the commissioner, for the commissioner's approval, a copy of that contract. The filing shall be made no later than 60 days prior to the date that the contract is intended to be in effect. If the contract is not disapproved prior to the effective date by the commissioner, the contract shall be deemed approved.
L.1999, c.409, s.6; amended 2012, c.17, s.42.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-7 - Suspension, revocation of certification, grounds.

17:48H-7 Suspension, revocation of certification, grounds.
7. The Commissioner of Banking and Insurance may suspend or revoke a certification issued to an organized delivery system pursuant to this act upon the commissioner's determination that:
a. The certified organized delivery system is operating in contravention of its basic organizational documents;
b. The certified organized delivery system is unable to fulfill its obligations to the carriers with whom it contracts;
c. The continued operation of the certified organized delivery system would be hazardous to the health and welfare of the enrollees or contract holders to whom it is obligated to provide health care services or detrimental to a carrier with whom it has contracted to provide the services;
d. The certified organized delivery system is unable to maintain the standards as set forth by the commissioner by regulation;
e. The certified organized delivery system has failed, as provided by the contract, to comply with the provisions of P.L.1997, c.192 (C.26:2S-1 et seq.);
f. The certified organized delivery system has failed to provide the health care services for which it has been certified or has provided health care services which are in contravention of the contract or contracts filed with the commissioner;
g. The certified organized delivery system has otherwise failed to comply with this act or with other applicable law; or
h. There are other reasonable grounds that warrant suspension or revocation.
L.1999, c.409, s.7; amended 2012, c.17, s.43.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-8 - Notification of grounds for suspension, revocation of certification.

17:48H-8 Notification of grounds for suspension, revocation of certification.
8. a. If the Commissioner of Banking and Insurance has cause to believe that grounds exist for the suspension or revocation of the certification issued to an organized delivery system, the commissioner shall notify the system, in writing, specifically stating the grounds for suspension or revocation and fixing a time for a hearing in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). If the certification is revoked, the organized delivery system shall submit a plan to the commissioner within 15 days of the revocation, for the winding up of its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of its business. The commissioner may, by written order, permit such further operation of the organized delivery system as the commissioner finds to be in the best interest of individuals receiving health care services from the system.
b. The commissioner shall notify all carriers with contracts with the system that are on file with the Department of Banking and Insurance of the proceedings.
L.1999, c.409, s.8; amended 2012, c.17, s.44.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-9 - Fees.

17:48H-9 Fees.
9. A certified organized delivery system shall pay to the Commissioner of Banking and Insurance those application and examination fees as are established by the commissioner by regulation.
L.1999, c.409, s.9; amended 2012, c.17, s.45.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-10 - Civil administrative penalty.

17:48H-10 Civil administrative penalty.
10. The Commissioner of Banking and Insurance may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $250 nor more than $10,000 for each day that a certified organized delivery system is in violation of this act. Penalties imposed by the commissioner pursuant to this section may be in lieu of, or in addition to, suspension or revocation of a certification pursuant to this act. A penalty may be recovered in a summary proceeding pursuant to "The Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.).
L.1999, c.409, s.10; amended 2012, c.17, s.46.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-11 - Application for licensure.

17:48H-11 Application for licensure.
11. a. An organized delivery system which receives compensation on a basis that entails the assumption of financial risk shall submit an application for licensure to the Commissioner of Banking and Insurance. The organized delivery system may continue to operate during the pendency of its application, but in no case longer than 12 months after the date of submission of the application to the Department of Banking and Insurance, unless the commissioner, by regulation, extends the 12-month limitation. In the event the application is denied, the applicant shall be treated as an organized delivery system whose license has been revoked pursuant to sections 23 and 24 of this act.
Notwithstanding the obligations imposed by this act regarding licensure requirements, nothing in this subsection shall operate to impair any contract in force on the effective date of this act, but this act shall apply to any contract renewed on or after the effective date of this act.
b. An organized delivery system which receives compensation on a basis that entails the assumption of financial risk, but meets the criteria set forth in this subsection, may apply to the commissioner for an exemption from the licensure requirements of this act based on the system's current contractual arrangements.
The commissioner may grant the exemption for such period of time that the commissioner determines that the financial risk of the organized delivery system is de minimis because the organized delivery system's exposure to financial loss is limited in amount or likelihood to the degree that it reasonably will not prevent the system from satisfying the liabilities imposed under the terms of its contracts.
The commissioner may revoke the organized delivery system's exemption from licensure, after notice and an opportunity to be heard, if the commissioner determines that the system's contracts no longer meet the requirements for exemption set forth in this subsection. Upon revocation of the exemption, the system shall be required to obtain licensure from the department within 90 days.
c. An organized delivery system that is granted an exemption from licensure shall apply to and obtain certification as an organized delivery system from the Department of Banking and Insurance pursuant to the provisions of this act.
d. A licensed organized delivery system shall not directly issue health benefits plans.
L.1999, c.409, s.11; amended 2012, c.17, s.47.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-13 - Review of application.

17:48H-13 Review of application.
13. Following receipt of an application for licensure, the Commissioner of Banking and Insurance shall review it and notify the applicant of any deficiencies contained therein.
a. The Commissioner of Banking and Insurance shall issue a license to an organized delivery system if the commissioner finds that the system meets the standards provided for in this act, including, but not limited to:
(1) All of the material required by section 12 of this act has been filed;
(2) The persons responsible for conducting the applicant's affairs are competent, trustworthy, and possess good reputations, and have had appropriate experience, training, and education;
(3) The persons who are to perform the health care services are properly qualified;
(4) The organized delivery system has demonstrated the ability to assure that health care services will be provided in a manner which will assure the availability and accessibility of the services;
(5) The standard forms of provider agreements to be used by the organized delivery system are acceptable;
(6) The applicant is financially sound and may reasonably be expected to meet its obligations to enrollees, contract holders and carriers. In making this determination, the commissioner shall consider:
(a) The financial soundness of the applicant's compensation arrangements for the provision of health care services;
(b) The adequacy of working capital, other sources of funding and provisions for contingencies; and
(c) Whether any deposit of cash or securities, or any other evidence of financial protection submitted, meets the requirements set forth in this act or by the commissioner by regulation;
(7) Any deficiencies identified by the commissioner have been corrected; and
(8) Any other factors determined by the commissioner to be relevant have been addressed to the satisfaction of the commissioner.
b. (Deleted by amendment, P.L.2012, c.17).
c. The Commissioner of Banking and Insurance, may deny an application for a license if the applicant fails to meet any of the standards provided in this act or on any other reasonable grounds. If the license is denied, the Commissioner of Banking and Insurance shall notify the applicant and shall set forth the reasons for the denial in writing. The applicant may request a hearing by notice to the commissioner within 30 days of receiving the notice of denial. Upon such denial, the applicant shall submit to the commissioner a plan for bringing the organized delivery system into compliance or providing for the closing down of its business.
L.1999, c.409, s.13; amended 2012, c.17, s.49.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-14 - Notice of change, modification

17:48H-14. Notice of change, modification
14. a. A licensed organized delivery system, unless otherwise provided in this act, shall not materially modify any matter or document furnished pursuant to section 12 of this act, unless the system files with the Commissioner of Banking and Insurance, at least 60 days prior to use or adoption of the change, a notice of the change or modification, together with that information required by the commissioner to explain the change or modification. If the commissioner fails to affirmatively approve or disapprove the change or modification within 60 days of submission of the notice, the notice of modification shall be deemed approved. The commissioner may extend the 60-day review period for not more than 30 additional days by giving written notice of the extension before the expiration of the 60-day period. If a change or modification is disapproved, the commissioner shall notify the system in writing and specify the reason for the disapproval.
b. Prior to entering into any contract with a carrier, a licensed organized delivery system shall file with the commissioner, for the commissioner's approval, a copy of the contract. The filing shall be made no later than 60 days prior to the date that the contract is intended to be in effect. The commissioner shall either approve the contract or state in writing the commissioner's reasons for disapproval within 60 days of receipt of the filing.
L.1999,c.409,s.14.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-15 - Services provided by licensed organized delivery system.

17:48H-15 Services provided by licensed organized delivery system.
15. A licensed organized delivery system may:
a. Contract with an insurer licensed in this State for the provision of indemnity coverage against the cost of services provided by the system or other obligations of the system, either on an individual or aggregate attachment basis; and
b. In addition to comprehensive or limited services, as applicable, provided by the system for enrollees or contract holders, provide:
(1) Additional services as approved by the Commissioner of Banking and Insurance;
(2) Indemnity benefits covering urgent care or emergency services;
(3) Coverage for services from providers, other than participating providers, in accordance with the terms of the contract; and
(4) Any other function provided by law, in the system's organizational documents or in the license.
L.1999, c.409, s.15; amended 2012, c.17, s.50.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-16 - Treatment of organized delivery system as domestic insurer

17:48H-16. Treatment of organized delivery system as domestic insurer
16. a. A licensed organized delivery system which is organized under the laws of this State shall be treated as a domestic insurer for the purposes of P.L.1970, c.22 (C.17:27A-1 et seq.) and P.L.1992, c.65 (C.17B:32-31 et seq.).
b. A licensed organized delivery system shall be subject to the provisions of chapter 30 of Title 17B of the New Jersey Statutes.
c. The capital, surplus and other funds of a licensed organized delivery system shall be invested in accordance with the provisions of chapter 20 of Title 17B of the New Jersey Statutes and guidelines established by the Commissioner of Banking and Insurance by regulation.
L.1999,c.409,s.16.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-17 - Examination of licensed organized delivery system

17:48H-17. Examination of licensed organized delivery system
17. The Commissioner of Banking and Insurance may conduct an examination of a licensed organized delivery system as often as the commissioner deems necessary in order to protect the interests of providers, contract holders, enrollees, and the residents of this State. A licensed organized delivery system shall make its relevant books and records available for examination by the commissioner, and retain its records in accordance with a schedule established by the commissioner by regulation. The reasonable expenses of the examination shall be borne by the licensed organized delivery system being examined. In lieu of such examination, the commissioner may accept the report of an examination made by the commissioner of another state.
L.1999,c.409,s.17.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-18 - Contracts with providers, mandatory terms

17:48H-18. Contracts with providers, mandatory terms
18. All licensed organized delivery system contracts with providers shall contain the following terms and conditions:
a. In the event that the organized delivery system fails to pay or provide for comprehensive or limited health care services for any reason whatsoever, including, but not limited to, insolvency or breach of contract, neither the contract holder nor the covered person shall be liable to the provider for any sums owed to the provider under the contract.
b. No provider, or agent, trustee or assignee thereof may maintain an action at law or attempt to collect from the contract holder or covered person sums owed to the provider by the licensed organized delivery system, except that this subsection shall not be construed to prohibit collection of uncovered charges consented to or lawfully owed to providers by a contract holder or covered person.
L.1999,c.409,s.18.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-19 - Minimum net worth

17:48H-19. Minimum net worth
19. a. A licensed organized delivery system shall, at all times, have and maintain a minimum net worth, determined on a statutory accounting basis, in an amount established by the Commissioner of Banking and Insurance by regulation, which amount may vary in accordance with the size of the system, the services provided by the system, and the financial liabilities of the system.
b. With respect to any amounts that may be required by the commissioner pursuant to subsection a. of this section, the commissioner shall take into account any limitation on the organized delivery system's exposure to financial loss that results from a contract with a carrier that provides that any liabilities of the system may be satisfied by means of reductions or offsets against monies due to the system from the carrier, which reductions or offsets will not adversely affect the system's ability to meet its contractual obligations.
L.1999,c.409,s.19.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-20 - Deposit of cash, securities

17:48H-20. Deposit of cash, securities
20. a. A licensed organized delivery system shall deposit with the Commissioner of Banking and Insurance, or with an entity or trustee acceptable to the commissioner through which a custodial or controlled account is utilized, cash, securities, or any combination of these or other measures that is acceptable to the commissioner in an amount established by the commissioner, by regulation, which amount shall be adjusted annually by the commissioner in accordance with changes in the Consumer Price Index. The deposit shall be deemed an admitted asset of the system in the determination of net worth.
b. All income from deposits shall be an asset of the licensed organized delivery system. A licensed organized delivery system may withdraw a deposit or any part thereof after making a substitute deposit of equal amount and value, except that a security may not be substituted unless it has been approved by the commissioner.
c. If a licensed organized delivery system is placed in rehabilitation or liquidation, the deposit shall be treated as an asset subject to the provisions of P.L.1992, c.65 (C.17B:32-31 et seq.).
L.1999,c.409,s.20.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-21 - Maintenance of fidelity bond

17:48H-21 Maintenance of fidelity bond
21. A licensed organized delivery system shall maintain in force a fidelity bond in its own name on its officers and employees, in an amount established by the Commissioner of Banking and Insurance by regulation.
L.1999,c.409,s.21.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-22 - Annual report

17:48H-22. Annual report
22. A licensed organized delivery system shall file an annual report with the Commissioner of Banking and Insurance, on or before March 1 of each year, attested to by at least two principal officers, which covers the preceding calendar year. The report shall be on a form prescribed by the commissioner and shall include:
a. A financial statement of the licensed organized delivery system, including its balance sheet, income statement and statement of changes in financial position for the preceding year, certified by an independent public accountant, or a consolidated audited financial statement of its parent company certified by an independent certified public accountant, attached to which shall be consolidating financial statements of the system;
b. At the discretion of the commissioner, a statement by a qualified actuary setting forth the actuary's opinion as to the adequacy of reserves; and
c. Any other information relating to the performance of the licensed organized delivery system as may be required by the commissioner.
The commissioner may assess a civil administrative penalty of up to $100 per day for each day a required report is late. The commissioner may require the submission of additional reports from time to time, as the commissioner deems necessary. A penalty may be recovered in a summary proceeding pursuant to "The Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.).
L.1999,c.409,s.22.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-22.1 - Definitions.

17:48H-22.1 Definitions.
41. As used in sections 41 through 45 of P.L.2014, c.81 (C.17:48H-22.1 through C.17:48H-22.5):
"Commissioner" means the Commissioner of Banking and Insurance.
"Licensed organized delivery system" means an entity authorized to transact business in this State as a licensed organized delivery system pursuant to P.L.1999, c.409 (C.17:48H-1 et seq.).
L.2014, c.81, s.41.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-22.3 - Determination of increase, revision or redetermination; factors.

17:48H-22.3 Determination of increase, revision or redetermination; factors.
43. In determining any increase, revision or redetermination in the capital or surplus of a licensed organized delivery system pursuant to the provisions of section 42 of P.L.2014, c.81 (C.17:48H-22.2) the commissioner shall take into account the following factors:
a. Methods and techniques used to measure risk exposure and variability;
b. The information available relating to the magnitude of the various risks described in section 42 of P.L.2014, c.81 (C.17:48H-22.2);
c. The extent to which risks described in section 42 of P.L.2014, c.81 (C.17:48H-22.2) are independent or interrelated, and whether any dependency is direct or inverse;
d. The extent to which the licensed organized delivery system has provided protection against contingencies in ways other than the establishment of surplus, including, but not limited to: redundancy of premiums; margin in reserves and liabilities; adjustability of contracts pursuant to the terms of the contracts; voluntary or mandatory investment valuation reserves; reinsurance; the use of conservative actuarial assumptions to provide a margin of security; reserve adjustments after rate increases for policies written at earlier and less adequate rates; contingency or catastrophe reserves; and diversification of assets and underwriting risk; and
e. Any other relevant factors, including the National Association of Insurance Commissioners' reports and independent judgments of the soundness of the licensed organized delivery system's financial condition, as evidenced by the rating and reports of reliable professional financial services.
L.2014, c.81, s.43.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-22.4 - Suspension, revocation of authority to do business.

17:48H-22.4 Suspension, revocation of authority to do business.
44. The commissioner may suspend or revoke the authority to do business in this State of any licensed organized delivery system that does not comply with the provisions of sections 41 through 45 of P.L.2014, c.81 (C.17:48H-22.1 through C.17:48H-22.5).
L.2014, c.81, s.44.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-22.5 - Rules, regulations.

17:48H-22.5 Rules, regulations.
45. 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 sections 41 through 45 of P.L.2014, c.81 (C.17:48H-22.1 through C.17:48H-22.5). Such rules and regulations shall be consistent with the standards for risk based capital for health organizations adopted by the National Association of Insurance Commissioners.
L.2014, c.81, s.45.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-23 - Suspension, revocation of license, grounds

17:48H-23. Suspension, revocation of license, grounds
23. The Commissioner of Banking and Insurance may suspend or revoke the license issued to an organized delivery system pursuant to this act upon the commissioner's determination that:
a. The licensed organized delivery system is operating in contravention of its basic organizational documents;
b. The licensed organized delivery system is unable to fulfill its obligations to the carriers with whom it contracts;
c. The net worth of the licensed organized delivery system is less than that required by this act, or the licensed organized delivery system has failed to correct any deficiency in its net worth as required by the commissioner;
d. The continued operation of the licensed organized delivery system would be hazardous to the health and welfare of the enrollees or contract holders with whom it has contracted to provide health care services or detrimental to a carrier with whom it has contracted to provide the services;
e. The licensed organized delivery system has failed to file any report required pursuant to this act;
f. The licensed organized delivery system has failed to provide the health care services for which it has been licensed or has provided health care services which are in contravention of the contract or contracts filed with the commissioner;
g. The licensed organized delivery system is unable to maintain the standards set forth by regulation;
h. The licensed organized delivery system has failed, as provided by the contract, to comply with the provisions of P.L.1997, c.192 (C.26:2S-1 et seq.);
i. The licensed organized delivery system has otherwise failed to comply with this act or with other applicable law; or
j. There are other reasonable grounds that warrant suspension or revocation.
L.1999,c.409,s.23.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48H-24 - Notification of grounds for suspension, revocation of license

17:48H-24. Notification of grounds for suspension, revocation of license
24. a. If the Commissioner of Banking and Insurance has cause to believe that grounds exist for the suspension or revocation of a license, the commissioner shall notify the licensed organized delivery system, in writing, specifically stating the grounds for suspension or revocation and fixing a time for a hearing in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). If a license is revoked, the licensed organized delivery system shall submit a plan to the commissioner within 15 days of the revocation, for the winding up of its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of its business. The commissioner may, by written order, permit such further operation of the system as the commissioner finds to be in the best interest of individuals receiving health care services from the system.
b. The commissioner shall notify all carriers with contracts with the system that are on file with the Department of Banking and Insurance of the proceedings.
L.1999,c.409,s.24.