reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 22 - INDIVIDUAL LIFE INSURANCE: USE OF GENDER BLENDED MORTALITY TABLES › Section 11:4-22.8 - Separability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provision of this subchapter or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter provides for the reasonable standardization of coverage and the simplification of terms and benefits of Medicare supplement policies; facilitates comparison of such policies in order to increase public understanding; eliminates provisions which may be misleading or confusing in connection with the purchase of such policies or with the settlement of claims; and provides for full disclosure in the sale of health care service benefits and insurance to persons eligible for Medicare.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.2 - Applicability and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter shall apply to:
1. All Medicare supplement policies, as defined by this subchapter, delivered or issued for delivery in this State;
2. All certificates, as defined by this subchapter, issued under group Medicare supplement policies, which certificates have been delivered or issued for delivery in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.4 - Policy definitions and terms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this section.
1. "Accident," "accidental injury," or "accidental means" shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.
i. "Injury" shall not be defined more restrictively than as a bodily injury sustained by the covered person as a result of an accident, which injury is the direct cause of the loss, independent of disease, bodily infirmity or any other cause, and which occurs while coverage is in force.
ii. The definition may provide that injuries shall not include injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, mandatory motor vehicle no-fault plan, unless prohibited by law.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.5 - Policy provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No policy or certificate shall be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy if the policy or certificate contains limitations or exclusions that are more restrictive than those of Medicare, except with respect to preexisting condition limitations.
(b) No Medicare supplement policy or certificate shall provide benefits which duplicate benefits provided by Medicare.
(c) No Medicare supplement policy or certificate shall use waiver endorsements or riders to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.
(d) Subject to 11:4-23.6(b)4  and 7, 23.6(c), 23.7(c) and 23.8(b), a Medicare supplement policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006 shall be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
(e) A Medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.
(f) After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:
1. The policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Part D plan; and
2. Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.6 - General minimum benefit standards for all Medicare supplement policies and certificates

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No policy or certificate shall be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy if it does not meet the minimum standards contained in this section.
(b) The following general standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this subchapter.
1. A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred as a result of a preexisting condition after six months from the effective date of coverage, nor shall a preexisting condition be defined more restrictively than as set forth at 11:4-23.4(a)9.
2. A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
3. A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment, or coinsurance amounts. Premiums may be correspondingly modified subject to the requirements of 11:4-23.1 1.
4. A Medicare supplement policy or certificate shall not:
i. Provide for termination of coverage of an eligible spouse because of termination of coverage of the insured other than for nonpayment of premium; or
ii. Provide for termination of a covered persons' coverage by the carrier solely on the grounds of age or deterioration of health.
5. Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy or certificate was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the covered person limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining continuous loss.
6. Existing Medicare supplement policies and certificates shall be appropriately amended or endorsed to eliminate benefit duplications with Medicare which are caused by Medicare benefit changes. Any riders or endorsements shall specify the benefits deleted, or shall otherwise result in a clear description of the Medicare supplement benefits provided by the policy. Such riders or endorsements shall be submitted for filing by the Commissioner.
7. If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Pub. L. 108-173, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.9 - Open enrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall not deny or condition the effectiveness or issuance, nor discriminate in the pricing, of Medicare supplement policies or certificates based on the health status, claims experience, receipt of health care by, or medical condition of an applicant if the application is submitted for Medicare supplement coverage prior to or during the six month period beginning with the first day of the first month in which the applicant is 65 years of age or older and is enrolled for benefits under Medicare Part B. Each Medicare supplement policy and certificate shall be made available to all applicants who qualify under this section without regard to age.
(b) If an applicant qualifies under (a) above and submits an application during the time period referenced in (a) above and, as of the date of application, has had a continuous period of creditable coverage of at least six months, the carrier shall not exclude benefits based on a preexisting condition.
(c) If the applicant qualifies under (a) above and submits an application during the time period referenced in (a) above and, as of the date of application, has had a continuous period of creditable coverage that is less than six months, the carrier shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date.
(d) Except as provided in 11:4-23.1 2, 23.16(d) and in (b) and (c) above, nothing in (a) above shall be construed to prohibit or limit a carrier's use of permissible preexisting condition exclusion provisions in any Medicare supplement policy or certificate as set forth in this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.10 - Standards for claims payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier providing Medicare supplement policies and certificates shall comply with Section 1882(c)(3) of the Social Security Act as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 ( P.L. 100-203 ) by:
1. Acceptance of notice from a Medicare-Carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits under the Medicare supplement policy or certificate as sufficient claim notice without requiring other or additional claims forms to be submitted, and making a payment determination based on the information contained in the notice from the Medicare-Carrier;
2. Notification of the participating physician or supplier, and the beneficiary, of the payment determination, and making payment directly to the participating physician or supplier;
3. Providing each enrollee, at the time of enrollment, a card listing the policy name, policy number, and a mailing address to which notices from a Medicare-Carrier may be sent;
4. Payment of user fees for claim notices that are transmitted electronically or otherwise; and
5. Providing to the Secretary of Health and Human Services at least annually, a central mailing address to which all claims may be sent by the Medicare-Carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.11 - Loss ratio standards, annual filing of premium rates and refund or credit calculation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For both the entire past and future periods for which revised or existing rates are computed to provide coverage, Medicare supplement policy forms or certificate forms shall be expected to return to policyholders and certificateholders, in the form of aggregate benefits under the policy or certificate calculated on the basis of paid claims experience (or paid health care expenses for coverage provided by a health maintenance organization on a service rather than reimbursement basis) and written premiums for such period, and with adjustment for interest to reflect the timing of payments:
1. At least 75 percent of the aggregate amount of premiums or subscription charges collected in the case of group policies and policies issued as conversions from group policies.
2. At least 65 percent of the aggregate amount of premiums or subscription charges collected in the case of individual policies.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.13 - Filing requirements for policies, certificates and premium rates, including procedures for review and intervention by the Public Advocate, Division of Rate Counsel

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No carrier shall deliver or issue for delivery in this State any Medicare supplement policy or certificate, any written application therefor, or any printed rider or endorsements to be applied thereto, unless the forms thereof have been submitted to and filed by the Commissioner.
1. At the expiration of 30 days after submission, the form shall be deemed filed unless affirmatively disapproved for filing by the Commissioner prior thereto.
2. If any such form is disapproved for filing by the Commissioner during the said 30-day period, it may not be delivered or issued for delivery unless and until such disapproval for filing is withdrawn. Such disapproval shall be subject to review in accordance with the Administrative Procedure Act, 52:14B-1 et seq. and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
3. The Commissioner may extend the 30-day period no more than another 30 days if written notice is provided to the insurer before the expiration of the initial 30 day period, in which event all but this paragraph shall apply to the extended period.
4. Forms filed by or deemed filed by the Commissioner may subsequently be withdrawn from filing. Insurers shall have the right to a hearing in accordance with the Administrative Procedure Act, 52:14B-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1. An insurer may continue to deliver or issue for delivery such forms until a final decision in accordance with the withdrawal is rendered, following the request for a hearing, or, if no hearing is requested, delivery or issuance for delivery of such forms may continue no later than 30 days following notice of the withdrawal of that form.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.14 - Compensation arrangements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No carrier or other entity shall provide to any producer a first year commission or first year compensation for the sale of Medicare supplement policies or certificates in an amount which exceeds 200 percent of the commission or compensation to be provided by that insurer or other entity for the selling or servicing of that policy or certificate in the second year or period of that policy or certificate.
(b) The commission or other compensation which may be provided in subsequent renewal years shall be, for no fewer than five renewal years, the same as that commission or compensation provided in the second year or period.
(c) No carrier or other entity shall provide compensation or commission to any producer, nor shall any producer receive commission or other compensation greater than the renewal commission or compensation payable by the replacing carrier on renewal policies or certificates when an existing policy or certificate is replaced.
(d) For purposes of this section, "compensation" means a pecuniary or nonpecuniary remuneration of any kind relating to the sale of a policy or certificate, including, but not limited to:
1. Bonuses;
2. Gifts;
3. Prizes;
4. Awards; and
5. Finders fees.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.17 - Filing requirements for advertising

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier providing Medicare supplement policies or certificates in this State shall file with the Commissioner a copy of all advertisements to which residents of this State will have access, and through which the carrier intends, or by implication purports to the reasonable targeted consumer its intent to make its Medicare supplement product(s) available for purchase or enrollment in this State, whether through written, radio, television or other electronic media, 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) All advertisements shall be in accord with the standards set out in N.J.A.C. 11:2-11 and any other disclosure and advertising rules which may be applicable to carriers.
(c) The Commissioner may disapprove an advertisement at any time if the advertisement is not in compliance with this rule or is in violation of the Trade Practices Act, 17B:30-1 et seq. An advertisement which has been disapproved by the Commissioner shall continue to be disapproved until disapproval is withdrawn by the Commissioner.
(d) The Commissioner may institute any and all procedures and penalties available pursuant to 17:35C-1 et seq., 17B:26A-1 et seq., and 17B:30-1 et seq., against a carrier which is determined by the Commissioner to be in violation of this rule.
(e) All actions of the Commissioner are subject to review pursuant to the provisions of the Administrative Procedures Act, 52:14B-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.18 - Standards for marketing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier, directly or through its producers, shall:
1. Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate;
2. Establish marketing procedures to assure excessive coverage is not sold or issued to any consumer;
3. Display prominently by type, stamp or other appropriate means, on the first page of the policy or certificate the following:
"Notice to buyer: This policy may not cover all of your medical expenses."
4. Make every reasonable effort to identify when a prospective applicant or enrollee already has Medicare supplement and/or accident and sickness coverage, the quantity of such policies and extensiveness of such coverage; and
5. Establish procedures which are auditable for purposes of verifying compliance with this section.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.19 - Appropriateness of recommended purchase and excessive coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In recommending the purchase or replacement of any Medicare supplement policy or certificate, an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.
(b) Any sale of Medicare supplement coverage which will provide an individual with more than one Medicare supplement policy or certificate is prohibited.
(c) A carrier shall not issue a Medicare supplement policy or certificate to an individual enrolled in Medicare Part C unless the effective date of the coverage is after the termination of the individual's Part C coverage.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.20 - Reporting of multiple policies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier shall report annually, on or before March 1, to the Commissioner, the policy and certificate number and date of issuance of each policy or certificate, grouped by individual insureds for every individual resident of this State for which the carrier has in force more than one Medicare supplement policy or certificate.
(b) Carriers shall submit reports of multiple policies on a form substantially similar to that form set forth in Exhibit G of the Appendix to Subchapters 16 and 23 of this Chapter, incorporated herein by reference. Carriers shall submit separate forms for each insured for which multiple policies or certificates are being reported. No form shall contain information relevant to more than one insured. In any instance in which one form provides insufficient reporting space for an insured's policies or certificates, additional pages should be attached containing the additional information.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.21 - Addresses for submissions for filing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All forms, rates, loss ratio reporting and advertisements submitted for filing with or by the Commissioner shall be submitted to the Office of Life and Health Actuarial Services, New Jersey Department of Insurance, PO Box 470, Trenton, New Jersey 08625-0470.
(b) Annual reports of multiple policy issues submitted for filing with the Commissioner shall be submitted to the Division of Legislative and Regulatory Affairs, New Jersey Department of Insurance, PO Box 325, Trenton, New Jersey 08625-0325, to the attention of Medicare Supplement Multiple Policy Report.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.22 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Failure to comply with the terms of this subchapter may result in the assessment of any and all penalties available in accordance with the laws of this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.23 - Severability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provision of this subchapter or the application thereof to any person or circumstance is held to be invalid for any reason, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish a mechanism to provide Plan C coverage of the standardized Medicare supplement plans to persons under 50 years of age residing in this State who are enrolled in Medicare due to disability, or due to end stage renal disease.
(b) Except when inconsistent with a provision of this subchapter, the provisions of N.J.A.C. 11:4-23 shall apply.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.3 - Creation of Medicare Supplement-Under 50 Coverage Plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There is created in the State of New Jersey a plan to provide Medicare Supplement Plan C coverage of the standardized Medicare supplement plans to New Jersey residents under 50 years of age who are enrolled in Medicare due to disability or due to end stage renal disease to be known as the Medicare Supplement--Under 50 Plan ("Under 50 Plan").
(b) The Under 50 Plan shall be administered by a governing board appointed pursuant to this subchapter and a plan of operation adopted by the governing board and approved by the Commissioner.
(c) Any administrative office of the governing board of the Under 50 Plan shall be located within the State of New Jersey and all meetings of the governing board shall take place in New Jersey. The contracting carrier shall at all times maintain an office and records relating to the Under 50 Plan in the State of New Jersey.
(d) Coverage by the Under 50 Plan shall be provided through a contracting carrier appointed pursuant to this subchapter and the approved plan of operation.
(e) Annually, no later than 120 days after December 31st, the governing board of the Under 50 Plan shall submit to the Commissioner a financial report in a form approved by the Commissioner and an operational report of its activities during the preceding calendar year.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.4 - Governing board

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Under 50 Plan shall be administered by a governing board composed of eight directors, one of whom shall be the Commissioner or the Commissioner's designee, one of whom shall be the contracting carrier upon its selection and appointment by the governing board, and six of whom shall be appointed by the Commissioner as follows:
1. Two directors shall be insurers writing Medicare Supplement insurance coverage in this State;
2. One director shall be an HMO nominated by the New Jersey Association of Health Maintenance Organizations;
3. One director shall be an insurer nominated by the Health Insurance Association of America; and
4. Two directors shall be members of the public who are knowledgeable about Medicare Supplement coverages, but who are not employed by or otherwise affiliated with insurers, health maintenance organizations, insurance producers, or other entities of the insurance industry.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.5 - Plan of operation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The plan of operation shall provide for the fair, reasonable and equitable administration of the Under 50 Plan and shall include:
1. The internal organization and proceedings of the governing board;
2. Procedures to select, appoint, terminate and compensate a contracting carrier to service the Under 50 Plan coverage;
3. Procedures in accordance with section 4 of P.L. 1995, c.229 for the equitable sharing of any losses incurred by the Under 50 Plan;
4. Procedures for handling complaints and appeals to the governing board;
5. Procedures for individuals to apply for coverage;
6. Procedures for cancellation or nonrenewal of coverage, including refunds of unearned premium;
7. Procedures for the collection, investment and disbursement of funds; and
8. Such other provisions as are deemed necessary by the governing board for the proper operation of the Under 50 Plan.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.7 - Rates

Current through Register Vol. 56, No. 14, July 15, 2024
The rates for Under 50 Plan coverage shall be no greater than the lowest rate charged by the contracting carrier for Medicare Supplement Plan C policies or contracts issued by the contracting carrier to persons 65 years of age or older.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.8 - Reports

Current through Register Vol. 56, No. 14, July 15, 2024
(a) By March 1, 1996 and following the close of each calendar year thereafter, on a date set by the Commissioner:
1. Every insurer and HMO in this State shall file with the Commissioner its net earned premium in the preceding calendar year;
2. The contracting carrier shall file with the Commissioner its net earned premiums and investment income on Under 50 Plan contracts and the claims paid and administrative expenses attributable to those contracts in the preceding calendar year; and
3. The contracting carrier shall file with the Commissioner any net loss for Under 50 Plan contracts in the preceding calendar year along with any supporting information requested by the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.9 - Equitable sharing of losses and audit

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Net losses of the Under 50 Plan shall be apportioned among insurers and HMOs as set forth in the plan of operation of the Under 50 Plan.
(b) Assessments for net losses of the Under 50 Plan may be determined or apportioned, and may include calculations based upon the information provided pursuant to 11:4-23A.8, but the contracting carrier shall not be reimbursed for its total reported net losses until the conclusion of an audit of the losses reported by the contracting carrier and its related operations, conducted in accordance with the Under 50 Plan of operation. The contracting carrier may be paid for a portion of its reported net losses prior to the completion of the audit, as provided in the Under 50 Plan plan of operation. The cost of such audit shall be paid as an administrative expense of the Under 50 Plan.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.10 - Assessments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every insurer and HMO providing health benefits plans or health maintenance organization subscriber contracts in this State shall be liable for an assessment to pay its equitable share of any net loss incurred by the Under 50 Plan in the previous calendar year, unless the insurer or HMO has received an exemption or deferment from the Commissioner.
(b) The assessment of each insurer and HMO described in (a) above shall be in the proportion that its net earned premium bears to the net earned premium of all insurers and HMOs, except that no insurer or HMO shall be liable for an assessment amount greater than 35 percent of the total net loss incurred by the Under 50 Plan in any calendar year.
(c) Assessment amounts for insurers or HMOs granted a deferment or exemption, or that portion of assessment that exceeds the 35 percent limit noted in (b) above, shall be reapportioned to other insurers and HMOs based on their respective adjusted market share.
(d) Assessments shall be due and payable upon receipt by the insurer or HMO of the invoice for the assessment. Any assessment, or portion of an assessment, not paid within 30 days of the date of the invoice shall be subject to interest of 1.5 percent of the assessment amount not timely paid per month, accruing from the date of the invoice of the assessment.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.11 - Appeal to the Commissioner

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any person may petition for appeal to the Commissioner from an adverse decision of the governing board by filing a request in writing within 20 days of the date of receipt of the written decision of the governing board.
1. The written request to appeal shall set forth the facts upon which it is based and include a copy of the written decision of the governing board.
2. The Commissioner shall notify the petitioner and the governing board within 30 days whether the request to appeal shall be granted.
3. Notice from the Commissioner that an appeal has been granted pursuant to this section shall also provide a statement about whether the action of the governing board has been stayed pending the disposition of the appeal.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23A - MEDICARE SUPPLEMENT-UNDER 50 COVERAGE › Section 11:4-23A.12 - Assessment relief requests

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer or HMO seeking relief from any assessment imposed pursuant to section 4 of P.L. 1995, c.229 shall submit to the Department a request for such relief no later than 15 days prior to the due date of payment of the assessment.
(b) Each request shall be in loose leaf form inserted into two-ring or three-ring binders tabbed or otherwise indexed to correspond to the exhibits set forth in (f) below. The loose leaf sheets used in the request shall be eight and one-half inches wide and 11 inches long and punched for two-ring or three-ring binders, as appropriate.
(c) All insurers and HMOs requesting relief pursuant to this rule shall submit five copies of each request in the format set forth in (b) above.
(d) If a request fails to materially comply with the filing format and information requirements set forth in this section, the Department shall notify the insurer or HMO that its request for relief is deficient and is denied on such grounds. The notice shall also set forth any information or other action required to cure the deficiency. The insurer or HMO shall submit the additional information or otherwise submit a filing in accordance with the format requirements specified in this rule within 15 days of receipt of the Department's notice of deficiency. Failure to submit within 15 days the information necessary in the proper format to cure the deficiency shall result in the request being denied.
(e) All requests for relief or other information required pursuant to this section shall be filed with the Department at the following address:
Under 50 Plan--Request for Relief
New Jersey Department of Banking and Insurance
Division of Solvency Regulation
20 West State Street
PO Box 325
Trenton, New Jersey 08625
(f) When requesting relief from assessments imposed pursuant to section 4 of P.L. 1995, c.229, an insurer or HMO shall provide with its request the following information in a clear, concise and complete manner:
1. A cover letter stating:
i. The name of the applicant;
ii. The form of relief and, if a deferral of less than the full amount, the specific amount/percentage of relief which the applicant is requesting;
iii. A statement of facts relied upon as the basis under which relief is sought, including the specific reasons for which the Commissioner may find that the applicant is or would be placed in a financially impaired position; and
iv. The name, title, telephone number and telefax number of a contact person familiar with the filing to whom the Department may direct additional questions;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23B - MEDICARE SUPPLEMENT-AGE 50 THROUGH 64 COVERAGE › Section 11:4-23B.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every insurer issuing or renewing standardized Medicare supplement insurance policies or contracts in this State shall offer, at a minimum, Medicare Supplement Plan C policies or contracts to New Jersey residents 50 years of age or older who are enrolled in Medicare due to disability or due to end stage renal disease, except that:
1. An insurer that does not currently issue or renew individual standardized Medicare supplement insurance policies or contracts and does issue or renew standardized Medicare supplement insurance policies or contracts for groups whose membership in the group is not based on health status, claims experience, receipt of health care or medical condition, shall not be required to provide coverage, other than to members of the group.
2. No group to which the provisions of (a)1 apply shall institute an age requirement for participation in the group on or after June 1, 1995.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23B - MEDICARE SUPPLEMENT-AGE 50 THROUGH 64 COVERAGE › Section 11:4-23B.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 an insurer, has attained the age of 50 years but not attained the age of 65 years. In the event that an applicant for coverage pursuant to this subchapter is disqualified solely because of age, the date of the original application to the insurer shall be deemed to apply to any application for Under 50 Plan coverage pursuant to N.J.A.C. 11:4-23A where the individual under 50 years of age, or to any application pursuant to N.J.A.C. 11:4-23 where the individual is 65 years of age or older.
"Health benefits plan" means a hospital and medical expense insurance policy, hospital service corporation contract, medical service corporation contract or health service corporation contract delivered or issued for delivery in this State or a health maintenance organization subscriber contract delivered or issued for delivery in this State.
"Insurer" means an insurance company or hospital, medical or health service corporation authorized to issue health benefits plans in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23B - MEDICARE SUPPLEMENT-AGE 50 THROUGH 64 COVERAGE › Section 11:4-23B.3 - Open enrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No insurer shall deny or condition the issuance or renewal, or discriminate in the pricing of Medicare supplement policies or contracts available pursuant to section 2 of P.L. 1995, c.229 because of the health status, claims experience, receipt of health care or medical condition of an applicant if the application for a policy or contract is submitted during the six-month period beginning with the first month in which an individual is enrolled for benefits under Medicare Part B or if the application is submitted within six months of August 16, 1995.
(b) Nothing in (a) above shall be construed to prohibit the exclusion of benefits under a policy or contract during the first three months, based on a preexisting condition for which the insured received treatment or was otherwise diagnosed during the six months before the policy or contract became effective, except that this limitation shall not apply to an individual who has, under a prior health benefits policy or contract, with no intervening lapse in coverage, been treated or diagnosed for a condition under that policy or contract or satisfied a three month preexisting condition limitation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23B - MEDICARE SUPPLEMENT-AGE 50 THROUGH 64 COVERAGE › Section 11:4-23B.4 - Rates

Current through Register Vol. 56, No. 14, July 15, 2024
Rates for Medicare supplement insurance policies or contracts issued pursuant to section 2 of P.L. 1995, c.229 shall be no greater than the lowest rate charged by the insurer for the same type of policies or contracts issued to persons 65 years of age or older and shall be calculated and filed in accordance with 11:4-23.1 1 and 23.12.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 24 - SMOKER AND NONSMOKER MORTALITY TABLES › Section 11:4-24.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this subchapter is to authorize the use of mortality tables adopted after September 11, 1981 by the National Association of Insurance Commissioners in determining minimum nonforfeiture standards and minimum valuation standards.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 24 - SMOKER AND NONSMOKER MORTALITY TABLES › Section 11:4-24.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.
"1980 CSO Table" means that mortality table, consisting of separate rates of mortality for male and female lives, prescribed by N.J.S.A. 17B:19-8a(i) and N.J.S.A. 17B:25-19h(viii) and referred to therein as the Commissioners 1980 Standard Ordinary Mortality Table, with or without Ten Year Mortality Factors.
"1980 CET Table" means that mortality table, consisting of separate rates of mortality for male and female lives, prescribed by N.J.S.A. 17B:25-19h(viii) and referred to therein as the Commissioners 1980 Extended Term Insurance Table.
"1958 CSO Table" means that mortality table prescribed by N.J.S.A. 17B:9-8a(i) and N.J.S.A. 17B:25-19g and referred to therein as the Commissioners 1958 Standard Ordinary Mortality Table.
"1958 CET Table" means that mortality table prescribed by N.J.S.A. 17B:25-19g and referred to therein as the Commissioners 1958 Extended Term Insurance Table.
"Composite mortality tables" means the 1980 CSO, 1980 CET, 1958 CSO and 1958 CET mortality tables defined above, as they were originally published with rates of mortality that do not distinguish between smokers and nonsmokers.
"Juvenile" means a person or persons under 15 years of age.
"Smoker and nonsmoker mortality tables" means the mortality tables with separate rates of mortality for smokers and nonsmokers derived from the 1980 CSO, 1980 CET, 1958 CSO and 1958 CET tables defined above and approved by the National Association of Insurance Commissioners in December 1983.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 24 - SMOKER AND NONSMOKER MORTALITY TABLES › Section 11:4-24.3 - Smoker and nonsmoker mortality tables

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In determining minimum cash surrender values, minimum amounts and minimum periods of nonforfeiture benefits for any policy of insurance delivered or issued for delivery in this State after the operative date of N.J.S.A. 17B:25-19h(xi) for that policy form and before January 1, 1989 and in determining the minimum reserve liabilities for any policy of insurance delivered or issued for delivery after the operative date of N.J.S.A. 17B:25-19h(xi) for that policy form and prior to January 1, 1989, at the option of the insurer and subject to the conditions in (e) below, the following tables may be substituted:
1. The 1958 CSO Smoker and Nonsmoker Mortality Tables may be substituted for the 1980 CSO Table; and
2. The 1958 CET Smoker and Nonsmoker Mortality Tables may be substituted for the 1980 CET Table.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 24 - SMOKER AND NONSMOKER MORTALITY TABLES › Section 11:4-24.4 - Juvenile insureds

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Because the smoker and nonsmoker mortality tables do not extend below age 15, the Department shall permit the following uses of the composite and smoker and nonsmoker mortality tables for juvenile insureds, as hereafter provided:
1. Insurers may use the composite mortality table for juvenile issues and continue to use such table for all future attained ages; or
2. Insurers may use the composite mortality table for juvenile issues and change to use of a smoker and nonsmoker mortality table when the insured's attained age is a specified age between 15 and 23.
i. When the insured reaches the attained age, the insurer shall notify the insured in writing at least 30 days prior to the effective date of the change in mortality tables of his or her option to elect smoker or nonsmoker status.
ii. Each insurer shall adopt a uniform default classification of either smoker or nonsmoker to which the insurer shall assign an insured who fails to respond to the notice described in (a)2i above.
iii. An insurer may only apply a default classification of smoker pursuant to ii above to an insured whose attained age is at least 18.
iv. The insurer shall identify such adopted uniform default classification in the notice described in (a)2i above and advise the insured therein that the insured shall be assigned the uniform default classification if the insured fails to respond to the notice.
v. Alternatively, at the insurer's option, the insurer may reclassify the insured as a nonsmoker upon reaching the attained age.
3. Insurers may use a reasonable extrapolation of the smoker and nonsmoker mortality tables for ages 15 and below. The submission shall include an actuarial memorandum which describes the basis for the extrapolation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 24 - SMOKER AND NONSMOKER MORTALITY TABLES › Section 11:4-24.5 - Separability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provision of this subchapter or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 25 - FUNERAL INSURANCE POLICIES › Section 11:4-25.1 - Purpose; scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish rules for the filing and review of funeral insurance policies pursuant to 17B:17-5.1.
(b) This subchapter shall apply to all life insurance policy or annuity contract forms delivered or issued for delivery, marketed, used or designated as intended for use, as funeral insurance policies after the operative date hereof.
(c) Any insurance policy or annuity contract used as a funeral insurance policy in this State on or after December 21, 1993, whether issued within this State or outside of this State, whether on a group or individual basis, and any certificates, policies, contracts, applications, forms and related material, shall be subject to all the laws and regulations of this State and the terms and conditions of the Department of Banking and Insurance, as though issued in this State, and shall at the time of submission and filing be designated as being intended for use as a funeral insurance policy.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 25 - FUNERAL INSURANCE POLICIES › Section 11:4-25.3 - Forms submission requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No insurer shall deliver or issue for delivery any funeral insurance policy in this State that has not been filed pursuant to law on or after December 21, 1993, or as otherwise permitted under this subchapter.
(b) The requirements of this subchapter apply to all previously filed forms as well as any forms submitted in the future. Previously filed forms which do not comply with these requirements shall be deemed withdrawn as of July 15, 1996.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 25 - FUNERAL INSURANCE POLICIES › Section 11:4-25.4 - Disclosure requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The submission for the filing of any funeral insurance policy shall be accompanied by a copy of the prepaid funeral agreement to which the policy is related. The prepaid funeral agreement shall provide that:
1. Cancellation of the funeral arrangements will not cancel or otherwise invalidate the funeral insurance policy;
2. Cancellation, withdrawal of, or loans made against, the proceeds or cash value of the policy shall void any price guarantees and indicate, therefore, the likelihood that inadequate funds will exist to pay for the original arrangements as intended; and
3. Cancellation of the prepaid funeral agreement will not result in the refund of premiums paid.