reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48D-21 - Confidentiality of diagnostic, treatment information.

17:48D-21 Confidentiality of diagnostic, treatment information.
21. Data or information pertaining to the diagnosis, treatment or health of any covered person obtained by the dental plan organization from the covered person or any dentist shall be confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this act, or upon the express consent of the covered person, or pursuant to statute or court order for the production of evidence or the discovery thereof, or in the event of claim or litigation between the covered person and the dental plan organization wherein the data or information is pertinent. A dental plan organization shall be entitled to claim any statutory privileges against such disclosure which the dentist who furnished the information to the dental organization is entitled to claim.
L.1979,c.478,s.21; amended 2005, c.38,s.16.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48D-24 - Severability

17:48D-24. 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, and the remaining sections, terms and provisions shall be and remain in full force and effect.
L.1979, c. 478, s. 24.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-2 - Establishment of health service corporation

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 medical service corporation.
b. A health service corporation shall be incorporated under and shall conduct its business pursuant to the provisions of Title 15A of the New Jersey Statutes, except that where the provisions of that title are inconsistent with the provisions of this act, the provisions of this act shall govern.
L. 1985, c. 236, s. 2, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-4 - Certificate of authority

17:48E-4. Certificate of authority
a. A health service corporation, other than a health service corporation which is formed as the result of a merger of a medical service corporation and a hospital service corporation, which seeks a certificate of authority shall file in the Department of Insurance a certified copy of its certificate of incorporation, a copy of its bylaws and a statement of its financial condition in the form and detail required by the commissioner, signed and sworn to by its president and secretary or other proper officers. The certificate of authority shall be issued if the commissioner is satisfied, on the basis of examination or otherwise, that the health service corporation has complied with the requirements of this act, that its condition or methods of operation are not such as would render its operations hazardous to the public or to its subscribers, and that the issuance of the certificate of authority would not be contrary to the public interest. No change in, amendment to, alteration in, addition to, or substitution for any document, instrument, or other paper so filed shall become operative or effective until it shall also have been filed in the manner required by this section. No certificate of authority shall be issued to any health service corporation not incorporated under the laws of this State.
b. No certificate of authority shall be issued to any health service corporation except on receipt of evidence by the commissioner that the corporation is in possession of unencumbered funds of not less than $1,250,000.00 to be held in cash or in a federally insured depository institution to the credit of the corporation.
c. No certificate of authority shall be issued to any health service corporation and no health service corporation which is established as a result of a merger of a hospital service corporation and a medical service corporation shall commence business unless the board of directors of the corporation is constituted in accordance with the provisions of this act.
L. 1985, c. 236, s. 4, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-5 - Merger procedure

17:48E-5. Merger procedure
Upon the merger of a medical service corporation into a hospital service corporation, the surviving corporation shall qualify as a health service corporation, and the surviving corporation need not obtain a new charter or certificate of authority to act as a health service corporation, provided that:
a. The board of directors of the surviving corporation is constituted pursuant to the provisions of section 6 of this act; and
b. The certificate of incorporation of the hospital service corporation is amended, within 30 days of the merger, in accordance with the provisions of this act; and
c. The bylaws of the hospital service corporation are amended, within 30 days of the merger, in accordance with the provisions of this act; and
d. Evidence of compliance with subsections a., b., and c. of this section is filed with the Commissioner of Insurance.
L. 1985, c. 236, s. 5, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-6 - Board of health service corporation formed through merger.

17:48E-6 Board of health service corporation formed through merger.
6. The board of a health service corporation which is formed as the result of a merger between a medical service corporation and a hospital service corporation shall be composed of not more than 17 members as provided in this section. Initially, after the merger has been effected, the board shall be constituted of 15 members as follows:
a. Four members of the board shall be public members, who shall be appointed by the Governor with the advice and consent of the Senate. The public members so appointed shall be persons whose background and experience indicate that they are qualified to act in the broad public interest, who may or may not have coverage under a contract or contracts issued by the corporation, its subsidiaries or affiliates, and who, or whose spouses or minor children, are not officers, directors or owners of more than 10% of the stock of a corporation whose aggregate sales to hospitals, other health care facilities or other providers of health care services exceed 5% of its total sales. The remaining 11 members shall be selected by the board of directors of the health service corporation in accordance with the provisions of its certificate of incorporation and bylaws.
b. Of the initial members of the board, as provided for in subsection a. of this section, one public member and three members selected by the board of the health service corporation shall serve for a term of one year; one public member and three members selected by the board of the health service corporation shall serve for a term of two years; and two public members and five members selected by the board of the health service corporation shall serve for a term of three years. Thereafter, all members of the board shall serve for a term of three years, and shall hold office until their successors are appointed or elected and qualified.
c. After the constitution of the initial board as provided in subsection b. of this section, and as the initial terms expire as provided for in that section, the board shall be constituted of 17 members as follows:
(1) Four members shall be public members of the board appointed by the Governor with the advice and consent of the Senate;
(2) Eleven members shall be elected by the board of directors, as provided in the bylaws; and
(3) One member shall be a public member appointed by the Senate President and one member shall be a public member appointed by the Speaker of the General Assembly, each of whom shall have experience in either finance, insurance, or health care delivery.
d. The provisions of subsection c. of this section shall not be construed to preclude the reappointment or reelection of any member appointed or elected pursuant to subsection a. of this section. L.1985, c.236, s.6; amended 1991, c.208, s.20; 2017, c.100, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-7 - Board of directors of health service corporation.

17:48E-7 Board of directors of health service corporation.
7. The board of directors of a health service corporation which is established in accordance with paragraph (1) of subsection a. of section 2 of P.L.1985, c.236 (C.17:48E-2) shall have four public members appointed by the Governor with the advice and consent of the Senate, one public member appointed by the Senate President who shall have experience in either finance, insurance, or health care delivery, one public member appointed by the Speaker of the General Assembly who shall have experience in either finance, insurance, or health care delivery, and 11 members elected as provided in the bylaws.
L.1985, c.236, s.7; amended 1991, c.208, s.21; 2017, c.100, s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-8 - Vacancy procedure

17:48E-8. Vacancy procedure
Within 10 days after a vacancy in the board of directors of a health service corporation has occurred, the corporation shall notify the commissioner in writing that a vacancy exists. If the vacancy is in one of the positions on the board which has been appointed by the Governor, the commissioner shall so notify the Governor, who shall appoint a candidate to serve for the remaining term. If the vacancy occurs in a position which is elected by the board, the vacancy shall be filled in accordance with the bylaws. Not more than 10 days after the selection of a person by the board to fill the vacancy, the corporation shall furnish, in writing, the following information to the commissioner: the name and address of the person so elected; whether the person is representative of the participating providers of health care services of the corporation, and is qualified to serve under the provisions of this act. If the commissioner finds, after a hearing, that the composition of the board of directors of the health service corporation, with respect to the members elected by the board, is not in compliance with the provisions of this act, he may direct that the board be reconstituted in accordance with his findings.
L. 1985, c. 236, s. 8, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-9 - Executive committee

17:48E-9. Executive committee
The board of directors of a health service corporation may, by resolution, elect an executive committee of the board, one-fourth of which shall be members appointed by the Governor. Vacancies in the executive committee shall be filled by the board of directors in accordance with the bylaws.
To the extent provided in the resolution of the board, or in the bylaws, the executive committee shall have and may exercise all the authority of the board, except that no executive committee shall:
a. Make, alter or repeal any bylaw of the corporation;
b. Elect or appoint any director, or remove any officer or director;
c. Submit to members any action that requires members' approval; or
d. Amend or repeal any resolution previously adopted by the board.
L. 1985, c. 236, s. 9, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-11 - Professional Advisory Committee

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 care issues, including, but not limited to, (1) the eligibility of and reimbursement for medical, surgical, or other health care procedures or services; and (2) the establishing of guidelines for the utilization of health care services and procedures.
b. The advisory committee created pursuant to subsection a. of this section shall be composed of at least five physicians, of whom not less than two shall also be directors, and all of whom shall be participating providers. In the case of a merger of a hospital service corporation and a medical service corporation, the initial advisory committee shall be elected by the board of the merging medical service corporation. Thereafter, all members of the advisory committee shall be elected by the directors, in a manner provided by the bylaws.
L. 1985, c. 236, s. 11, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-12 - Eligible providers' services.

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 laboratory or physical therapist, a certified nurse-midwife, a registered professional nurse, or a licensed podiatrist, dentist, optometrist, psychologist or chiropractor, when the provider performs an eligible service within the scope of his practice and for which he is not being compensated by a hospital or other health care facility. The practices of the providers of health care services shall be deemed to be within the provisions of this act and the providers shall have the privileges and benefits in the scope of their practices under this act afforded hereunder to other approved providers of health care services in the scope of their practices.
L.1985,c.236,s.12; amended 2005, c.259, s.28.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-13 - Approval of forms

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 issuance or renewal thereof in accordance with the provisions of section 12 of P.L.1995, c.73 (C.17:48E-13.2).
Contract forms shall not be unfair, inequitable, misleading or contrary to law, nor shall they produce rates that are excessive, inadequate or unfairly discriminatory.
L.1985,c.236,s.13; amended 1995,c.73,s.14.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-13.1 - Health service corporation contract; compliance

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 contract, or a printed rider or an endorsement for use with that contract, shall be delivered or issued for delivery in this State unless its provisions comply with all of the applicable requirements P.L.1985, c.236 (C.17:48E-1 et seq.) and any regulations adopted or guidelines published by the commissioner consistent with the requirements thereof. Any contract, application, rider, or endorsement issued or delivered in this State that is not in compliance with that law or regulations or guidelines shall be deemed to be in compliance with the requirements and shall be interpreted by the courts and among the persons affected by the contract as if that contract form were in compliance with the requirements; except that this provision shall not relieve the health service corporation from any penalty that may be imposed for violation of this act or any other applicable provision of P.L.1985, c.236 (C.17:48E-1 et seq.).
L.1995,c.73,s.11.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-14 - Individual contract requirements

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 first page and on its filing back in type of which the face is not smaller than 14 point;
c. The exceptions of the contract shall appear with the same prominence as the benefits to which they apply; and
d. If the contract contains any provision purporting to make any portion of the articles, constitution or bylaws of the corporation a part of the contract, that portion shall be set forth in full.
L. 1985, c. 236, s. 14, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-15 - Classification permitted

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 those services, and the subscription certificate issued to any subscriber affected thereby shall contain the provisions thereof and shall specify the circumstances.
L. 1985, c. 236, s. 15, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-15.1 - Eligibility for enrollment in health service corporation

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 the equivalent statute in another state, when determining the person's eligibility for enrollment in, or the provision of benefits under, a health service corporation contract providing hospital or medical expense benefits delivered, issued or executed in this State, or approved for issuance in this State by the Commissioner of Insurance.
L.1995,c.291,s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-15.2 - Health service corporation contract, exclusion, rates, terms based on genetic information prohibited

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 this State pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.) 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 not exclude any person or eligible dependent and shall not establish any rates or terms therefor on the basis of an actual or expected health condition or on the basis of any genetic characteristic. For the purposes of this section, "genetic characteristic" means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with statistically increased risk of development of a disease, disorder or syndrome.
L.1996,c.126,s.13.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-16 - Joint ventures

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 pursuant to similar statutes of other states, jointly issue individual or group contracts for health care and other benefits, including complete employee welfare and other employee benefit programs, or (2) with the participation of any other corporation, jointly enter into contracts to provide or receive services in connection with the providing of health care or conducting the business of insurance in accordance with the provisions of this act or as permitted by the commissioner. The commissioner may establish any policy nonforfeiture requirements or reserve requirements as he deems necessary. Agreements between a health service corporation and other corporations pursuant to this section may provide for experience rating, if the experience rating is done on an equitable basis between the health service corporation and the other corporations; or for a sharing of the premiums, claims, and expenses by the participating corporations; or subject to regulation by the commissioner, for acceptance or ceding of the whole or portions of risks on a reinsurance basis, except that a health service corporation may not accept risks on a reinsurance basis which it may not accept on a primary basis pursuant to its powers as a health service corporation and may not, under any circumstances, act as a reinsurer of life insurance. Agreements made pursuant to this section shall be filed with and approved by the commissioner before becoming effective.
b. In the case of any joint venture for the sale of insurance with other than an insurer or hospital, medical, or health service corporation licensed to do business in this or any other state, the other partner or partners in the venture shall be licensed to sell insurance as producers pursuant to P.L. 1987, c. 293 (C. 17:22A-1 et seq.).
P.L. 1985, c. 236, s. 16; amended by P.L. 1988, c. 71, s. 2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-17 - Expense limits; investments; administrative services

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 subscribers, except that during the first year after the issuance of a certificate of authority a health service corporation may so disburse not more than 20% of that amount and during the second year, not more than 15%.
b. No health service corporation shall, during any one year, disburse a sum greater than 20% of the payments received from subscribers during that year as administrative expenses. The term "administrative expenses," as used in this section, shall include all expenditures for nonprofessional services and in general all expenses not directly connected with the furnishing of services or benefits, but not including expenses of soliciting subscribers.
c. The funds of any health service corporation may be invested to the same extent now or hereafter permitted by law for the investment of funds of domestic life insurance companies, including investments as provided in subsection e. of section 3 of P.L.1985, c.236 (C.17:48E-3) in life, health or accident insurance companies or other for-profit subsidiaries such as insurance agencies, suppliers of administrative services only, or any other subsidiaries permitted pursuant to N.J.S.17B:20-4, and for the purpose of engaging in any aspect of its business directly or through one or more subsidiaries or affiliates, including life, health or accident insurance companies.
In calculating the amount of such investments pursuant to N.J.S. 17B:20-4, investments in health maintenance organizations shall be excluded.
d. A health service corporation may supply administrative services only, and may supply administrative services either directly or through a subsidiary or affiliate.
e. (Deleted by amendment, P.L.1988, c.71.)
f. (Deleted by amendment, P.L.1988, c.71.)
L.1985,c.236,s.17; amended 1988, c.71, s.3; 1992, c.21; 1998, c.132.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-17.2 - Special contingent surplus required for health service corporation

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 deems that health service corporations have met the purpose of section 5 of P.L.1988, c.71 (C.17:48E-17.1) on its group and other activities, excluding individual business, whichever date is earlier, no health service corporation shall commence or continue to transact group business or other activities, excluding individual business, in this State unless its special contingent surplus for its group and other activities, excluding contingent surplus for individual contracts, meets the financial requirements set forth in sections 2 through 4 of P.L.1993, c.235 (C.17B:18-68 through C.17B:18-70). For purposes of this section, "special contingent surplus" shall have the same meaning as surplus in applying the requirements set forth in sections 2 through 4 of P.L.1993, c.235 (C.17B:18-68 through C.17B:18-70).
L.1993,c.235,s.8.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-17.3 - Examination of annual regulatory filings; annual audit.

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 725%. If at any time the commissioner determines that a health service corporation surplus results in a ratio that exceeds this range, the department shall notify the health service corporation and the health service corporation shall, within 30 days of notice from the commissioner, file a report with the commissioner to reduce the surplus to be within the range. The report shall include a plan to benefit subscribers, which may include but not be limited to proposals to lessen potential rate increases in the future. The commissioner shall review the plan to affirm that it meets the requirements of P.L.2017, c.100 (C.17:48E-17.3 et al.).
b. The department shall annually audit the financial statements and surplus of the health service corporation to verify risk-based capital. In order to implement the provisions of this section, the department may engage independent actuaries, as necessary, at the expense of the health service corporation.
L.2017, c.100, s.4.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-17.4 - Health service corporation, aggregate benefits.

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 aggregate benefits for all large group health benefits plans offered by the health service corporation, at least 85 percent of the aggregate premiums collected for all of those plans.
b. A health service corporation shall annually report to the Commissioner of Banking and Insurance no later than August 1 of each year, the loss ratio calculated for all of the health benefits plans for the previous calendar year. In each case in which the loss ratio fails to substantially comply with the 85 percent loss ratio requirement, the health service corporation shall issue a dividend or credit against future premiums for all contract holders in an amount sufficient to assure that the aggregate benefits paid in the previous calendar year plus the amount of the dividends and credits shall equal 85 percent of the premiums collected. The health service corporation shall distribute all dividends and credits by December 31 of the year following the calendar year in which the loss ratio requirements were not satisfied. The health service corporation's annual report shall include the health service corporation's calculation of the dividends and credits applicable to all health benefits plans, as well as an explanation of the health service corporation's plan to issue dividends or credits.
c. The commissioner shall specify by regulation:
(1) any informational filings required to be submitted by a health service corporation to the commissioner in order to determine whether the health service corporation is in compliance with the loss ratio requirements;
(2) the instructions and format for calculating and reporting loss ratios and issuing dividends or credits;
(3) procedures for the distribution of a dividend or credit in the event of cancellation or termination by a contract holder; and
(4) the instructions and format for submitting annual reports.
d. As used in this section, "large employer" means an employer with more than 50 employees, who is not a small employer as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).
L.2019, c.358, s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-18 - Annual contract, renewal; family coverage

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 than one year after the actual date of the making of the contract, without the prior approval of the commissioner. The contract may provide that it shall be automatically renewed from year to year unless there shall have been at least 30 days' prior written notice of termination by either the subscriber or the health service corporation. In the absence of fraud or material misrepresentation in the application for a contract or for reinstatement, no contract with an individual subscriber shall be terminated by the health service corporation unless all contracts of the same type, in the same group or covering the same classification of persons are terminated under the same conditions.
b. No contract between a health service corporation and a subscriber shall entitle more than one person to coverage, except that a contract issued as a family contract may provide that coverage will be furnished to a husband and wife, or husband, wife and their dependent child or children, or the subscriber and his, or her, dependent child or children. Adult dependents of a subscriber may also be included for coverage under the contract of the subscriber.
L. 1985, c. 236, s. 18, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-20 - Coverage for newborn child.

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 children shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and abnormalities. If a subscription payment is required to provide coverage for a child, the contract may require that notification of birth of a newly-born child and the required payment must be furnished to the health service corporation within 60 days after the date of birth in order to have the coverage continue beyond such 60-day period.
b. Nonfamily type individual contracts which provide for coverage to the subscriber but not to family members or dependents of that subscriber shall also provide coverage to newly-born children of the subscriber, which shall commence with the moment of birth of each child and shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital abnormalities, if application therefor and payment of the required subscription amount are made to include in the contract the coverage described in subsection a. of this section within 60 days from the date of birth of a newborn child.
L.1985, c.236, s.20; amended 2017, c.361, s.5.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-21 - Coverage for former spouse

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, separate coverage for the former spouse shall be made available by the health service corporation on an individual basis under the following conditions:
a. Application for coverage shall be made to the health service corporation by or on behalf of the former spouse no later than 31 days following the date his or her coverage under the prior contract terminated.
b. No new evidence of insurability shall be required in connection with the application for coverage but any health exception, limitation or exclusion applicable to the former spouse under the prior coverage may, at the option of the health service corporation, be carried over to the new coverage.
c. The effective date of the new coverage shall be the day following the date on which the former spouse's coverage under the prior contract terminated.
d. The benefits provided under the coverage offered to the former spouse shall be at least equal to the basic benefits provided in contracts then being offered by the health service corporation to new individual nongroup applicants of the same age and family status.
L. 1985, c. 236, s. 21, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-22 - Coverage for child with intellectual disability, physical handicap.

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 reason of intellectual disability or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon the subscriber for support and maintenance, shall not terminate while the contract remains in force and the dependent remains in that condition, if the subscriber has within 31 days of the dependent's attainment of the termination age submitted proof of the dependent's incapacity as described herein. The provisions of this section shall not apply retrospectively or prospectively to require a health service corporation to insure as a covered dependent any child with an intellectual disability or physical handicap of the applicant where the contract is underwritten on evidence of insurability based on health factors required to be set forth in the application. A contract heretofore or hereafter issued may, however, specifically exclude such child with an intellectual disability or physical handicap from coverage.
L.1985, c.236, s.22; amended 2010, c.50, s.7.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-23 - Group contracts

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 established by one or more employers, or issued to a labor union or to an association formed for purposes other than obtaining a group contract, or issued to the trustees of a fund established by one or more labor unions, or by one or more employers and one or more labor unions, covering employees and members of associations and labor unions; or
(2) A contract issued to cover any other group which the commissioner determines may be covered in accordance with sound underwriting principles.
b. Benefits may be provided for one or more members of the families or one or more dependents of persons who may be covered under a group contract referred to in paragraph (1) or (2) of subsection a. of this section.
L. 1985, c. 236, s. 23, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-25 - "Employee" coverage

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, proprietorships and partnerships, if the business of the employer and those corporations, proprietorships or partnerships is under common control through stock ownership, contract or otherwise. The contract may provide that the term "employees" includes the individual proprietor or partners of an individual proprietorship or a partnership. The contract may provide that the term "employees" shall include retired employees. A contract issued to trustees may provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally connected with the trusteeship. A contract issued to the trustees of a fund established by the members of an association of employers may provide that the term "employees" shall include the employees of the association.
L. 1985, c. 236, s. 25, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-27 - Rate schedule filing

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 shall be formulated so that the anticipated minimum loss ratio for a contract form shall not be less than 75% of the premium. The health service corporation shall submit with its rate filing supporting data that the corporation is in compliance with the anticipated loss ratio requirement. The supporting data and certification required pursuant to subsection e. of section 8 of P.L.1992, c.161 (C.17B:27A-9) shall satisfy the requirements of this section.
L.1985,c.236,s.27, amended 1988,c.71,s.6; 1992,c.161,s.19.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-27.1 - Individual contract rate changes

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 e. of section 8 of P.L.1992, c.161 (C.17B:27A-9), prior to the rates becoming effective.
L.1988,c.71,s.7; amended 1992,c.161,s.20.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-28 - Group coverage for newborn child.

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 children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and abnormalities. If a subscription payment is required to obtain coverage for a child, the contract may require that notification of birth of a newly-born child and the required payment shall be furnished to the health service corporation within 60 days after the date of birth in order to have the coverage continue beyond that 60-day period.
b. Non-family type group coverage, other than under contracts which provide no dependent coverage whatsoever for the subscriber's class, shall also provide coverage for newly-born children of the subscriber, which coverage shall commence with the moment of birth of each child and shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and abnormalities, if application therefor and payment of the required subscription amount are made to include in the contract the coverage described in subsection a. of this section within 60 days from the date of birth of a newborn child.
L.1985, c.236, s.28; amended 2017, c.361, s.6.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-29 - Nongroup coverage for former spouse

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 dependent by reason of divorce, separate coverage for the former spouse shall be made available by the health service corporation on an individual nongroup basis under the following conditions:
a. Application for the nongroup coverage shall be made to the health service corporation by or on behalf of the former spouse no later than 31 days following the date his or her coverage under the prior group contract terminated.
b. No new evidence of insurability shall be required in connection with the application for the nongroup coverage but any health exception, limitation or exclusion applicable to the former spouse under the prior coverage may, at the option of the health service corporation, be carried over to the new nongroup coverage.
c. The effective date of the new coverage shall be the day following the date on which the former spouse's coverage under the prior group contract terminated.
d. The benefits provided under the nongroup coverage issued to the former spouse shall be at least equal to the basic benefits provided in contracts then being issued by the health service corporation to new nongroup applicants of the same age and family status.
L. 1985, c. 236, s. 29, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-30 - Group coverage for child with intellectual disability, physical handicap.

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 reason of intellectual disability or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon the covered employee or member for support and maintenance, shall not terminate while the coverage of the employee or member remains in force and the dependent remains in that condition, if the employee or member has within 31 days of the dependent's attainment of the termination age submitted proof of the dependent's incapacity as described herein. The provisions of this section shall not apply retrospectively or prospectively to require a health service corporation to insure as a covered dependent any child with an intellectual disability or physical handicap of the applicant where the contract is underwritten on evidence of insurability based on health factors required to be set forth in the application. Any contract heretofore or hereafter issued may, however, specifically exclude a child with an intellectual disability or physical handicap from coverage.
L.1985, c.236, s.30; amended 2010, c.50, s.8.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-31 - Family coverage after member's death

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, family members or dependents are permitted to have coverage continued for at least 180 days after the death of the person in the insured group.
L. 1985, c. 236, s. 31, eff. July 15, 1985.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48E-32.1 - Coverage provided by health service corporation for subscriber's child.

17:48E-32.1 Coverage provided by health service corporation for subscriber's child.
5. a. A health service corporation contract which provides hospital or medical expense benefits under which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A contract shall not deny coverage for a subscriber's child on the grounds that:
(1) The child was born out of wedlock;
(2) The child is not claimed as a dependent on the subscriber's federal tax return;
(3) The child does not reside with the subscriber or in the health service corporation's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the contract with respect to the use of specified providers;
(4) The child is married;
(5) The child has or adopts a child; or
(6) The child starts or leaves school.
b. If a child has coverage through a health service corporation contract of a noncustodial parent, the health service corporation shall:
(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child's noncustodial parent's coverage;
(2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and
(3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.
c. When a parent who is the subscriber is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the health service corporation shall:
(1) Permit the parent to enroll his child as a dependent, without regard to any open enrollment restrictions;
(2) Permit the child's other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the contract if the parent who is the subscriber fails to enroll the child; and
(3) Not terminate coverage of the child unless the parent who is the subscriber provides the health service corporation with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage.
L.1995, c.288, s.5; amended 2019, c.356, s.3.