reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.50 - Contract, health care services, coverage, prescription asthma inhaler.

26:2J-4.50 Contract, health care services, coverage, prescription asthma inhaler.
18. A contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State 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 health maintenance organization 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.18.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-5 - Powers of health maintenance organizations

26:2J-5. Powers of health maintenance organizations
a. The powers of a health maintenance organization include the following:
(1) the purchase, lease, construction, renovation, operation, or maintenance of health care facilities, and their ancillary equipment, and such property as may reasonably be required for its principal office or for such other purposes as may be necessary in the transaction of the business of the organization;
(2) the receiving of funds by loan or otherwise;
(3) the making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation or corporations under its control for the purpose of acquiring or constructing health care facilities or in furtherance of a program providing health care services to enrollees;
(4) the assumption of responsibility for the furnishing of health care services through providers which are under contract with or employed by the health maintenance organization to persons including but not limited to enrollees;
(5) the contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment and administration;
(6) the contracting with an insurance company licensed in this State, or with a hospital or medical service corporation authorized to do business in this State, for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization which may include provisions for reasonable classifications for the purpose of establishing rates and reasonable restrictions based on underwriting consideration; and
(7) the offering, in addition to basic health care services, of:
(a) additional health care services;
(b) indemnity benefits covering out-of-area or emergency services; and
(c) indemnity benefits, in addition to those relating to out-of-area and emergency services, provided through insurers or hospital or medical service corporations.
b. (1) A health maintenance organization shall file notice, with adequate supporting information, with the commissioner prior to the exercise of any power granted in subsection a. (1) or (2) of this section. The commissioner shall disapprove such exercise of power if in his opinion it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the commissioner does not disapprove within 30 days of filing, it shall be deemed approved.
(2) The commissioner may promulgate rules and regulations exempting from the filing requirements of paragraph (1) of this subsection those activities having a de minimis effect.
L.1973, c. 337, s. 5, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-6 - Governing body

26:2J-6. Governing body
a. The governing body of any health maintenance organization may include providers, other individuals, or both.
b. Such governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions, or through the use of other mechanisms.
L.1973, c. 337, s. 6, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-7 - Protection against wrongful acts

26:2J-7. Protection against wrongful acts
Any director, officer employee or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of such organization shall be bonded in an amount to be determined by the commissioner.
L.1973, c. 337, s. 7, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-9 - Annual report

26:2J-9. Annual report
a. Every health maintenance organization shall annually, on or before March 1, file a report verified by at least two principal officers with the commissioner, with a copy to the Commissioner of Insurance covering the preceding calendar year.
b. Such report shall be on forms prescribed by the commissioner and shall include:
(1) a financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding year certified by an independent public accountant;
(2) any material changes in the information submitted pursuant to section 3 c. hereof;
(3) the number of persons enrolled during the year, the number of enrollees as of the end of the year and the number of enrollments terminated during the year;
(4) a summary of information compiled pursuant to section 4 a. (2)(c) hereof in such form as required by the commissioner"; and
(5) such other information relating to the performance of the health maintenance organization as is necessary to enable the commissioner to carry out his duties under this act.
L.1973, c. 337, s. 9, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-10 - Information to enrollees

26:2J-10. Information to enrollees
a. Every health maintenance organization shall annually provide to its enrollees:
(1) a summary of any material changes since the issuance of the last report;
(2) a description of the available health care services and information as to where and how to secure them; and
(3) a clear and understandable description of the health maintenance organization's method for resolving enrollee complaints.
b. Every health maintenance organization shall make available to its enrollees the most recent annual statement of financial condition.
L.1973, c. 337, s. 10, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-10.1 - Coverage provided by health maintenance organization for subscriber's child.

26:2J-10.1 Coverage provided by health maintenance organization for subscriber's child.
13. a. A health maintenance organization contract or certificate in which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A contract or certificate shall not deny coverage for an enrollee's child for health care services on the grounds that:
(1) The child was born out of wedlock;
(2) The child is not claimed as a dependent on the enrollee's federal tax return;
(3) The child does not reside with the enrollee or in the health maintenance organization's service area, provided that the child complies with the terms and conditions of the coverage with respect to the use of specified providers;
(4) The child is married;
(5) The child has or adopts a child; or
(6) The child starts or leaves school.
b. If a child has coverage through a health maintenance organization plan of a noncustodial parent, the health maintenance organization shall:
(1) Provide such information to the custodial parent as may be necessary for the child to obtain health care services 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 health care 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 enrollee is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the health maintenance organization 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 if the parent who is the enrollee fails to enroll the child; and
(3) Not terminate coverage of the child unless the parent who is the enrollee provides the health maintenance organization 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.13; amended 2019, c.356, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-10.2 - Requirements applicable to State Medicaid

26:2J-10.2. Requirements applicable to State Medicaid
14. A health maintenance organization 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 enrollee.
L.1995,c.288,s.14.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-11 - Annual open enrollment period

26:2J-11. Annual open enrollment period
a. After a health maintenance organization has been in operation 24 months, it shall have an annual open enrollment period of at least one month during which it accepts enrollees up to the limits of its capacity, as determined by the health maintenance organization, in the order in which they apply for enrollment. A health maintenance organization may apply to the commissioner for authorization to impose such underwriting restrictions upon enrollment as are necessary to preserve its financial stability, to prevent excessive adverse selection by prospective enrollees, or to avoid unreasonably high or unmarketable charges for enrollee coverage for health care services. The commissioner shall approve or deny such application within 30 days of the receipt thereof from the health maintenance organization. The Commissioner of Insurance shall certify to the commissioner the appropriateness of any requested underwriting restrictions.
b. Health maintenance organizations providing or arranging for services exclusively on a group contract basis may limit the open enrollment provided for in subsection a. to all members of the group or groups covered by such contracts.
c. A health maintenance organization shall notify its enrollees in writing at the time of enrollment, and include a notice in the promotional material which it distributes to prospective enrollees, that a person's choice of health benefits plan will determine his coverage until the next annual open enrollment period, regardless of the continued availability of a particular health care provider who contracts with that health maintenance organization, unless the enrollee moves his place of residence outside of the organization's designated service area.
L.1973, c.337, s.11; amended 1989,c.321,s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-11.1 - Failure to agree on terms; four-month extension; notification of options

26:2J-11.1. Failure to agree on terms; four-month extension; notification of options
If a health maintenance organization authorized to operate in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) and a general hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) with which the health maintenance organization has a contract to provide services to its enrollees, are unable to agree on the terms of a new contract upon the expiration of the current contract, the hospital and the health maintenance organization shall continue to abide by the terms of the most current contract for a period of four months from a severance date mutually agreed upon by both parties. In that event, the health maintenance organization shall promptly notify the health care providers with which it has contracted to provide services and provide notification within the four-month extension period to those of its enrollees who reside in the county in which the hospital is located or in an adjacent county in writing as to the extension of the terms of the most current contract, and shall in the notice to its enrollees advise them of the options available to them with respect to their health care coverage.
L.1989, c.321, s.2.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-12 - Complaint system

26:2J-12. Complaint system
a. (1) Every health maintenance organization shall establish and maintain a complaint system to provide reasonable procedures for the resolution of written complaints initiated by enrollees concerning health care services.
(2) Each health maintenance organization shall submit to the commissioner an annual report in a form prescribed by him which shall include:
(a) a description of the procedures of such complaint system;
(b) the total number of written complaints handled through such complaint system and a compilation of causes underlying the complaints filed; and
(c) the number, amount, and disposition of malpractice claims settled during the year by the health maintenance organization and any of the providers used by it.
b. The health maintenance organization shall maintain records of written complaints filed with it concerning other than health care services and shall submit to the commissioner a summary report at such times and in such format as the commissioner may require.
c. The commissioner may examine such complaint system.
L.1973, c. 337, s. 12, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-13 - Investments

26:2J-13. Investments
With the exception of investments made in accordance with section 5 a. (1) and (3) hereof, the investable funds of a health maintenance organization shall be only in securities or other investments permitted by the laws of this State for the investment of assets constituting the legal reserves of life insurance companies or such other securities or investments as the commissioner may permit with the approval of the Commissioner of Insurance.
L.1973, c. 337, s. 13, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-14 - Protection against insolvency

26:2J-14. Protection against insolvency
Each health maintenance organization shall deposit cash or a form of guaranty or security in such amount as will assure that the obligations to the enrollees will be performed in such amount and for such time as prescribed by the commissioner, or where applicable by the Commissioner of Insurance. The commissioner may waive this requirement whenever satisfied that the assets of the organization or its contracts with insurers, hospital or medical service corporation governments, or other organizations are sufficient to reasonably assure the performance of its obligations.
L.1973, c. 337, s. 14, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-15.1 - Health care services contract, exclusion, rates, terms based on genetic information prohibited

26:2J-15.1. Health care services contract, exclusion, rates, terms based on genetic information prohibited
16. Every contract for health care services that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall not exclude any person or eligible dependent and shall not establish any rates or terms therefor on the basis of an actual or expected health condition or on the basis of any genetic characteristic. For the purposes of this section, "genetic characteristic" means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with statistically increased risk of development of a disease, disorder or syndrome.
L.1996,c.126,s.16.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-16 - Regulation of agents

26:2J-16. Regulation of agents
The commissioner may, after notice and hearing, promulgate such reasonable rules and regulations, which have been approved by the Commissioner of Insurance, as are necessary to provide for the certification of agents. An agent as used herein means a person directly or indirectly associated with a health maintenance organization who engages in solicitation or enrollment for compensation.
L.1973, c. 337, s. 16, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-17 - Powers of insurers and hospital and medical service corporations

26:2J-17. Powers of insurers and hospital and medical service corporations
a. An insurance company licensed in this State, or a hospital or medical service corporation authorized to do business in this State, may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this act. Notwithstanding any other law which may be inconsistent herewith, any two or more such insurance companies, hospital or medical service corporations, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization.
b. Notwithstanding any provision of Title 17 of the Revised Statutes and Title 17B of the New Jersey Statutes, an insurer or a hospital or medical service corporation may contract with a health maintenance organization to provide insurance or protection against the cost of care furnished through health maintenance organizations and to provide coverage in the event of the failure of health maintenance organization to meet its obligations. The enrollees of a health maintenance organization constitute a permissible group under such laws. Among other things, under such contracts, the insurer or hospital or medical service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers.
L.1973, c. 337, s. 17, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-18 - Examinations

26:2J-18. Examinations
a. Not less frequently than once every 3 years the commissioner may make an examination concerning the quality of health care services and other affairs of the health maintenance organization and providers with whom such organization has contracts, agreements, or other arrangements. The commissioner may make such examination at any time.
b. Every health maintenance organization and provider shall submit its books and records to such examinations. For the purpose of examinations, the commissioner may administer oaths to, and examine the officers and agents of the health maintenance organization and the principals of such providers concerning their business.
c. The expenses of examinations under this section up to $1,000.00 annually shall be assessed against the organization being examined and such amount shall be remitted to the commissioner.
d. In lieu of such examination, the commissioner may accept the report of an examination made by the Commissioner of Health or Commissioner of Insurance of another state.
L.1973, c. 337, s. 18, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-18.1 - Examination of HMO by Commissioner of Banking and Insurance.

26:2J-18.1 Examination of HMO by Commissioner of Banking and Insurance.
20. The Commissioner of Banking and Insurance may conduct an examination of a health maintenance organization in accordance with the procedures provided in P.L.1993, c.236 (C.17:23-20 et seq.) as often as he deems necessary in order to protect the interests of providers, contract holders, members, and the residents of this State. An organization shall make its relevant books and records available for examination by the Commissioner of Banking and Insurance, and retain its records in accordance with a schedule established by the Commissioner of Banking and Insurance by regulation. The reasonable expenses of the examination shall be borne by the organization being examined. In lieu of such examination, the Commissioner of Banking and Insurance may accept the report of an examination made by the commissioner of another state.
L.1997,c.192,s.20; amended 2005, c.65, s.7.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-18.2 - Definitions relative to risk based capital requirements for HMOs.

26:2J-18.2 Definitions relative to risk based capital requirements for HMOs.
1. As used in sections 1 through 5 of P.L.2005, c.65 (C.26:2J-18.2 et seq.):
"Commissioner" means the Commissioner Banking and Insurance.
"Health maintenance organization" means an entity authorized to transact business in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.).
L.2005,c.65,s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-18.4 - Factors in determining change in capital, surplus.

26:2J-18.4 Factors in determining change in capital, surplus.
3. In determining any increase, revision or redetermination in the capital or surplus of a health maintenance organization pursuant to the provisions of section 2 of P.L.2005, c.65 (C.26:2J-18.3) the commissioner shall take into account the following factors:
a. Methods and techniques used to measure risk exposure and variability;
b. The information available relating to the magnitude of the various risks described in section 2 of P.L.2005, c.65 (C.26:2J-18.3);
c. The extent to which risks described in section 2 of P.L.2005, c.65 (C.26:2J-18.3) are independent or interrelated, and whether any dependency is direct or inverse;
d. The extent to which the health maintenance organization has provided protection against contingencies in ways other than the establishment of surplus, including, but not limited to: redundancy of premiums; margin in reserves and liabilities; adjustability of contracts pursuant to the terms of the contracts; voluntary or mandatory investment valuation reserves; reinsurance; the use of conservative actuarial assumptions to provide a margin of security; reserve adjustments after rate increases for policies written at earlier and less adequate rates; contingency or catastrophe reserves; and diversification of assets and underwriting risk; and
e. Any other relevant factors, including the National Association of Insurance Commissioners' reports and independent judgments of the soundness of the health maintenance organization's financial condition, as evidenced by the rating and reports of reliable professional financial services.
L.2005,c.65,s.3.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-18.5 - Noncompliance, penalties.

26:2J-18.5 Noncompliance, penalties.
4. The commissioner may suspend or revoke the authority to do business in this State of any health maintenance organization that does not comply with the provisions of P.L.2005, c.65 (C.26:2J-18.2 et al.).
L.2005,c.65,s.4.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-18.6 - Regulations.

26:2J-18.6 Regulations.
5. The commissioner may promulgate regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to effectuate the purposes of P.L.2005, c.65 (C.26:2J-18.2 et al.).
L.2005,c.65,s.5.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-21 - Regulation

26:2J-21. Regulation
The commissioner may, upon notice and hearing, promulgate reasonable rules and regulations, as are necessary or proper to carry out the provisions of this act. Where applicable, such rules and regulations shall be promulgated after consultation with the Commissioner of Insurance. Such rules and regulations shall specify those determinations in this act which are to be made by the Commissioner of Insurance and shall be subject to review in accordance with the Administrative Procedure Act, P.L.1968, c. 410 (C. 52:14B-1 et seq.).
L.1973, c. 337, s. 21, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-22 - Administrative procedures

26:2J-22. Administrative procedures
a. When the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, he shall notify the health maintenance organization and the Commissioner of Insurance in writing specifically stating the grounds for denial, suspension, or revocation and fixing a time of at least 20 days thereafter for a hearing on the matter.
b. The Commissioner of Insurance, or his designated representative, shall be in attendance at the hearing and shall participate in the proceedings. The recommendation and findings of the Commissioner of Insurance with respect to matters relating to the doing of an insurance business or contract with an insurer or hospital or medical services corporation, provided in connection with any decision regarding denial, suspension, or revocation of a certificate of authority, shall be conclusive and binding upon the commissioner. After such hearing, or upon the failure of the health maintenance organization to appear at such hearing, the commissioner shall take action as is deemed advisable on written findings which shall be mailed to the health maintenance organization with a copy thereof to the Commissioner of Insurance. The action of the commissioner and the recommendation and findings of the Commissioner of Insurance and the levy of any administrative penalty shall be subject to judicial review in accordance with chapter 34 of Title 17B of the New Jersey Statutes.
c. The provisions of the Administrative Procedure Act, P.L.1968, c. 410 (C. 52:14B-1 et seq.) of this State shall apply to proceedings under this section to the extent they are not in conflict with subsections a. and b. of this section.
L.1973, c. 337, s. 22, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-23 - Fees.

26:2J-23 Fees.
23. Every health maintenance organization subject to this act shall pay to the commissioner the following fees:
a. for filing an application for a certificate of authority or amendment thereto, $100.00;
b. for filing each annual report, $10.00; and
c. for the purpose of supporting the activities of the Department of Banking and Insurance associated with the regulation of health maintenance organizations, $1.50 per life per year, with payment being made annually no later than July 15 for the preceding calendar year. Payments made by a health maintenance organization pursuant to this act shall not in any way reduce payments that may be owed by a health maintenance organization pursuant to P.L.1995, c.156 (C.17:1C-19 et seq.) and subsequent amendments thereto. No such payment shall be required for any per life per year that is funded through the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) or the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.).
In accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), the commissioner may promulgate rules and regulations directing that additional fees be paid.
From fees collected under the provisions of subsection c. of this section, the Legislature shall in each fiscal year appropriate to the community health law project the sum of $100,000 to fund a grant in support of a program to provide any senior citizen resident of this State who is covered as an enrollee in or beneficiary of a health plan administered by a health maintenance organization with information concerning the person's rights under the program and assistance with the procedures for receiving the benefits to which the person is entitled under the program.
L.1973, c.337, s.23; amended 2002, c.34, s.18; 2012, c.17, s.277.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-25 - Statutory construction and relationship to other laws.

26:2J-25 Statutory construction and relationship to other laws.
25. Statutory construction and relationship to other laws.
a. Except as otherwise provided in this act, provisions of the insurance law and provisions of hospital, medical or health service corporation laws shall not be applicable to any health maintenance organization granted a certificate of authority under this act. This provision shall not apply to an insurer or hospital, medical or health service corporation licensed and regulated pursuant to the insurance laws or the hospital, medical or health service corporation laws of this State except with respect to its health maintenance organization activities authorized and regulated pursuant to this act. Charges paid by or on behalf of enrollees of a health maintenance organization with respect to health care services shall not be subject to taxation by the State or any of its political subdivisions, except as otherwise provided in section 3 of P.L.2004, c.49 (C.26:2J-47).
b. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
c. Any health maintenance organization authorized under this act shall not be deemed to be practicing medicine and shall be exempt from the provisions of chapter 9 of Title 45, Medicine and Surgery, of the Revised Statutes relating to the practice of medicine.
d. Except as provided in P.L.2001, c.187 (C.2A:53A-30 et al.), no person participating in the arrangements of a health maintenance organization other than the actual provider of health care services or supplies directly to enrollees and their families shall be liable for negligence, misfeasance, nonfeasance or malpractice in connection with the furnishings of such services and supplies. The provisions of this subsection shall not be construed to eliminate any cause of action against a health maintenance organization otherwise provided by law.
e. A health maintenance organization shall be subject to the provisions of P.L.1970, c.22 (C.17:27A-1 et seq.), including those relating to merger or acquisition of control.
L.1973,c.337,s.25; amended 2001, c.2, s.1; 2001, c.187, s.8; 2004, c.49, s.4; 2005, c.129, s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-26 - Filings and reports as public documents.

26:2J-26 Filings and reports as public documents.
26. Filings and reports as public documents.
All applications, filings and reports required under this act shall be treated as public documents and, except for any examination being conducted pursuant to section 20 of P.L.1997, c.192 (C.26:2J-18.1), any matter pertaining to a change in capital or surplus pursuant to the provisions of P.L.2005, c.65 (C.26:2J-18.2 et al.) and contracts referred to in paragraphs (4) and (5) of subsection c. of section 3 of P.L.1973, c. 337 (C.26:2J-3), shall not be considered to be confidential.
L.1973,c.337,s.26; amended 2005, c.65, s.6.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-27 - Confidentiality of medical information

26:2J-27. Confidentiality of medical information
Any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant obtained from such enrollee or from any provider by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this act; or upon the express consent of the enrollee or applicant; or pursuant to statute or court order for the production of evidence or the discovery thereof; or in the event of claim or litigation between such enrollee and the health maintenance organization wherein such data or information is pertinent. A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the provider who furnished such information to the health organization is entitled to claim.
L.1973, c. 337, s. 27, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-28 - Commissioner of health's authority to contract

26:2J-28. Commissioner of health's authority to contract
The commissioner or where applicable the Commissioner of Insurance, in carrying out his obligations under sections 4 a. (2), and 18 a. hereof, may contract with qualified persons to make recommendations concerning the determinations required to be made by him. Such recommendations may be accepted in full or in part by the commissioner or Commissioner of Insurance.
L.1973, c. 337, s. 28, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-29 - Enrollment of State employees

26:2J-29. Enrollment of State employees
Any employee of the State or any subdivision of the State or any institution supported in whole or in part by the State may elect to enroll in a health maintenance organization and have all deductions from his salary or wages and all contributions being paid by his employer to any health insurer paid instead to a health maintenance organization; provided, however, in no event, shall an employer under this section make a contribution to any alternative health benefits program greater than the contribution being made to any health plan pursuant to a contract in existence on the effective date of this act. Any such employee shall at least annually be allowed to choose an alternative health benefits program made available through his employer.
L.1973, c. 337, s. 29, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-30 - Severability

26:2J-30. Severability
If any section, term, or provision of this act shall be adjudged invalid for any reason, such judgment shall not affect, impair, or invalidate any other section, term, or provision of this act, but the remaining sections, terms, and provisions shall be and remain in full force and effect.
L.1973, c. 337, s. 30, eff. Dec. 27, 1973.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-31 - Definitions

26:2J-31. Definitions
1. As used in this act:
"Applicant" means any individual who seeks enrollment with a health maintenance organization for the purpose of obtaining medicare supplement health care services.
"Commissioner" means the Commissioner of Insurance.
"Department" means the Department of Insurance.
"Enrollee" means an individual who is enrolled with a health maintenance organization.
"Evidence of coverage" means any booklet, certificate, agreement or contract issued to an enrollee setting out the services and other benefits to which he is entitled.
"Health care services" means those services, including, but not limited to, inpatient hospital and physician care, and outpatient medical services, as set forth in the evidence of coverage.
"Health maintenance organization" means any person which, directly or through contracts with providers, furnishes health care services on a prepaid basis to enrollees in a designated geographic area in this State pursuant to the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.).
"Medicare" means the program established by the "Health Insurance for the Aged Act," Title XVIII of the "Social Security Act," Pub.L. 89-97, as then constituted or later amended (42 U.S.C. s.1395 et seq.).
"Medicare supplement contract" means a group or individual contract or plan which is advertised, marketed or designed primarily as providing, or is otherwise held out to provide, medicare supplement health care services and under which an individual is enrolled, other than a contract issued pursuant to a contract under 42 U.S.C. s.1395l or 42 U.S.C. s.1395mm or a contract issued under a demonstration project authorized pursuant to the "Health Insurance for the Aged Act," 42 U.S.C. s.1395 et seq. The term does not include health care services provided pursuant to a contract or plan issued to one or more employers or labor organizations, or to the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees of the employers, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.
"Medicare supplement evidence of coverage" means an evidence of coverage delivered to an enrollee who has medicare supplement health care services coverage under a medicare supplement contract.
"Medicare supplement health care services" means health care services which supplement medicare, provided under a medicare supplement contract as set forth in a medicare supplement evidence of coverage.
"Provider" means any physician, hospital or other person which is licensed or otherwise authorized in this State to furnish health care services.
L.1992,c.164,s.1.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-32 - Applicability of act

26:2J-32. Applicability of act
2. Except as otherwise specifically provided:
a. This act shall apply to all medicare supplement health care services provided pursuant to a medicare supplement contract or evidence of coverage delivered or issued for delivery in this State.
b. This act shall not apply to any health maintenance organization contract or evidence of coverage, including group conversion plans, provided to medicare eligible persons that are not advertised, marketed, designed primarily as or otherwise held out to provide medicare supplement health care services.
L.1992,c.164,s.2.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-33 - Avoidance of duplication of benefits, regulations

26:2J-33. Avoidance of duplication of benefits, regulations
3. a. No medicare supplement contract or evidence of coverage shall provide for health care services which duplicate any benefits provided by medicare.
b. The commissioner shall promulgate regulations to establish specific standards for the provisions to be contained in any medicare supplement contract or evidence of coverage, which shall be in addition to and in accordance with the applicable laws of this State. The regulations may provide, but shall not be limited to:
(1) Terms of renewability;
(2) Initial and subsequent conditions of eligibility;
(3) Non-duplication of coverage;
(4) Probationary periods;
(5) Benefit limitations, exceptions and reductions;
(6) Elimination periods;
(7) Requirements for replacement;
(8) Recurrent conditions; and
(9) Definition of terms.
c. The commissioner may promulgate regulations that specify prohibited medicare supplement contract or evidence of coverage provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any applicant for, or enrollee with, medicare supplement health care services coverage.
L.1992,c.164,s.3.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-34 - Coverage for preexisting condition

26:2J-34. Coverage for preexisting condition
4. Notwithstanding any other provision of law to the contrary, a medicare supplement contract or evidence of coverage shall not deny medicare supplement health care services for losses incurred more than six months from the effective date of enrollment for a preexisting condition. The contract or evidence of coverage shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months of the effective date of enrollment.
L.1992,c.164,s.4.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-35 - Regulations

26:2J-35. Regulations
5. The commissioner shall promulgate regulations to effectuate and enforce the provisions of this act and any regulations which are necessary to conform medicare supplement health care services provided under a medicare supplement contract or evidence of coverage with federal law. These regulations shall include, but not be limited to:
a. Establishment of minimum standards for benefits, claim payments, marketing and reporting practices and compensation arrangements;
b. Establishment of a uniform methodology for calculating and reporting loss ratios, and requiring refunds or credits if the medicare supplement contracts do not meet loss ratio requirements;
c. Establishment of a process for filing of all requests for premium increases and rate changes which may include public hearings as determined appropriate by the commissioner prior to approval of any premium increases;
d. Assurance of access by the public to policy, premium and loss ratio information; and
e. Establishment of standards for Medicare Select contracts at such time as this State is authorized under federal law to authorize Medicare Select contracts.
L.1992,c.164,s.5.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-36 - Authorization for health maintenance organization to offer, provide medicare supplement health care services

26:2J-36. Authorization for health maintenance organization to offer, provide medicare supplement health care services
6. No health maintenance organization shall offer or provide medicare supplement health care services in this State without authorization by the commissioner. The commissioner shall grant authorization if he determines that the health maintenance organization has the financial and operational capability to provide such services. In making a determination, the commissioner may consider, but shall not be limited to, the following:
a. The number of enrollees;
b. The geographic area to be serviced;
c. The current and prospective financial condition of the health maintenance organization;
d. The anticipated impact on the health maintenance organization of providing medicare supplement health care services in addition to other services which it provides.
L.1992,c.164,s.6.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-39 - 30-day return provision, refunds

26:2J-39. 30-day return provision, refunds
9. Notice shall be prominently printed on the first page of each medicare supplement contract and evidence of coverage stating in substance that the applicant shall have the right to return the contract or evidence of coverage within 30 days of its delivery and to have any premium or other fee refunded if, after examination of the contract or evidence of coverage, the applicant is not satisfied for any reason. Refunds made pursuant to this section shall be made in a timely manner and shall be paid directly to the applicant.
L.1992,c.164,s.9.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-40 - Filing of copy of advertising materials, regulations

26:2J-40. Filing of copy of advertising materials, regulations
10. a. Every health maintenance organization shall file with the department a copy of all advertising materials to be used in promoting medicare supplement health care services to which residents of this State will have access, and through which the health maintenance organization intends, or by implication purports to the reasonable, targeted consumer its intent, to make such services available for enrollment in this State. The requirements of this section shall apply to all advertisements in any medium whether in print or by means of television or radio broadcast. Filings shall be made at least 30 days prior to the date on which the advertisement is to be used in this State, or made accessible to residents of this State.
b. The commissioner may, in the public interest, promulgate regulations governing medicare supplement health care services advertising including, but not limited to, specific filing procedures, standards upon which review may be based, celebrity endorsements, unfair practices and review and disapproval procedures.
c. Notwithstanding the provisions of subsection b. of this section, the commissioner may disapprove any advertisement for use in this State at any time if he determines that the advertisement misrepresents the product, misleads the targeted consumer, uses a strategy which involves scare tactics, unnecessarily confusing data or representations, false or fraudulent statements or otherwise violates any applicable law of this State or regulation promulgated thereunder.
L.1992,c.164,s.10.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-41 - Additional remedies

26:2J-41. Additional remedies
11. In addition to any other applicable penalties for violation of the relevant provisions of law, the commissioner may require a health maintenance organization violating the provisions of this act to cease marketing any medicare supplement contract or evidence of coverage in this State which is related directly or indirectly to the violation, require the health maintenance organization to take such action as is necessary to comply with the provisions of this act, or both.
L.1992,c.164,s.11.