reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-7.33 - Individual health benefits plan, coverage, prescription asthma inhaler.

17B:27A-7.33 Individual health benefits plan, coverage, prescription asthma inhaler.
21. An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide benefits to an enrollee or other person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
Nothing in this section shall prevent a carrier from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section.
L.2023, c.105, s.21.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-8 - Offering of certain coverage not required

17B:27A-8. Offering of certain coverage not required
7. a. A health maintenance organization shall not be required to offer coverage to or accept an applicant pursuant to this act if:
(1) the eligible individual does not live, reside, or work within the health maintenance organization's approved service area; and
(2) the carrier has demonstrated to the commissioner that the carrier will not have the capacity to deliver services adequately to additional eligible persons because of its obligations to existing group contract holders and enrollees and individual enrollees and it applies this paragraph uniformly to individuals without regard to any health status-related factor of such individuals and without regard to whether the individuals are eligible persons. Upon denying individual health benefits coverage pursuant to this paragraph, a carrier may not offer such coverage in the individual market for a period of 180 days after the date the coverage is denied. If the health maintenance organization does not have the capacity in its facilities for additional individual enrollees, it also shall not offer coverage to or accept any new group enrollees.
b. A carrier shall not be required to offer coverage or accept applications pursuant to this act if the commissioner determines that the carrier does not have the financial reserves necessary to underwrite additional coverage. Upon denying individual health benefits coverage pursuant to this subsection, a carrier may not offer such coverage in the individual market for a period of 180 days after the date the coverage is denied or until the carrier has demonstrated to the commissioner that the carrier has sufficient financial reserves to underwrite additional coverage, whichever is later.
L.1992,c.161,s.7; amended 1997, c.146, s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.2 - Purpose of act.

17B:27A-10.2 Purpose of act.
2. It is the intent of the Legislature to stabilize or reduce premiums in the individual health insurance market by providing reinsurance payments to health insurance carriers with respect to claims for eligible individuals. The Commissioner of Banking and Insurance, and the board of directors of the New Jersey Individual Health Coverage Program, are authorized to apply for, accept and receive federal funds to implement and sustain market stabilization programs. Preliminary planning, analysis, and implementation to effectuate the purposes of this act shall continue under the direction of the commissioner and the board.
L.2018, c.24, s.2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.3 - Definitions relative to health insurance premiums.

17B:27A-10.3 Definitions relative to health insurance premiums.
3. For the purposes of this act:
"Affiliated carrier" means the same as defined in N.J.A.C.11:20-1.2.
"Affordable Care Act" or "PPACA" means the federal Patient Protection and Affordable Care Act, Pub.L.111-148, as amended by the federal "Health Care and Education Reconciliation Act of 2010," Pub.L.111-152, and any federal rules and regulations adopted pursuant thereto.
"Attachment point" means an amount as provided in subsection h. of section 4 of this act.
"Benefit year" means the calendar year for which an eligible carrier provides coverage through an individual health benefits plan.
"Board" means the board of directors of the New Jersey Individual Health Coverage Program established pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.).
"Carrier" means any entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefits plan, including a sickness and accident insurance company, a health maintenance organization, a hospital, medical or health service corporation, or any other entity providing a health benefits plan. For purposes of this act, carriers that are affiliated carriers shall be treated as one carrier.
"Paid claim" means a claim by a covered person for payment of benefits under a health benefits plan for which the financial obligation for the payment of the claim under the contract rests upon and has been paid by the carrier, excluding claims adjustment expenses.
"Coinsurance rate" means the rate as provided in subsection i. of section 4 of this act.
"Commissioner" means the Commissioner of Banking and Insurance.
"Department" means the Department of Banking and Insurance.
"Eligible carrier" means a carrier that offers individual health benefits plans in the State.
"Fund" means the New Jersey Health Insurance Premium Security Fund created pursuant to section 10 of this act.
"Health benefits plan" means the same as that term is defined in section 1 of P.L.1992, c.161 (C.17B:27A-2).
"Payment parameters" means the attachment point, reinsurance cap, and coinsurance rate for the plan.
"Plan" means the Health Insurance Premium Security Plan established pursuant to section 4 of this act.
"Reinsurance cap" means the threshold amount as provided in subsection j. of section 4 of this act.
"Reinsurance payment" means an amount paid by the board to an eligible carrier under the plan.
L.2018, c.24, s.3.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.4 - Health Insurance Premium Security Plan.

17B:27A-10.4 Health Insurance Premium Security Plan.
4. a. There is hereby established, and the board in consultation with the commissioner shall administer, the Health Insurance Premium Security Plan.
b. The board or commissioner may apply for any available federal funding for the plan. All funds received pursuant to an application for federal funding, assessed by the board pursuant to this act, or otherwise dedicated to the fund shall be remitted to the State Treasurer and deposited in the fund.
c. The commissioner, in consultation with the board, shall collect data from carriers necessary to determine the reinsurance payment parameters and shall share this data with the board.
d. For each applicable benefit year, the board shall notify carriers, the commissioner, and the State Treasurer of the reinsurance payments to be made for the applicable benefit year no later than June 30 of the year following the applicable benefit year.
e. On a quarterly basis during the applicable benefit year, the board shall provide each eligible carrier and the commissioner with the calculation of total reinsurance payment requests.
f. By November 1 of the year following the applicable benefit year, the State Treasurer shall disburse all applicable reinsurance payments to an eligible carrier.
g. The board, subject to the disapproval of the commissioner pursuant to section 5 of this act, shall design and adjust the payment parameters to ensure the payment parameters:
(1) will stabilize or reduce premium rates in the individual market by achieving between a 10% and 20% reduction in what indicated premium rates would be for the applicable benefit year without the plan;
(2) will encourage increased participation in the individual market;
(3) mitigate the impact high-risk individuals have on premium rates in the individual market;
(4) take into account any federal funding available for the plan;
(5) take into account the total amount available to fund the plan; and
(6) encourage cost savings mechanisms related to the management of health care services.
h. The attachment point for the plan is the threshold amount for paid claims by an eligible carrier for an enrolled individual's covered benefits in a benefit year, beyond which the paid claims are eligible for reinsurance payments. The attachment point shall be set by the board, but shall not exceed the reinsurance cap.
i. The coinsurance rate for the plan is the rate at which the board will reimburse an eligible carrier for paid claims for an enrolled individual's covered benefits in a benefit year above the attachment point and below the reinsurance cap. The coinsurance rate shall be set by the board.
j. The reinsurance cap is the amount for paid claims of an eligible carrier for an enrolled individual's covered benefits, above which the paid claims for benefits are no longer eligible for reinsurance payments. The reinsurance cap shall be set by the board.
L.2018, c.24, s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.5 - Payment parameters.

17B:27A-10.5 Payment parameters.
5. The board shall propose to the commissioner the payment parameters for the next benefit year by April 30 of the year before the applicable benefit year. The commissioner shall have 15 days to review the payment parameters. If the commissioner takes no affirmative action to disapprove the payment parameters within that time the proposed payment parameters are final and effective.
L.2018, c.24, s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.6 - Calculation of reinsurance payment.

17B:27A-10.6 Calculation of reinsurance payment.
6. a. Each reinsurance payment shall be calculated with respect to an eligible carrier's paid claims for an individual enrollee's covered benefits in the applicable benefit year. If the paid claims do not exceed the attachment point, a reinsurance payment shall not be made. If the paid claims exceed the attachment point, the reinsurance payment shall be calculated as the product of the coinsurance rate and the lesser of:
(1) the paid claims minus the attachment point; or
(2) the reinsurance cap minus the attachment point.
b. The board shall ensure that reinsurance payments made to eligible carriers do not exceed the total amount paid by the eligible carrier for any eligible claim. "Total amount paid" means the amount paid by the eligible carrier based upon the allowed amount less any deductible, coinsurance, or co-payment, as of the time the data are submitted or made accessible under section 7 of this act.
L.2018, c.24, s.6.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.7 - Requests for reinsurance payments.

17B:27A-10.7 Requests for reinsurance payments.
7. a. An eligible carrier shall submit a request to the board for reinsurance payments when the eligible carrier's total amount paid for an enrollee meets the criteria for reinsurance payments.
b. An eligible carrier shall make requests for reinsurance payments in accordance with any requirements established by the board.
c. An eligible carrier shall calculate the premium amount the carrier would have charged for the applicable benefit year if the plan was not in effect and submit this information as part of its rate filing.
d. An eligible carrier shall maintain documents and records, whether paper, electronic, or in other media, sufficient to substantiate the requests for reinsurance payments made pursuant to this section for a period of at least six years. An eligible carrier shall also make those documents and records available upon request from the commissioner for purposes of verification, investigation, audit, or other review of reinsurance payment requests.
e. (1) At least once every five years the board shall engage an independent audit firm to audit eligible carriers that receive reinsurance payments to assess compliance with the requirements of this act. The eligible carrier shall cooperate with an audit. If an audit results in a proposed finding of material weakness or significant deficiency with respect to compliance with any requirement of this act or overpayment of reinsurance payments in the audited benefit years, the eligible carrier may respond to the draft audit report within 30 days of the draft audit report's issuance.
(2) Within 30 days of the issuance of the final audit report, if the final audit results in a finding of material weakness or significant deficiency with respect to compliance with any requirement of this act or overpayment of reinsurance payments in the audited benefit years, the eligible carrier shall:
(a) provide a written corrective action plan to the board for approval, that includes recoupment of any reinsurance overpayments;
(b) upon board approval, implement the corrective action plan described; and
(c) provide the board with documentation of the corrective actions taken.
L.2018, c.24, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.8 - Accounting for each benefit year.

17B:27A-10.8 Accounting for each benefit year.
8. The board shall keep an accounting for each benefit year, including but not limited to, the following:
a. funds appropriated for reinsurance payments and administrative and operational expenses;
b. requests for reinsurance payments received from eligible carriers;
c. reinsurance payments made to eligible carriers; and
d. administrative and operational expenses incurred for the plan.
L.2018, c.24, s.8.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.9 - Application for waiver of ACA.

17B:27A-10.9 Application for waiver of ACA.
9. The commissioner shall apply to the United States Secretary of Health and Human Services under 42 U.S.C. s.18052 for a waiver of applicable provisions of the Affordable Care Act with respect to health insurance coverage in the State for a plan year beginning on or after January 1, 2019, to effectuate the provisions of this act. If the waiver is approved, the commissioner may accept the waiver so long as the commissioner determines that implementation of the plan:
a. will be beneficial to policyholders; and
b. is expected to stabilize or reduce premiums in the individual health insurance market through a reduction in what indicated premium rates would be without the plan.
If the commissioner accepts the waiver, the commissioner and the board shall implement the plan to meet the waiver requirements in a manner consistent with federal and State law, as approved by the United States Secretary of Health and Human Services, and consistent with the provisions of this act. The commissioner may contract for actuarial services as necessary to implement the waiver application required pursuant to this section.
L.2018, c.24, s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.10 - New Jersey Health Insurance Premium Security Fund.

17B:27A-10.10 New Jersey Health Insurance Premium Security Fund.
10. a. The New Jersey Health Insurance Premium Security Fund is hereby created in the State Treasury for the purposes of this act. This fund shall be the repository for monies collected pursuant to this act and other monies received as grants in support of this act, or monies otherwise appropriated or directed to be remitted to the fund. The establishment of this fund, the funding sources contained herein, and the plan shall be contingent upon approval from the United States Secretary of Health and Human Services and the United States Secretary of the Treasury of a State Innovation Waiver application pursuant to section 1332 of the Affordable Care Act (42 U.S.C. s.18052) and the commissioner's acceptance of any approval as provided in section 9 of this act.
b. All interest earned on the moneys that have been deposited into the fund shall be retained in the fund and used for purposes consistent with the fund.
c. The fund shall be funded to levels based upon actuarial analysis to stabilize or reduce premiums rates in the individual market achieving between a 10% and 20% reduction in what indicated rates would be for the applicable benefit year without the plan and to cover all necessary administrative costs of the reinsurance provided by the plan.
d. The fund shall be fully funded in accordance with this section by:
(1) All funds collected by the State pursuant to P.L.2018, c.31 (C.54A:11-1 et seq.);
(2) Federal payments received as a result of any waiver of requirements granted or other arrangements agreed to by the United States Secretary of Health and Human Services or other appropriate federal officials; and
(3) For the purpose of providing the funds necessary to carry out the provisions of this act, and in amounts sufficient to ensure funding levels as required by this act after the monies received pursuant to paragraphs (1) and (2) of this subsection, there shall be appropriated annually out of the General Fund of the State an amount as the board, in consultation with the commissioner, determines necessary to fully fund the plan to accomplish the objectives of this act. The board, in consultation with the commissioner, shall calculate the amount necessary to cover the submitted reinsurance requests taking into account all federal waiver payments and other monies in the fund. The board shall issue an order memorializing those amounts and requesting the Legislature to appropriate that amount to the fund.
e. Moneys in the fund shall only be used for the purposes established in this act.
L.2018, c.24, s.10.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.11 - Annual report.

17B:27A-10.11 Annual report.
11. a. The board shall present an annual report to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), which contains a summary of the operations of the Health Insurance Premium Security Plan and the impact of the plan on health insurance premiums. The report shall be made available to the public upon request and by posting on the department's website.
b. (1) The board shall engage and cooperate with an independent certified public accountant to perform an audit for each benefit year of the plan, in accordance with generally accepted auditing standards. The audit shall at a minimum:
(a) assess compliance with the requirements of this act; and
(b) identify any material weaknesses or significant deficiencies and address manners in which to correct any such material weaknesses or deficiencies.
(2) The board, after receiving the completed audit, shall:
(a) provide the commissioner the results of the audit excluding any proprietary information;
(b) identify to the commissioner any material weakness or significant deficiency identified in the audit and address in writing to the commissioner how the board recommends to correct any such material weakness or significant deficiency in compliance with this subsection; and
(c) make available to the public a summary of the results of the audit by posting the summary on the department website and making the summary otherwise available, including any material weakness or significant deficiency and how the board intends to correct the material weakness or significant deficiency.
c. Documents, materials or other information that are in the possession or control of the commissioner or the board and that are obtained by or disclosed to the commissioner, the board, or any other person in the course of an examination or investigation made pursuant to this act shall be confidential by law and privileged and shall not be subject to disclosure or dissemination under P.L.1963, c.71 (C.47:1A-1 et seq.), or any other act. However, the commissioner is authorized to use the documents, materials or other information in the furtherance of any regulatory or legal action brought as a part of the commissioner's official duties. The commissioner shall not otherwise make the documents, materials or other information public without the prior written consent of the carrier.
L.2018, c.24, s.12.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.12 - Violations, penalties.

17B:27A-10.12 Violations, penalties.
12. If a carrier violates any provision of this act, the commissioner may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $1,000 nor more than $10,000 for each day the carrier is in violation of this act. The 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.).
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-10.13 - Rules, regulations.

17B:27A-10.13 Rules, regulations.
13. The board, pursuant to section 8 of P.L.1993, c.164 (C.17B:27A-16.1), and the commissioner, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and in consultation with each other, shall each adopt such rules and regulations as may be necessary to effectuate the purposes of this act.
L.2018, c.24, s.13.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-11 - Powers, authority of program, board.

17B:27A-11 Powers, authority of program, board.
10. The program shall have the general powers and authority granted under the laws of New Jersey to insurance companies, health service corporations and health maintenance organizations licensed or approved to transact business in this State, except that the program shall not have the power to issue health benefits plans directly to either groups or individuals.
The board shall have the specific authority to:
a. assess members their proportionate share of program losses and administrative expenses in accordance with the provisions of section 11 of this act, and make advance interim assessments, as may be reasonable and necessary for organizational and reasonable operating expenses and estimated losses. An interim assessment shall be credited as an offset against any regular assessment due following the close of the fiscal year;
b. establish rules, conditions, and procedures pertaining to the sharing of program losses and administrative expenses among the members of the program;
c. (Deleted by amendment, P.L.2008, c.38).
d. define the provisions of individual health benefits plans in accordance with the requirements of this act;
e. enter into contracts which are necessary or proper to carry out the provisions and purposes of this act;
f. establish a procedure for the joint distribution of information on individual health benefits plans issued pursuant to section 3 of this act;
g. establish, at the board's discretion, standards for the application of a means test for individual health benefits plans issued pursuant to section 3 of this act;
h. establish, at the board's discretion, reasonable guidelines for the purchase of new individual health benefits plans by persons who already are enrolled in or insured by another individual health benefits plan;
i. establish minimum requirements for performance standards for carriers that are reimbursed for losses submitted to the program and provide for performance audits from time to time;
j. sue or be sued, including taking any legal actions necessary or proper for recovery of an assessment for, on behalf of, or against the program or a member;
k. appoint from among its members appropriate legal, actuarial, and other committees as necessary to provide technical and other assistance in the operation of the program, in policy and other contract design, and any other function within the authority of the program;
l. borrow money to effect the purposes of the program. Any notes or other evidence of indebtedness of the program not in default shall be legal investments for carriers and may be carried as admitted assets; and
m. contract for an independent actuary and any other professional services the board deems necessary to carry out its duties under P.L.1992, c.161 (C.17B:27A-2 et al.).
L.1992, c.161, s.10; amended 1993, c.164, s.6; 2008, c.38, s.17.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-12.1 - Exemption from liability, certain, for HMO formed by UMDNJ.

17B:27A-12.1 Exemption from liability, certain, for HMO formed by UMDNJ.
2. Notwithstanding the provisions of any statute to the contrary, a health maintenance organization established by the University of Medicine and Dentistry of New Jersey pursuant to the provisions of P.L.1992, c.84 shall be exempt from liability for the assessment provided for in section 11 of P.L.1992, c.161 (C.17B:27A-12) for the 1999-2000 two-year calculation period.
L.2001,c.349,s.2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-13 - Statement of net paid losses

17B:27A-13. Statement of net paid losses
12. a. No later than March 1, 1993, any carrier issuing individual health benefits plans in the State shall file with the board a statement of any net paid losses for the calendar year ending December 31, 1992, as calculated pursuant to subsection a. of section 11 of this act, along with any supporting information required by the board.
b. The losses filed pursuant to subsection a. of this section shall be reimbursed in an amount up to $10,000,000 or 50% of the paid losses, whichever amount is less, to the carrier filing the losses. The assessment shall be made as a separate assessment from those required pursuant to section 11 of this act, but shall be assessed in the same manner and at the same time as the first assessment made after the effective date of this act as provided for in section 11 of this act, except that the carrier filing for the reimbursement shall not be subject to an assessment pursuant to this section.
L.1992,c.161,s.12.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-14 - Determination of disproportionate share of substandard risks

17B:27A-14. Determination of disproportionate share of substandard risks
13. The board shall determine whether any carrier has a disproportionate share of substandard risks insured or enrolled under its individual health benefits plans and shall make recommendations to the Governor and the Legislature for remedial action to minimize the losses sustained by the carrier as a result of insuring these risks.
L.1992,c.161,s.13.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-15 - Sale of health benefits plan

17B:27A-15. Sale of health benefits plan
14. A health benefits plan issued pursuant to section 3 of this act may be sold through an insurance producer licensed pursuant to P.L.1987, c.293 (C.17:22A-1 et seq.).
L.1992,c.161,s.14.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-16 - Submission of rate filings by health maintenance organization not required

17B:27A-16. Submission of rate filings by health maintenance organization not required
15. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a health maintenance organization shall not be required to submit any rate filings with the commissioner for an individual health benefits plan that is subject to the provisions of this act, but shall be subject to the minimum loss ratio provisions of section 8 of this act.
L.1992,c.161,s.15.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-16.2 - Adoption of temporary plan of operation

17B:27A-16.2. Adoption of temporary plan of operation
9. a. The commissioner shall, under the procedures provided pursuant to section 7 of P.L.1993, c.164, adopt a temporary plan of operation prepared pursuant to section 9 of P.L.1992, c.161 (C.17B:27A-10), pending submission or approval of a plan of operation prepared by the board pursuant to that section 9.
b. Subsequent amendments to the plan of operation shall be reviewed and approved by the commissioner pursuant to the procedures provided in sections 7 and 8 of P.L.1993, c.164 (C.17B:27A-16.1), as applicable.
L.1993,c.164,s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-16.3 - Purchase of other insurance coverage not required

17B:27A-16.3. Purchase of other insurance coverage not required
10. A carrier shall not require an eligible person to purchase any other insurance coverage, including, but not limited to, life insurance, accident insurance or disability insurance, as a condition of or in conjunction with the purchase of a health benefits plan pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.).
L.1993,c.164,s.10.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-16.4 - Adoption of standard claim form

17B:27A-16.4. Adoption of standard claim form
11. The board, in conjunction with the board of the New Jersey Small Employer Health Benefits Program established pursuant to section 12 of P.L.1992, c.162 (C.17B:27A-28), shall adopt one standard claim form.
In order to provide a standard system of payment for medical services, all claim forms for a claimant's use under an individual health benefits plan issued or delivered in this State shall conform to the form adopted by the board.
L.1993,c.164,s.11.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-16.5 - Hospital, medical insurance policy renewals; filing of rates.

17B:27A-16.5 Hospital, medical insurance policy renewals; filing of rates.
5. A domestic mutual insurer which has converted from a health service corporation pursuant to the provisions of sections 2 through 4 of P.L.1995, c.196 (C.17:48E-46 through C.17:48E-48) shall not renew individual hospital or medical insurance policies or health service contracts originally issued prior to November 30, 1992, until it has made an informational filing with the commissioner. The rates shall be formulated so that the anticipated minimum loss ratio for such policy or contract form shall not be less than 80% of the premium. Such domestic mutual insurer shall submit with its rate filing supporting data and a certification that the insurer is in compliance with the anticipated loss ratio requirement. The content and form of 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. Any other insurer may irrevocably elect to become subject to the provisions of this section by written notice to the commissioner in a format specified by the commissioner.
L.1995, c.196, s.5; amended 2008, c.38, s.19.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-18 - Providers of health benefits, services subject to provisions of act

17B:27A-18. Providers of health benefits, services subject to provisions of act
2. Every health insurer, health service corporation, medical service corporation, hospital service corporation, and health maintenance organization licensed or authorized to provide health benefits or services in this State which offers health insurance policies or coverages to small employers shall be subject to the provisions of this act. Carriers shall offer coverage to all eligible employees of small employers and their dependents and shall not exclude any employee or eligible dependent on the basis of a health status-related factor.
L.1992,c.162,s.2; amended 1997, c.146, s.8.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-18.1 - Provision of benefits to subscriber's child under small employer policy, contract.

17B:27A-18.1 Provision of benefits to subscriber's child under small employer policy, contract.
9. a. A policy or 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 policy or contract shall not deny coverage for a covered employee'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 covered employee's federal tax return;
(3) The child does not reside with the covered employee or in the carrier's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the policy or 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 policy or contract of a noncustodial parent, the carrier 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 covered employee is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the carrier 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 policy or contract if the parent who is the covered employee fails to enroll the child; and
(3) Not terminate coverage of the child unless the parent who is the covered employee provides the carrier 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.9; amended 2019, c.356, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-18.2 - Requirements applicable to State Medicaid

17B:27A-18.2. Requirements applicable to State Medicaid
10. A carrier shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other covered employee.
L.1995,c.288,s.10.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19a - Small employer carrier, offering of high deductible plan.

17B:27A-19a Small employer carrier, offering of high deductible plan.
17. A small employer carrier, as a condition of transacting business in this State, may offer, on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), a health benefits plan pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), if that health benefits plan is offered to an eligible small employer that:
a. is a policy or contract holder prior to and on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) which does not qualify as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223);
b. is not a policy or contract holder on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) which does not qualify as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223) for a period of five years; or
c. was not a policy or contract holder under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) prior to the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.).
L.2005,c.248,s.17.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.1 - Hospital confinement, other supplemental limited benefit insurance plans; requirements

17B:27A-19.1. Hospital confinement, other supplemental limited benefit insurance plans; requirements
10. a. A carrier shall not deliver or issue for delivery a hospital confinement or other supplemental limited benefit insurance plan unless the applicant for such coverage signs a statement on the application form that confirms that the applicant is already covered under a health benefits plan contract or policy. The application form shall be filed with the board on an informational basis.
b. A hospital confinement plan or other supplemental limited benefit insurance plan issued to a small employer or other group health benefits plan provider or to individual employees of a small employer or other group health benefits provider:
(1) shall be subject to the same rating requirements that apply to health benefits plans issued pursuant to paragraph (2) of subsection a. of section 9 of P.L.1992, c.162 (C.17B:27A-25), except that a hospital confinement plan and supplemental limited benefit insurance plan shall be subject to the commissioner's exclusive review and regulation with regard to loss ratios, medical underwriting and eligibility requirements, and form approval; and
(2) may include preexisting condition exclusions.
c. A health benefits plan shall not coordinate benefits against any hospital confinement or other supplemental limited benefit insurance plan.
L.1994,c.11,s.10.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.2 - Coverage for birth and natal care; small employer health policy.

17B:27A-19.2 Coverage for birth and natal care; small employer health policy.
6. a. Every policy that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide benefits for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
b. Notwithstanding the provisions of subsection a. of this section, a policy that provides coverage for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child.
c. Every insurer shall provide notice to policyholders regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the policyholder; (2) the yearly informational packet sent to the policyholder; or (3) January 1, 1996.
L.1995,c.138,s.6.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.3 - Regulations governing rating methodology, calculation of loss ratios

17B:27A-19.3. Regulations governing rating methodology, calculation of loss ratios
7. The commissioner, in consultation with the board, shall establish regulations governing the applicable rating methodology and manner in which loss ratios shall be calculated for health benefits plans permitted to be renewed or continued pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19). In establishing these regulations, the commissioner may consider, but shall not be limited to, the impact of allowing these health benefits plans to continue to be rated separately from the standard health benefits plans established pursuant to subsection a. of section 3 of P.L.1992, c.162 (C.17B:27A-19) and on their own claims experience. If the commissioner determines that the continuation of separate rating pools adversely affects the small employer insurance market and serves to counter the public policy goals which led to the enactment of P.L.1992, c.162 (C.17B:27A-17 et seq.), the commissioner shall develop a methodology which creates a linkage between the standard health benefits plans established pursuant to subsection a. of section 3 of P.L.1992, c.162 (C.17B:27A-19) and the plans permitted to be continued or renewed pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19) for the purpose of rating and loss ratio calculation.
Regulations established under the provisions of this section shall detail all additional obligations of carriers continuing or renewing health benefits plans pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19) which are necessary to meet the general requirements of P.L.1992, c.162 (C.17B:27A-17 et seq.).
The regulations shall be adopted pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) no later than 180 days following the effective date of this act. Until such time as the regulations are adopted, the health benefits plans shall continue to be rated and subject to the loss ratio calculations in accordance with applicable law in effect on the effective date of P.L.1995, c.340.
L.1995,c.340,s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.4 - Coverage for minimum inpatient care following mastectomy by small employer health benefits plan

17B:27A-19.4. Coverage for minimum inpatient care following mastectomy by small employer health benefits plan
7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide benefits for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The health benefits plan shall not require a health care provider to obtain authorization from the carrier for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.
The provisions of this section shall not be construed to: require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate: or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the carrier under the health benefits plan.
The benefits shall be provided to the same extent as for any other sickness under the health benefits plan.
The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
b. The New Jersey Small Employer Health Benefits Program Board shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.
L.1997,c.149,s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.5 - Applicability of Health Care Quality Act

17B:27A-19.5 Applicability of Health Care Quality Act
23. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy or contract meets the requirements of P.L.1997, c.192 (C.26:2S-1 et al.) and regulations adopted thereto. The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.
L.1997,c.192,s.23.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.6 - Coverage for treatment of inherited metabolic diseases by small employer health benefits plan.

17B:27A-19.6 Coverage for treatment of inherited metabolic diseases by small employer health benefits plan.
7. No small employer health benefits plan subject to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the health benefits plan provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.
For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.
The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.
L.1997,c.338,s.7.