New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Applicant" means an individual who, at the time of application to the Under 50 Plan, has not attained the age of 50 years. In the event that an applicant for Under 50 Plan coverage is disqualified solely because of age, the date of application to the Under 50 Plan shall be deemed to apply to any application for coverage pursuant to N.J.A.C. 11:4-23B.
"Commissioner" means the Commissioner of the Department of Banking and Insurance.
"Continuous period of creditable coverage" means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual had no breaks in coverage greater than 63 days.
"Contracting carrier" means an insurer selected and appointed to service the Under 50 Plan in accordance with its plan of operation.
"Creditable coverage" means coverage of the individual, other than coverage of excepted benefits, provided under any of the following: a group health plan; health insurance coverage; Title XIX of the Social Security Act (Medicaid), other than the coverage consisting solely of benefits under section 1928 ( 42 U.S.C. §
										1396s ); Chapter 55 of Title 10 United States Code (CHAMPUS) ( 10 U.S.C. §§
										1071 et seq.); a medical care program of the Indian Health Service or of a tribal organization; a State health benefits risk pool; a health plan offered under Chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program) ( 5 U.S.C. §§
										8901 et seq.); a public health benefit plan as defined in 45 C.F.R. 146.113(a)(1)(ix); and a health benefit plan under section 5(e) of the Peace Corps Act ( 22 U.S.C. §
										2504(e) ).
"Excepted benefits" means coverage 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; worker's compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage specified in Federal regulations under which benefits for medical care are secondary or incidental to other insurance benefits. When provided under a separate policy, certificate or contract of insurance or, when otherwise not an integral part of the plan, excepted benefits include: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or such other similar, limited benefits as are specified in Federal regulations. When offered as independent, non-coordinated benefits, excepted benefits include: hospital indemnity or other fixed indemnity insurance; and coverage for specified diseases or illnesses. When offered as a separate policy, contract, certificate or contract of insurance, excepted benefits include: Medicare supplement health insurance as defined under section 1882(g)(1) of the Social Security Act ( 42 U.S.C. §
										1395ss(s)(1) ); coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code ( 10 U.S.C. §§
										1071 et seq.); and similar supplemental coverage provided under a group health plan.
"Financially impaired" means an insurer or HMO which, after August 16, 1995, is not insolvent, but is deemed by the Commissioner to be potentially unable to fulfill its contractual obligations, or an insurer or HMO which is under an order of liquidation, rehabilitation or conservation by a court of competent jurisdiction.
"Health benefits plan" shall have the meaning set forth at 17B:27A-2.
"HealthStart Plus" means the program providing coverage to pregnant women and infants up to one year of age who are in families with incomes between 185 percent and 300 percent of the poverty level, established pursuant to the Health Care Cost Reduction Act, P.L. 1991, c.187, section 25 (N.J.S.A. 26:2H-18.4 7).
"HMO" means a health maintenance organization authorized in accordance with 26:2J-1 et seq.
"Insurer" means an insurance company or hospital, medical or health service corporation authorized to issue health benefits plans in this State.
"Medicaid" means the program administered by the New Jersey Division of Medical Assistance and Health Services Program in the New Jersey Department of Human Services, providing medical assistance to qualified applicants, in accordance with P.L. 1968, c.413 (30:4D-1 et seq.) and amendments thereto.
"Net earned premium" means the premium earned in New Jersey or health benefits plans, less return premiums thereon and dividends paid or credited to policy or contract holders on the health benefits plans. "Net earned premium" shall include the aggregate premiums earned in the insurer's insured group and individual business and HMO business, including premiums from contracts covering Medicaid and HealthStart Plus recipients and premiums from Medicare cost and risk contracts. "Net earned premium" shall not include premiums from any stop loss or excess coverage to the extent that such coverage:
1. Is issued to self-funded arrangements to reimburse only the self-funded arrangements for expenses exceeding per person or aggregate limits, and for which employees or other individuals are not third party beneficiaries under the policy; and
2. The per person limit is no less than $ 20,000 per year, and additionally, or in the alternative, the aggregate limit is no less than 125 percent of expected claims.
"Net loss of the contracting carrier" means net earned premiums and any investment income thereon less the amount in claims and reasonable administrative expenses of the contracting carrier paid in the preceding calendar year.
"Net loss of the Under 50 Plan" means the net loss of the contracting carrier plus any administrative expenses of the governing board and any other associated administrative expenses.
"Reasonable administrative expenses of the contracting carrier" means actual expenses or the expense allowance, but in no event shall the administrative expenses exceed 25 percent of premium.
"Resident" means a person whose primary residence for the majority of a year is in the State of New Jersey.