reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-63 - Additional information requested by department.

17B:27A-63 Additional information requested by department.
3. a. If the department determines that a carrier's requested rate increase exceeds the 10 percent threshold for expanded rate review set forth in section 2 of this act, the department shall require the carrier to submit to the department, in addition to any other information required to be filed, a written description justifying the rate increase that complies with all of the provisions of this section.
b. The carrier shall include in its written description all information prescribed by the department, including:
(1) a simple and brief narrative describing the data and assumptions that were used to develop the rate increase;
(2) an explanation of the most significant factors causing the rate increase, including a brief description of the relevant claims and non-claims expense increases reported in the rate increase summary;
(3) a brief description of the overall experience of the plan, including historical and projected expenses, and loss ratios; and
(4) an actuarial memorandum that contains the reasoning and assumptions supporting the data.
c. (1) Upon completion of the department's review of the rate filing, the department shall promptly make available to the public a consumer-friendly version of the written description justifying the rate increase as provided by the carrier, excluding information that is a trade secret or that is confidential commercial or financial information.
(2) The department shall include on its website, along with each written description posted on the website, information that explains:
(a) the purpose and role of the expanded rate review process; and
(b) how the public can submit comments to the department on the written description justifying the rate increase.
L.2019, c.355, s.3.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-64 - Disclosure of information.

17B:27A-64 Disclosure of information.
4. a. Any information filed with the department pursuant to this act may be disclosed in accordance with P.L.1963, c.73 (C.47:1A-1 et seq.), except that confidential information shall not be disclosed by the department to any person other than employees and representatives of the department.
b. A carrier shall separately identify any confidential information filed with the department pursuant to this act. Any information that is not identified as confidential information shall be considered public information and subject to disclosure.
c. As used in this section, "confidential information" means information contained in an actuarial memorandum filed with the department pursuant to this act that has been certified by the actuary preparing the memorandum as confidential or proprietary information.
L.2019, c.355, s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-65 - Definitions relative to certain assessments.

17B:27A-65 Definitions relative to certain assessments.
1. As used in this act:
"Commissioner" means the Commissioner of Banking and Insurance.
"Entity subject to this act" or "entity" means an insurance company, health service corporation, hospital service corporation, medical service corporation, health maintenance organization, or dental plan organization authorized to issue health benefits or dental benefits plans in this State. "Entity" shall include a multiple employer welfare arrangement that is initially registered pursuant to the "Self-Funded Multiple Employer Welfare Arrangement Regulation Act," P.L.2001, c.352 (C.17B:27C-1 et seq.) after the date of enactment of this act. "Entity" shall not include a dental service corporation or a multiple employer welfare arrangement that is registered pursuant to the "Self-Funded Multiple Employer Welfare Arrangement Regulation Act," P.L.2001, c.352 (C.17B:27C-1 et seq.) as of the date of enactment of this act.
"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through an entity subject to this act, including a vision or dental plan as defined pursuant to section 1 of P.L.2014, c.70 (C.26:2S-26). For the purposes of this act, "health benefits plan" shall not include the following plans, policies or contracts: Medicaid, Medicare, Medicare Advantage, Medicare supplement, accident only, credit, disability, long-term care, TRICARE supplement coverage, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.), small employer health benefits plans issued pursuant to P.L.1992, c.162 (C.17B:27A-17),and hospital confinement indemnity coverage.
"Net written premiums" means the premiums earned in this State on health benefits plans, less return premiums thereon and dividends paid or credited to policy or contract holders on the health benefits plan business. Net earned premium shall include the aggregate premiums earned on the entity's insured group and individual business, excluding premiums from any Medicaid or NJ FamilyCare contracts.
L.2020, c.61, s.1.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-66 - Filing of net written premiums.

17B:27A-66 Filing of net written premiums.
2. a. An entity subject to this act shall annually file with the commissioner its net written premiums for the preceding year, no later than April 1 of each year.
b. The commissioner shall calculate and issue to the entity a certified assessment, which shall be 2.5% of the entity's net written premiums.
c. An entity shall annually pay the assessment issued pursuant to subsection b. of this section to the State Treasurer no later than May 1 of each year, as prescribed by the commissioner.
d. If the commissioner determines that the amount of the assessment calculated pursuant to this section shall reduce the State's total revenue, the commissioner may reduce the assessment.
L.2020, c.61, s.2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-1 - Definitions relative to third party administrators, billing services.

17B:27B-1 Definitions relative to third party administrators, billing services.
1. As used in this act:
"Benefits payer" means an insurer authorized to issue health or dental benefits plans in this State, or any other person who undertakes to provide and assumes financial risk for the payment of health or dental benefits and is obligated to pay claims for health or dental benefits to providers or other claimants.
"Client" means a health care provider that contracts with a third party billing service to remit claims to benefits payers on behalf of the provider or other claimant.
"Commissioner" means the Commissioner of Banking and Insurance.
"Enrollee" means a person entitled to receive benefits under a health benefits plan.
"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense or dental benefits for covered services.
"Health care provider" or "provider" means an individual or entity which provides a covered benefit or service.
"Insurer" means a licensed health insurer, health, hospital or medical service corporation, health maintenance organization, dental service corporation or dental plan organization.
"Third party administrator" means a person or entity that: processes claims and pays claims on behalf of a benefits payer without the assumption of financial risk for the payment of health or dental benefits. Third party administrator shall include: (1) an entity not licensed as an insurer that is not an affiliate or subsidiary of an insurer, that processes claims on behalf of a benefits payer; (2) an entity that is a subsidiary or affiliate of an insurer that processes claims on behalf of the insurer; and (3) an entity that is a subsidiary or affiliate of an insurer that only processes claims on behalf of benefits payers other than insurers. Third party administrator shall not include an employee, affiliate or subsidiary of a benefits payer formed for the purpose of processing and paying claims solely on behalf of the benefits payer, nor shall it include a collection agency or bureau or pharmacy benefits manager.
"Third party billing service" means a person or entity that is paid by a health care provider to process claims or claims payments on behalf of the health care provider.
L.2001,c.267,s.1.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-3 - Additional information required for licensure, registration.

17B:27B-3 Additional information required for licensure, registration.
3. In addition to the information required by section 2 of this act, the applicant for licensure or registration shall file with the commissioner:
a. a description of the applicant's proposed method of marketing its services;
b. a statement setting forth the means by which the applicant is to be compensated;
c. a description of the complaint and appeals procedures instituted by the applicant; and
d. a description of the quality assurance procedures established by the applicant.
An applicant shall make available for inspection by the commissioner copies of all standard contracts with benefits payers or other persons with whom it does business, including subcontractors and reinsurers. In the case of an applicant for registration, the information required to be filed with the commissioner shall apply only to services provided to benefits payers other than an insurer.
L.2001,c.267,s.3.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-4 - Issuance of license, approval of application for registration.

17B:27B-4 Issuance of license, approval of application for registration.
4. The commissioner may issue a license to an applicant or approve an application for registration as a third party administrator if he finds that the applicant meets the standards established by this act, including, but not limited to, the following:
a. all of the materials required by this act or by the commissioner have been filed;
b. the persons responsible for conducting the applicant's affairs are competent, trustworthy and possess good reputations, and have appropriate experience, training and education;
c. the applicant has demonstrated the ability to assure that its services will be performed in a manner which will ensure the efficient operation of its business, including appropriate financial controls;
d. the standard contract forms to be used by the applicant are acceptable;
e. the applicant has adequate financial arrangements with the benefits payers for which it will perform its services and adequate arrangements for complying with the provisions of P.L.1999, c.154 (C.17B:30-23 et al.); and
f. the compensation arrangements made between the applicant and benefits payers do not result in the assumption of financial risk by the applicant.
In the case of an applicant for registration, the provisions of subsections d., e., and f. of this section shall apply only to services provided by the applicant to benefits payers other than an insurer.
L.2001,c.267,s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-5 - Denial of license, registration.

17B:27B-5 Denial of license, registration.
5. The commissioner may deny an application for licensure or registration as a third party administrator if he finds that any of the standards established by this act have not been met or for any other reasonable grounds. If the application for licensure or registration is denied, the commissioner shall notify the applicant in writing by certified mail, return receipt requested, setting forth his reasons for denial. The applicant may request a hearing by notice to the commissioner no later than the 30th day following receipt of the notice of denial.
L.2001,c.267,s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-6 - Provisions of written agreement; requirements.

17B:27B-6 Provisions of written agreement; requirements.
6. A third party administrator shall not conduct any business with a benefits payer in the absence of a written agreement between the administrator and the benefits payer, except that this shall not apply to a third party administrator registered under the provisions of section 2 of this act with respect to services performed for an insurer. The agreement shall be retained as part of the official records of the administrator for the duration of the agreement and for five years thereafter. The provisions of the agreement shall include, but shall not be limited to:
a. the services to be provided by the administrator and the means by which the administrator is to be compensated;
b. the responsibilities of the benefits payer to the administrator with respect to claims to be paid by the administrator on behalf of a benefits payer, including: the provision of enrollment and eligibility information; arrangement for a preliminary or escrowed deposit of funds by the benefits payer, if any; the method used for the transmittal of funds from the benefits payer to the administrator; notification by the benefits payer of modifications in the benefits payer's benefits plan; provisions setting forth the respective liability of the administrator and benefits payer for payment of ineligible claims; liability for claims payments that are overdue; and provisions regarding the procurement of reinsurance or stop-loss insurance; and
c. the responsibilities of the administrator to the benefits payer, including: the maintenance of appropriate back-up systems against the loss of records; establishment and maintenance of appropriate financial controls; provisions regarding the benefits payer's rights with respect to conducting claims audits by an outside auditor; the maintenance of appropriate insurance coverage, which may include, but not be limited to, general liability insurance, valuable papers insurance and errors and omissions coverage; appropriate access by the benefits payer to the administrator's records; and procedures for making available the claims experience or other information to the benefits payer at its request, including, but not limited to, monthly reports.
L.2001,c.267,s.6.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-7 - Access to books, records.

17B:27B-7 Access to books, records.
7. a. The commissioner shall have access to all books and records of a third party administrator for the purposes of examination, audit and inspection. Any trade secrets, proprietary information or the identity and addresses of enrollees contained in the books and records shall be kept confidential, except that the commissioner may use the information in any proceeding instituted against the administrator.
b. The benefits payer shall own the records generated by the administrator pertaining to the benefits payer, except that the administrator shall retain the right to continuing access to books and records to permit the administrator to fulfill all of its contractual obligations to the benefits payer.
c. In the event that an agreement between an administrator and a benefits payer is canceled, notwithstanding the provisions of section 6 of this act to the contrary, the administrator may, with the written agreement of the benefits payer, transfer all records to a new administrator instead of retaining them for five years.
L.2001,c.267,s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-8 - Payment to third party administrators not based solely on claims denials.

17B:27B-8 Payment to third party administrators not based solely on claims denials.
8. If a third party administrator adjudicates claims under a health benefits plan, the commissions, fees or charges that the benefits payer pays the administrator, shall not be based solely on the number or amount of claims denied by the administrator. This provision shall not prohibit an administrator from receiving performance-based compensation if that compensation is not predicated on denial of claims or coverage.
L.2001,c.267,s.8.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-9 - Fiduciary responsibility of third party administrators.

17B:27B-9 Fiduciary responsibility of third party administrators.
9. a. A third party administrator shall be deemed to act in a fiduciary capacity on behalf of the benefits payer in the receipt and transmittal of the benefits payer's funds, and shall have all responsibility attendant to a fiduciary as established by law. Funds transmitted shall be kept in a separate account and shall not be commingled with any other funds. If an account is jointly held by the administrator and the benefits payer, it shall be deposited in a State or federally chartered insured depository institution, and the administrator shall provide a monthly accounting of all transactions in that account. A benefits payer shall have the responsibility to make funds necessary to pay the claims available to the administrator in a timely manner, as provided in the contract. An administrator shall not be liable to any party for the failure of the benefits payer to make funds available to pay claims.
b. An administrator shall maintain in force a fidelity bond in its own name on its officers and employees, in an amount established by the commissioner by regulation.
L.2001,c.267,s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-10 - Separate accounts for funds remitted.

17B:27B-10 Separate accounts for funds remitted.
10. All funds remitted to an administrator by a benefits payer licensed or authorized to do business in this State shall be held by the third party administrator in a separate account maintained in the name of the benefits payer or in a separate account maintained jointly in the names of the benefits payer and the administrator. If funds have been collected by the administrator from a provider or enrollee on behalf of a benefits payer, they shall be maintained in a separate account maintained in the name of the benefits payer, maintained jointly in the names of the benefits payer and the administrator or remitted to the benefits payer, as provided in the contract. Copies of all records pertaining to the collection of funds shall be made available to the benefits payer as provided in the contract.
L.2001,c.267,s.10.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-11 - Prompt delivery of communications to enrollees.

17B:27B-11 Prompt delivery of communications to enrollees.
11. Any policies, certificates, booklets, termination notices or other written communications delivered by the benefits payer to the third party administrator for delivery to enrollees shall be delivered by the administrator promptly, in accordance with the instructions of the benefits payer.
L.2001,c.267,s.11.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-12 - Notification of material changes to commissioner.

17B:27B-12 Notification of material changes to commissioner.
12. A third party administrator shall immediately notify the commissioner of any material change in its ownership, control or other fact or circumstance affecting its qualification for a license.
L.2001,c.267,s.12.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-13 - Annual reports.

17B:27B-13 Annual reports.
13. A third party administrator shall file an annual report for the preceding calendar year with the commissioner on or before March 1 of each year, in a form and manner prescribed by the commissioner. The annual report shall contain the complete names and addresses of all benefits payers with which the administrator had a contract in effect during the preceding calendar year. The commissioner shall establish a filing fee for the report, by regulation.
L.2001,c.267,s.13.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-14 - Suspension, revocation of license, registration.

17B:27B-14 Suspension, revocation of license, registration.
14. The commissioner may suspend or revoke a license or registration issued pursuant to this act if he finds that the third party administrator:
a. is in an unsound financial condition;
b. is using methods or practices in the conduct of its business that render its further transaction of business in this State hazardous or injurious to the benefits payers with which it has contracted or the public;
c. has failed to pay any judgment rendered against it in this State within 60 days after the judgment has become final;
d. has violated any lawful rule or order of the commissioner or any provision of State law;
e. has refused to be examined or produce its accounts, records and files for examination, or if any of its officers has refused to give information with respect to its affairs or has refused to perform any other legal obligation as to an examination, when required by the commissioner;
f. has, without just cause, refused or failed to pay proper claims or perform services arising under its contracts;
g. at any time fails to meet any qualification for which issuance of the license could have been refused had that failure then existed and been known to the commissioner;
h. has been convicted of, or has entered a plea of guilty or nolo contendere to a felony or crime of the first, second or third degree in this State, without regard to whether adjudication was held;
i. is under suspension or revocation in another state; or
j. has willfully reimbursed enrollees for benefits not eligible under the benefits payer's benefits plan.
If the commissioner finds that one or more grounds exist for the suspension or revocation of a certificate of authority issued under this act, the commissioner may, in lieu of suspension or revocation, impose a fine upon the administrator.
L.2001,c.267,s.14.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-15 - Immediate suspension of license, registration, grounds.

17B:27B-15 Immediate suspension of license, registration, grounds.
15. The commissioner may, without advance notice or hearing, immediately suspend the license or registration of a third party administrator if he finds that one or more of the following circumstances exist:
a. the administrator is insolvent or impaired;
b. a proceeding for receivership, conservatorship, rehabilitation or other delinquency proceeding regarding the administrator has been commenced in another state; or
c. the financial condition or business practices of the administrator otherwise pose an imminent threat to the public health, safety or welfare of the residents of this State.
L.2001,c.267,s.15.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-16 - Certification required for third party billing services.

17B:27B-16 Certification required for third party billing services.
16. On or after January 1, 2002, no person shall act as, offer to act as or hold himself out to be a third party billing service in this State unless certified by the commissioner in accordance with this act. Application for certification shall be made to the commissioner on a form provided by the commissioner. The commissioner shall establish by regulation the information that shall accompany the application, which shall include, but need not be limited to:
a. a copy of the applicant's basic organizational documents, which shall include articles of incorporation, articles of association, partnership agreement, management agreement, trust agreement or other documents governing the operation of the applicant that are applicable to the applicant's form of business organization;
b. a copy of the executed bylaws, rules and regulations, or other documents relating to the operation of the applicant's internal affairs;
c. the names, addresses and official positions of the persons responsible for the conduct of the affairs of the applicant, including, but not limited to, if applicable: the members of the board of directors, executive committee or other governing board or committee, the principal officers or partners, shareholders owning or having the right to acquire 10% or more of the voting securities of the corporation or partnership interest of a partnership or equity interest, in the case of another form of business organization;
d. if the applicant accepts monies from benefits payers on behalf of clients, the application shall include a copy of the applicant's most recent financial statements audited by an independent certified public accountant;
e. a copy of the applicant's business plan, including information on staffing levels and the activities undertaken or to be undertaken in this State. The plan shall include a statement of the third party billing service's capability for providing a sufficient number of experienced and qualified personnel in the areas of claims processing and record keeping;
f. a list of the applicant's clients and a copy of the standard contract or contracts used by the applicant in the course of business; and
g. if the applicant accepts monies from benefits payers on behalf of clients, the application shall be accompanied by a power of attorney, duly executed by the applicant, if not domiciled in this State, appointing the commissioner and his successors in office as the true and lawful attorney of the applicant in and for this State upon whom all lawful process in any legal action or proceeding against the organization on a cause of action arising in this State may be served.
L.2001,c.267,s.16.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-17 - Additional information to be filed by third party billing services.

17B:27B-17 Additional information to be filed by third party billing services.
17. In addition to the information otherwise required by this act or by the commissioner, a third party billing service shall file with the commissioner:
a. a description of the applicant's proposed method of marketing its services;
b. a statement setting forth the means by which the applicant is to be compensated;
c. a description of the quality assurance procedures established by the applicant; and
d. a copy of the standard contract or contracts used by the applicant in contracting with providers.
L.2001,c.267,s.17.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-18 - Approval of applications for certification.

17B:27B-18 Approval of applications for certification.
18. The commissioner may approve an application for certification as a third party billing service if he finds that the applicant meets the standards established by this act, including, but not limited to, the following:
a. all of the material required by this act or by the commissioner have been filed;
b. the persons responsible for conducting the applicant's affairs are competent, trustworthy and possess good reputations, and have appropriate experience, training and education;
c. the applicant has demonstrated the ability to ensure that its services will be performed in a manner which will result in the efficient operation of its business, including, if the applicant accepts payments from benefits payers on behalf of its clients, appropriate financial controls;
d. the standard contract forms to be used by the applicant are acceptable; and
e. the applicant has adequate arrangements for complying with the provisions of P.L.1999, c.154 (C.17B:30-23 et al.).
L.2001,c.267,s.18.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-19 - Denial of applications for certification.

17B:27B-19 Denial of applications for certification.
19. The commissioner may deny an application for certification as a third party billing service if he finds that any of the standards established by this act have not been met or for any other reasonable grounds. If the application for certification is denied, the commissioner shall notify the applicant in writing by certified mail, return receipt requested, setting forth his reasons for denial. The applicant may request a hearing by notice to the commissioner no later than the 30th day following receipt of the notice of denial.
L.2001,c.267,s.19.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-20 - Written agreements required for conducting business as third party billing service.

17B:27B-20 Written agreements required for conducting business as third party billing service.
20. A third party billing service shall not conduct any business with a client in the absence of a written agreement between the billing service and the client. The agreement shall be retained as part of the official records of the third party billing service for the duration of the agreement.
The agreement shall include the services to be provided by the third party billing service on behalf of the client; financial arrangements to be used if the third party billing service accepts monies from benefits payers on behalf of a client; provisions setting forth the respective liability of the client and the third party billing service for the accuracy and eligibility of submitted claims, and for the prompt submission of claims pursuant to the provisions of P.L.1999, c.154 (C.17B:30-23 et al.); and the responsibilities of the third party billing service to the client with respect to the maintenance of appropriate back-up systems against the loss of records, and the maintenance of appropriate insurance coverage by the third party billing service against the risk of loss.
L.2001,c.267,s.20.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-21 - Fiduciary responsibility of third party billing services.

17B:27B-21 Fiduciary responsibility of third party billing services.
21. A third party billing service that accepts monies from health benefits payers on behalf of a client shall be deemed to act in a fiduciary capacity on behalf of the client in the receipt and transmittal of funds and shall have all responsibility attendant to a fiduciary as established by law. Monies transmitted by benefits payers or on behalf of clients shall be kept in a separate account maintained in the name of the client or jointly in the names of the client and the third party billing service and shall not be commingled with any other funds of the third party billing service or other clients of the third party billing service.
L.2001,c.267,s.21.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-22 - Notification of material changes to commissioner.

17B:27B-22 Notification of material changes to commissioner.
22. a. A third party billing service shall immediately notify the commissioner of any material change in its ownership, control, or other fact or circumstance affecting its qualification for certification.
b. A third party billing service shall file such reports, at such times as may be required by the commissioner, including reports that will verify compliance with the provisions of P.L.1999, c.154 (C.17B:30-23 et al.).
L.2001,c.267,s.22.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-23 - Suspension, revocation of certification.

17B:27B-23 Suspension, revocation of certification.
23. The commissioner may suspend or revoke a certification issued pursuant to this act if he finds that the third party billing service:
a. is using methods or practices in the conduct of its business that render its further transaction of business in this State hazardous or injurious to its clients or the public;
b. has failed to pay any judgment rendered against it within 60 days after the judgment has become final;
c. has violated any lawful rule or order of the commissioner or any provision of the laws of this State;
d. has, without just cause, refused or failed to perform services arising under its contracts with clients;
e. has been convicted of, or has entered a plea of guilty or nolo contendere to a felony or crime of the first, second or third degree in this State, without regard to whether adjudication was held; or
f. is under suspension or revocation in another State.
If the commissioner finds that one or more grounds exist for the suspension or revocation of a certification issued under this act, the commissioner may, in lieu of suspension or revocation, impose a fine upon the third party billing service.
L.2001,c.267,s.23.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-24 - Violations, penalties.

17B:27B-24 Violations, penalties.
24. The commissioner may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $250 nor more than $5,000 for each day that a third party administrator or third party billing service is in violation of this act. A penalty imposed by the commissioner pursuant to this section may be in lieu of, or in addition to, suspension or revocation of a license 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.2001,c.267,s.24.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27B-25 - Rules, regulations.

17B:27B-25 Rules, regulations.
25. 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 carry out the purposes of this act.
L.2001,c.267,s.25.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27C-2 - Purposes of act.

17B:27C-2 Purposes of act.
2. The purposes of this act are to:
a. provide for the registration of self-funded or partially self-funded multiple employer welfare arrangements;
b. regulate self-funded or partially self-funded multiple employer welfare arrangements in order to ensure the financial integrity of the arrangements;
c. provide reporting requirements for self-funded or partially self-funded multiple employer welfare arrangements; and
d. provide for sanctions against self-funded or partially self-funded multiple employer welfare arrangements that do not comply with the provisions of this act.
L.2001,c.352,s.2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27C-3 - Definitions relative to self-funded multiple employer welfare arrangements.

17B:27C-3 Definitions relative to self-funded multiple employer welfare arrangements.
3. For purposes of this act:
"Association" means a group of 100 or more persons organized and maintained in good faith for purposes other than that of obtaining insurance, in active existence for more than one year, having a constitution and bylaws that provide that: the association holds regular meetings not less than annually to further the purposes of the members; except for credit unions, the association collects dues or solicits contributions from members; and the members have voting privileges and representation on the governing board and committees.
"Commissioner" means the Commissioner of Banking and Insurance.
"Employee welfare benefit plan" has the meaning set forth in subsection (1) of 29 U.S.C. s.1002.
"Large employer" means a member employer with more than 50 eligible employees, as defined by section 1 of P.L.1992, c.162 (C.17B:27A-17).
"Multiple employer welfare arrangement" has the meaning set forth in subsection (40) of 29 U.S.C. s.1002.
"Self-funded multiple employer welfare arrangement" means a self-funded or partially self-funded multiple employer welfare arrangement that provides for health benefits plans that has two or more employers who each have two or more employees and that has one or more of the employer members either domiciled in this State or its principal headquarters or principal administrative office located in this State.
"Small employer" means the same as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).
L.2001, c.352, s.3; amended 2015, c. 172, s.1.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27C-5 - Deposit, maintenance of cash, securities.

17B:27C-5 Deposit, maintenance of cash, securities.
5. a. A self-funded multiple employer welfare arrangement shall deposit and continuously maintain with a financial institution licensed in this State, cash or securities as defined in N.J.S. 17B:18-37, having an admitted asset value of not less than $200,000. The deposit shall be held for the benefit and protection of all covered members of the self-funded multiple employer welfare arrangement. The self-funded multiple employer welfare arrangement shall further maintain a cash reserve for loss in an amount established by a qualified actuary as being adequate to provide for all incurred losses including unpaid claims.
b. A self-funded multiple employer welfare arrangement shall maintain aggregate stop-loss coverage, with a retention level of 125 percent of expected claims per year, including provisions to cover incurred, unpaid claims liability in the event of the termination or liquidation of the self-funded multiple employer welfare arrangement, and specific stop-loss coverage, with a retention level determined annually by a qualified actuary based on sound actuarial principles. Any stop-loss contract maintained pursuant to this subsection shall contain a provision that the stop-loss insurer shall give the self-funded multiple employer welfare arrangement and the commissioner a minimum of 180 days' notice of cancellation or nonrenewal. If the self-funded multiple employer welfare arrangement fails to secure replacement coverage within 90 days after receipt of the notice of cancellation or nonrenewal, the trustees of the self-funded multiple employer welfare arrangement shall provide for the orderly liquidation of the self-funded multiple employer welfare arrangement.
L.2001, c.352, s.5; amended 2015, c.172, s.2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27C-6 - Required filings.

17B:27C-6 Required filings.
6. Each self-funded multiple employer welfare arrangement shall file all of the following with the commissioner:
a. No later than May 15th of each calendar year or four months and 15 days after the end of each fiscal year of the self-funded multiple employer welfare arrangement, financial statements audited by a certified public accountant and on forms prescribed by the commissioner, an actuarial opinion rendered by a qualified actuary, a report of its Risk-Based Capital (RBC) as of the end of the immediately preceding calendar year, in a form and containing such information as is required by the instructions adopted by the National Association of Insurance Commissioners for health insurers, as amended from time to time and proof of the deposit required in accordance with section 5 of this act. The opinion shall be based on standards adopted from time to time by the Actuarial Standards Board and on any additional standards that the commissioner may prescribe by regulation. For purposes of this section and section 5 of this act, "qualified actuary" means a member in good standing of the American Academy of Actuaries who meets the requirements set forth in regulations of the commissioner.
b. Within 60 days after the end of each fiscal quarter, unaudited financial statements on forms prescribed by the commissioner, affirmed by an appropriate officer or agent of the self-funded multiple employer welfare arrangement.
c. Within 60 days after the end of each fiscal quarter, a report on forms prescribed by the commissioner certifying that the self-funded multiple employer welfare arrangement maintains cash or liquid assets in a claim reserve account sufficient to meet the requirements of section 5 of this act.
d. The information required to be filed pursuant to subsections a., b., and c. of this section shall be certified by an officer of the self-funded multiple employer welfare arrangement.
e. A majority of the board of trustees of a self-funded multiple employer welfare arrangement shall represent participating employer members, and at least one trustee shall be a non-participating independent trustee chosen by a majority vote of the trustees.
f. The self-funded multiple employer welfare arrangement shall establish and maintain a website upon which all of the filings required pursuant to this section and information concerning its governance and financial performance shall be publicly available for a period of at least five years after the reporting period. This website shall also, at all times, indicate the status of the deposit required to be continuously maintained with a financial institution licensed in this State, pursuant to subsection a. of section 5 of P.L.2001, c.352 (C.17B:27C-5) and the name of that institution.
L.2001, c.352, s.6; amended 2015, c.172, s.3.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27C-9 - Examination of loss reserves.

17B:27C-9 Examination of loss reserves.
9. a. The commissioner may, upon reasonable notice, conduct an examination of the loss reserves of a self-funded multiple employer welfare arrangement as often as the commissioner in his discretion may deem necessary. The expenses of the examination shall be paid by the self-funded multiple employer welfare arrangement so examined. The commissioner shall also annually review the RBC report of the self-funded multiple employer welfare arrangement.
b. If the commissioner finds that the reserves are inadequate, he shall notify the self-funded multiple employer welfare arrangement of the inadequacy. Capital and surplus shall be automatically considered inadequate if they do not meet or exceed the following: (1) for the calendar year ending December 31, 2002, 80 percent of the regulatory action level RBC determined in accordance with the RBC instructions; (2) for the calendar year ending December 31, 2003, 90 percent of the regulatory action level RBC determined in accordance with the RBC instructions; (3) for the calendar year ending December 31, 2004, 95 percent of the regulatory action level RBC determined in accordance with the RBC instructions; and (4) for the calendar years ending on or after December 31, 2005, the regulatory action level RBC determined in accordance with the RBC instructions. Within 30 days the self-funded multiple employer welfare arrangement shall file and implement a plan to correct the inadequacy. The inadequacy shall be corrected within 90 days of the implementation of the plan to correct the inadequacy.
L.2001,c.352,s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27C-10 - Revocation, suspension of certificate of registration; violations, penalties.

17B:27C-10 Revocation, suspension of certificate of registration; violations, penalties.
10. a. The commissioner may revoke or suspend the certificate of registration of any self-funded multiple employer welfare arrangement that fails to correct any inadequacy pursuant to section 9 of this act or violates any provision of this act.
b. Any person who violates any provision of this act or the rules and regulations issued pursuant thereto shall be liable to a penalty of not more than $1,000 for a first offense and not more than $5,000 for each subsequent offense.
L.2001,c.352,s.10.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27C-11 - Rehabilitation, liquidation, conservation, dissolution.

17B:27C-11 Rehabilitation, liquidation, conservation, dissolution.
11. Any rehabilitation, liquidation, conservation or dissolution of a self-funded multiple employer welfare arrangement shall be conducted under the supervision of the State Superior Court in the county in which the self-funded multiple employer welfare arrangement has its principal office.
L.2001,c.352,s.11.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27C-12 - Rules, regulations.

17B:27C-12 Rules, regulations.
12. The commissioner, in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), may adopt rules and regulations necessary to effectuate the purposes of this act.
L.2001,c.352,s.12.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27D-1 - Findings, declarations relative to mandated health benefits

17B:27D-1. Findings, declarations relative to mandated health benefits
1. The Legislature finds and declares that:
a. Health benefits coverage, while providing important protection for individuals, is costly for individuals and businesses that insure their employees;
b. Mandated health benefits have social, financial and medical implications for patients, providers and health benefits plans; and
c. It is, therefore, in the public interest to conduct a review of proposed mandated health benefits by an expert body to provide the Legislature with adequate and independent documentation defining the social and financial impact and medical efficacy of the proposed mandate.
L.2003,c.193,s.1.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27D-2 - Definitions relative to mandated health benefits

17B:27D-2. Definitions relative to mandated health benefits
2. As used in this act:
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State.
"Commission" means the Mandated Health Benefits Advisory Commission established pursuant to this act.
"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier. For the purposes of this act, health benefits plan shall not include the following plans, policies or contracts: accident only, credit, disability, long-term care, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.) or hospital confinement indemnity coverage.
"Mandated health benefit" or "mandate" means: a benefit or coverage that is required by law to be provided by a carrier and includes: coverage for specific health care services, treatments or practices; or direct reimbursement to specific health care providers.
L.2003,c.193,s.2.