New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 8 - HEALTH INSURANCE IDENTIFICATION CARDS › Section 11:22-8.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Card," "health insurance identification card" or "identification card" means a card issued by a health benefit plan to a subscriber or member and containing information related to the member's identity and health benefits plan.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefit plans in this State.
"Department" means the Department of Banking and Insurance.
"Group number" means the health benefit plan group number for the insured.
"Health benefit plan" means a hospital and medical expense insurance policy; health service corporation contract; hospital service corporation contract; medical service corporation contract; health maintenance organization subscriber contract; or other plan for medical care delivered or issued for delivery in this State.
"Health benefit plan" shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; stop loss or excess risk insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefit plans shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in Federal regulations. "Health benefit plan" shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to an event without regard to whether care or treatment was recommended or received as to that condition or as to a pregnancy existing on the effective date of coverage.
"Identification number" or "ID" means the identification number for the insured. This number shall be labeled "ID."
"Insured's name" means the name of the primary insured under the health benefit plan or, if a separate card is issued for another person included under the primary insured's coverage, the name of the covered person to whom the separate card is issued.
"Issuer name" means the name of the sponsor, carrier or administrator of the plan, which name may be abbreviated, or the name of a plan of benefits.
"Primary insured" means, in the case of group or individual coverage covering more than one person based on their relationship to an eligible person, such eligible person.
"Third party administrator" means a person or entity that processes and pays claims on behalf of a benefits payer without the assumption of financial risk for the payment of health or dental benefits and is licensed or registered pursuant to 17B:27B-1 et seq. and N.J.A.C. 11:23.