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New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of these rules is to provide life insurance policy illustrations that shall protect consumers and foster consumer education. These rules provide illustration formats, prescribe standards to be followed when illustrations are used, and specify the disclosures that are required in connection with illustrations. The goals of these rules are to ensure that illustrations do not mislead purchasers of life insurance and to make illustrations more understandable. Insurers shall, as far as possible, eliminate the use of footnotes and caveats and define terms used in the illustration in language that would be understood by a typical person within the segment of the public to which the illustration is directed.
(b) These rules shall apply to all group and individual life insurance policies and certificates except:
1. Variable life insurance;
2. Individual and group annuity contracts;
3. Credit life insurance; or
4. Life insurance policies with illustrated death benefits which at no duration or under any condition on an individual exceed $ 10,000.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.3 - Policies to be illustrated

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each insurer marketing policies to which these rules are applicable shall notify the Commissioner whether a policy form is to be marketed with or without an illustration.
1. For policy forms filed after July 6, 1998, the identification shall be made at the time of filing. Any previous identification may be changed by notice to the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.4 - General rules and prohibitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An illustration used in the sale of a life insurance policy shall satisfy the applicable requirements of these rules, be clearly labeled "life insurance illustration" and contain the following basic information:
1. The name of the insurer;
2. The name and business address of the producer or insurer's authorized representative, if any;
3. The name, age and sex of the proposed insured, except where a composite illustration is permitted under these rules. In the case of a composite illustration, it shall be so identified;
4. The underwriting or rating classification upon which the illustration is based;
5. The generic name of the policy, the company product name, if different, and State specific form number;
6. The initial death benefit; and
7. The dividend option election or application of non-guaranteed elements, if applicable.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.6 - Standards for supplemental illustrations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A supplemental illustration may be provided so long as:
1. It is appended to, accompanied by or preceded by a basic illustration that complies with these rules;
2. The non-guaranteed elements shown are not more favorable to the policy owner than the corresponding elements based on the scale used in the basic illustration;
3. It contains the same statement required by 11:4-52.5(a)12  to be included in a basic illustration that non-guaranteed elements are not guaranteed; and
4. For a policy that has a contract premium, the contract premium underlying the supplemental illustration is equal to the contract premium shown in the basic illustration. For policies that do not require a contract premium, the premium outlay underlying the supplemental illustration shall be equal to the premium outlay shown in the basic illustration.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.7 - Delivery of illustration and record retention

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If a basic illustration is used by an insurance producer or other authorized representative of the insurer in the sale of a life insurance policy and the policy is applied for as illustrated, a copy of that illustration, signed in accordance with these rules, shall be submitted to the insurer at the time of policy application. A copy also shall be provided to the applicant.
(b) If the policy is issued other than as applied for, a revised basic illustration conforming to the policy as issued shall be sent with the policy. The revised illustration shall conform to the requirements of these rules, shall be labeled "Revised Illustration" and shall be signed and dated by the applicant or policy owner and producer or other authorized representative of the insurer no later than the time the policy is delivered. A copy shall be provided to the insurer and the policy owner.
(c) If no illustration is used by an insurance producer or other authorized representative in the sale of a life insurance policy or if the policy is applied for other than as illustrated, the producer or representative shall certify to that effect in writing on a form provided by the insurer. On the same form the applicant shall acknowledge either that no illustration was provided or that the producer or representative advised the applicant that a basic illustration will be provided with the policy. This form shall be submitted to the insurer at the time of policy application.
(d) If the policy is issued, a basic illustration conforming to the policy as issued shall be sent with the policy and signed no later than the time the policy is delivered. A copy shall be provided to the insurer and the policy owner.
(e) If the basic illustration or revised illustration is sent to the applicant or policy owner by mail from the insurer, it shall include instructions for the applicant or policy owner to sign the duplicate copy of the numeric summary page of the illustration for the policy issued and return the signed copy to the insurer. The insurer's obligation under this subsection shall be satisfied if it can demonstrate that it has made a diligent effort to secure a signed copy of the numeric summary page. The requirement to make a diligent effort shall be deemed satisfied if the insurer includes in the mailing a self-addressed postage prepaid envelope with instructions for the return of the signed numeric summary page.
(f) A copy of the basic illustration and a revised basic illustration, if any, signed as applicable, along with any certification that either no illustration was used or that the policy was applied for other than as illustrated, shall be retained by the insurer until three years after the policy is no longer in force. A copy need not be retained if no policy is issued.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.8 - Annual report; notice to policy owners

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In the case of a policy designated as one for which illustrations will be used, the insurer shall provide each policy owner with an annual report on the status of the policy that shall satisfy the requirements of N.J.A.C. 11:4-45.
(b) Upon the request of the policy owner, the insurer shall furnish an in force illustration of current and future benefits and values based on the insurer's present illustrated scale. This illustration shall comply with the requirements of 11:4-52.4(a) and (b) and 52.5(a) and (e). No signature or other acknowledgment of receipt of this illustration shall be required.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.9 - Annual certifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The board of directors of each insurer shall appoint one or more illustration actuaries.
(b) The illustration actuary shall certify that the disciplined current scale used in illustrations is in conformity with the Actuarial Standard of Practice for Compliance with the NAIC Model Regulation on Life Insurance Illustrations promulgated by the Actuarial Standards Board, and that the illustrated scales used in insurer-authorized illustrations meet the requirements of these rules.
(c) The illustration actuary shall:
1. Be a member in good standing of the American Academy of Actuaries;
2. Be familiar with the standard of practice regarding life insurance policy illustrations;
3. Not have been found by the Commissioner, following appropriate notice and hearing to have:
i. Violated any provision of, or any obligation imposed by, the insurance law or other law in the course of his or her dealings as an illustration actuary;
ii. Been found guilty of fraudulent or dishonest practices;
iii. Demonstrated his or her incompetence, lack of cooperation, or untrustworthiness to act as an illustration actuary; or
iv. Resigned or been removed as an illustration actuary within the past five years as a result of acts or omissions indicated in any adverse report on examination or as a result of a failure to adhere to generally acceptable actuarial standards;
4. Not fail to notify the Commissioner of any action taken by a commissioner of another state similar to that under (c)3 above;
5. Disclose in the annual certification whether, since the last certification, a currently payable scale applicable for business issued within the previous five years and within the scope of the certification has been reduced for reasons other than changes in the experience factors underlying the disciplined current scale. If nonguaranteed elements illustrated for new policies are not consistent with those illustrated for similar in force policies, this must be disclosed in the annual certification. If nonguaranteed elements illustrated for both new and in force policies are not consistent with the nonguaranteed elements actually being paid, charged or credited to the same or similar forms, this must be disclosed in the annual certification; and
6. Disclose in the annual certification the single method used to allocate overhead expenses for all illustrations:
i. Fully allocated expenses;
ii. Marginal expenses or;
iii. A generally recognized expense table based on fully allocated expenses representing a significant portion of insurance companies and approved by the National Association of Insurance Commissioners.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.10 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
In addition to any other penalties provided by the laws of this State, an insurer or producer that violates a requirement of these rules shall be guilty of a violation of N.J.A.C. 11:2-17.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 52 - LIFE INSURANCE ILLUSTRATIONS › Section 11:4-52.11 - Transition

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Until January 1, 1999, insurers may use the following language instead of the statement required by 11:4-52.5(d)1: "I have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be either higher or lower. The agent has told me they are not guaranteed." After January 1, 1999, insurers shall comply with the requirements of 11:4-52.5(d)1.
(b) Until January 1, 1999, insurers may use the language set forth in the NAIC Life Insurance Illustrations Model Regulation at Section 9B(1), incorporated herein by reference, which includes an acknowledgement by the applicant that no illustration conforming to the policy applied for was provided and that an illustration conforming to the policy as issued will be provided no later than at the time of policy delivery. After January 1, 1999, insurers shall comply with the requirements of 11:4-52.7(c).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 53 - MINIMUM STANDARDS FOR SPECIFIED DISEASE AND CRITICAL ILLNESS COVERAGES › Section 11:4-53.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to:
1. Permit the sale of specified disease and critical illness coverage in New Jersey;
2. Provide for reasonable standardization of coverage and the simplification of terms and benefits of specified disease and critical illness policies;
3. Facilitate comparison of specified disease and critical illness policies in order to increase public understanding;
4. Prohibit policy provisions that may be misleading or confusing in connection with the purchase of specified disease and critical illness policies or with the settlement of claims;
5. Restrict provisions that may be contrary to the health care needs of the public;
6. Prohibit coverages that are so limited in scope as to be of no substantial economic value to the holders thereof; and
7. Provide for full disclosure in the sale of specified disease and critical illness policies.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 53 - MINIMUM STANDARDS FOR SPECIFIED DISEASE AND CRITICAL ILLNESS COVERAGES › Section 11:4-53.4 - Standards for specified disease coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Specified disease policies shall provide the following minimum benefits:
1. A fixed-sum benefit of at least $ 100.00 for each day of hospital confinement for at least 365 days; and
2. A fixed-sum benefit equal to at least one-half of the benefit for hospital confinement, for each day of hospital or non-hospital outpatient surgery or other medically appropriate outpatient treatment, including but not limited to chemotherapy and radiation therapy, for at least 365 days.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 53 - MINIMUM STANDARDS FOR SPECIFIED DISEASE AND CRITICAL ILLNESS COVERAGES › Section 11:4-53.5 - Standards for critical illness coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The total benefit amounts available under the policy shall only be available in increments of $ 1,000. As long as the policy clearly indicates, in cases of clearly identifiable forms of diseases with significantly lower treatment costs, lesser amounts may be provided, but in no event shall amounts be less than 25 percent of the largest benefit amount under the policy.
(b) The benefit shall be payable upon initial and medically appropriate diagnosis of a specified disease covered by the policy. There shall be no requirement that the insured survive for any period of time in order for the benefit to be payable.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 53 - MINIMUM STANDARDS FOR SPECIFIED DISEASE AND CRITICAL ILLNESS COVERAGES › Section 11:4-53.6 - Loss ratio standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to assure that benefits are reasonable in relation to the premium charged, the minimum loss ratio for specified disease and critical illness policies shall be as follows:
1. For policies issued to groups other than associations, at least 75 percent;
2. For individual policies, at least 60 percent; and
3. For group policies issued to associations, at least 65 percent.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 53 - MINIMUM STANDARDS FOR SPECIFIED DISEASE AND CRITICAL ILLNESS COVERAGES › Section 11:4-53.7 - Advertising

Current through Register Vol. 56, No. 14, July 15, 2024
All advertisements shall comply with the standards set forth at N.J.A.C. 11:2-11 (the Department's Rules Governing Advertisement of Health Insurance) and any other disclosure and advertising rules which may be applicable to carriers.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 53 - MINIMUM STANDARDS FOR SPECIFIED DISEASE AND CRITICAL ILLNESS COVERAGES › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
EXHIBIT A
(a) To comply with N.J.A.C. 11:4-53.3(b)5, specified disease and critical illness policies meeting the definitions of those terms contained in N.J.A.C. 11:4-53.2 shall use the following statements only, except that appropriate policy identification may be included:
Click here to view image.
This policy or certificate is (an individual policy of insurance) (a group policy or certificate). This policy or certificate provides specified disease coverage (critical illness coverage) ONLY. This policy or certificate does NOT provide comprehensive medical or hospital insurance, Medicare supplement insurance, long-term care insurance, nursing home insurance only, home health care insurance only, or nursing home and home care insurance. You may also contact your local social security office or this company and obtain a copy of the Guide to Health Insurance for People with Medicare.
(Accurately list benefits, exclusions, reductions and limitations of the policy or certificate in a manner which does not misrepresent the actual coverage provided.)
This outline of coverage is a very brief summary of your policy or certificate.
The policy or certificate itself sets forth the rights and obligations of both you and the insurance company. It is therefore imperative that you READ YOUR POLICY OR CERTIFICATE carefully.
The anticipated loss ratio for this policy or certificate is
(indicate either 75 percent for group policies, or 60 percent for individual policies).
This ratio is the portion of future premiums which the company expects to return as benefits, when averaged over all people with this policy or certificate.
EXHIBIT B
SPECIFIED DISEASE/CRITICAL ILLNESS POLICY
CALENDAR YEAR EXPERIENCE DATA
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 54 - BENEFIT STANDARDS FOR INFERTILITY COVERAGE › Section 11:4-54.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to implement P.L. 2001, c. 236 by establishing uniform definitions of terms associated with infertility coverage and benefits that must be provided for infertility in this State.
(b) This subchapter shall apply to the following:
1. All policies, contracts, riders and endorsements delivered, issued, executed or renewed in this State by health service corporations, hospital service corporations, medical service corporations and health insurance companies for groups other than small employers as defined at 17B:27A-17 that provide hospital or medical benefits, including pregnancy-related benefits;
2. All contracts and evidence of coverage forms issued by health maintenance organizations for groups other than small employers as defined at 17B:27A-17 that include pregnancy-related coverage; and
3. All certificates and evidence of coverage forms delivered, issued, executed or renewed in this State where the related group policy or contract is delivered, issued, executed or renewed in this State for groups other than small employers as defined at 17B:27A-17 that provide hospital or medical benefits, including pregnancy-related benefits.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 54 - BENEFIT STANDARDS FOR INFERTILITY COVERAGE › Section 11:4-54.3 - Infertility coverage provided to the same extent as other pregnancy-related procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall not impose a separate copayment, coinsurance, deductible, dollar maximum, visit maximum or procedure maximum on any infertility treatment other than limiting infertility coverage to four completed egg retrievals per lifetime of the covered person.
(b) A carrier shall not impose a separate preauthorization notice or other utilization management requirement on infertility treatment. (For example, if a carrier requires all hospitalizations or all surgeries to be preauthorized, and a particular infertility treatment is to be performed during a hospitalization or is a surgical procedure, the carrier may require preauthorization of the treatment. But a carrier shall not require that all infertility treatments be preauthorized.)
(c) A carrier may limit benefits required to be provided pursuant to this subchapter to services performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. Carriers shall not impose any additional standards in the group policy or contract and in the certificate or evidence of coverage applicable to fertility services on facilities or other providers.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 54 - BENEFIT STANDARDS FOR INFERTILITY COVERAGE › Section 11:4-54.4 - Required benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Infertility coverage shall include, but is not limited to, payment of benefits for the following services and procedures recognized by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists:
1. Artificial insemination with no limit as to the number of cycles;
2. Assisted hatching;
3. Diagnosis and diagnostic tests;
4. Fresh and frozen embryo transfer;
5. Four completed egg retrievals per lifetime of the covered person;
i. Where a live donor is used in the egg retrieval, the medical costs of the donor shall be covered until the donor is released from treatment by the reproductive endocrinologist;
ii. Egg retrievals where the cost was not covered by any carrier shall not count in determining whether the four completed egg retrieval limit has been met;
6. Gamete intrafallopian transfer and zygote intrafallopian transfer;
7. Intracytoplasmic sperm injections;
8. In vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate;
9. Medications, including injectible infertility medications, even if the contract or policy does not provide prescription drug benefits. Where a contract or policy provides both prescription drug and medical and hospital benefits, infertility drugs shall be covered under the prescription drug coverage;
10. Ovulation induction; and
11. Surgery, including microsurgical sperm aspiration.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 54 - BENEFIT STANDARDS FOR INFERTILITY COVERAGE › Section 11:4-54.5 - Permissible benefit exclusions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Following are the only permissible exclusions from the infertility benefit requirements of this subchapter:
1. Reversal of voluntary sterilization.
i. Coverage for infertility services provided to partners of persons who have successfully reversed sterilization may not be excluded provided that the partner is infertile as defined by P.L. 2001, c. 236 and this subchapter;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 54 - BENEFIT STANDARDS FOR INFERTILITY COVERAGE › Section 11:4-54.6 - Religious employer exclusions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall exclude coverage for in vitro fertilization, embryo transfer, artificial insemination, zygote intrafallopian transfer, gamete intrafallopian transfer, and intracytoplasmic sperm injection at the request of a religious employer only if the required coverage is contrary to the religious employer's bona fide religious tenets.
(b) A carrier that issues a policy or contract containing a religious employer exclusion shall provide written notice of such exclusion to each prospective insured or covered person. Such notice shall appear in not less than 10-point type in the certificate or evidence of coverage, the covered person's application or enrollment form, and all sales and marketing materials.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 54 - BENEFIT STANDARDS FOR INFERTILITY COVERAGE › Section 11:4-54.7 - Effect on previously filed forms

Current through Register Vol. 56, No. 14, July 15, 2024
Forms previously filed or approved by the Commissioner pursuant to 17B:27-49 and 26:2J-43 that contain provisions not in compliance with this subchapter shall be deemed withdrawn and shall not be delivered, issued, executed or renewed.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 55 - PHARMACY CARDS › Section 11:4-55.2 - Requirement to issue cards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each carrier, multiple employer welfare arrangement, or other provider of a health benefits plan that provides pharmacy benefits shall issue, or cause to be issued, to the primary insured a card satisfying the requirements of 17B:30-35 et seq. and this section. At the option of the issuer, additional cards may be issued to other persons included under the primary insured's coverage. Such additional cards shall bear the insured's name. The carrier or other provider may contract with an administrator, agent, contractor or other vendor to issue the cards; however, the carrier or other provider shall remain responsible for the proper issuance of the cards and for their compliance with the law.
(b) A card may be issued for pharmacy benefits only ("stand alone card") or may be issued for pharmacy benefits in combination with other benefits ("combined card").
(c) Until such time as State or Federal regulations are adopted pursuant to the "Health Insurance Portability and Accountability Act of 1996," P.L. 104-191, specifying data elements that may be used in place of the information listed below, the following information must, subject to (e) and (f) below, appear on all pharmacy benefits cards:
1. The issuer name, when required for proper claims adjudication;
2. The ANSI identification number (properly labeled), when required for proper claims adjudication;
3. The processor control number (properly labeled), if required by the party adjudicating claims, directing payment of claims or directing the adjudication of claims;
4. The group number (properly labeled), when required for proper claims adjudication;
5. An identification number (properly labeled);
6. The insured's name;
7. A telephone number for providers to call for pharmacy benefits assistance; and
8. Any other information necessary for proper claims adjudication, except for information provided on the prescription as required by law or regulation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 55 - PHARMACY CARDS › Section 11:4-55.3 - Time limits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier, multiple employer welfare arrangement, or health benefits provider shall provide each primary insured a new pharmacy identification card within 60 days of a health benefits plan becoming effective.
(b) A card shall be issued to the primary insured within 60 days of the primary insured initially becoming eligible for coverage under an existing health benefits plan (for example, new employee).
(c) A carrier, multiple employer welfare arrangement, or other health benefits provider shall provide each primary insured a new pharmacy identification card within a reasonable time, not to exceed 180 days, after a change in the insured's coverage that changes the information required to be on the card, if the issuance of a new card is required for proper claims adjustment. However, the carrier, multiple employer welfare arrangement, or other health benefits provider shall not be required to issue a new card reflecting changes in information more than once in a calendar year.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 55 - PHARMACY CARDS › Section 11:4-55.4 - Access to information

Current through Register Vol. 56, No. 14, July 15, 2024
If a card has not been issued, or if the information on a card does not reflect the insured's current coverage, the carrier, multiple employer welfare arrangement or other health benefits provider shall provide the primary insured with a telephone number that can be used to obtain the information that would or should be on the card. This number shall be maintained during normal business hours.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 55 - PHARMACY CARDS › Section 11:4-55.5 - Informational filing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier, multiple employer welfare arrangement or other health benefits provider issuing a card pursuant to this subchapter shall make an informational filing of the form of the card with the Department of Banking and Insurance within 30 days after issuing or causing the card to be issued. The filing shall contain:
1. The form of the card, with all required information specific to the fictitious insured. All variants of the form shall be identified; and
2. An explanation of any variation in information from the information listed in 11:4-55.2(c)  and this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter implements 17B:27C-1 et seq. by establishing rules for the registration, regulation and reporting of self-funded and partially self-funded multiple employer welfare arrangements (self-funded MEWAs). This subchapter also implements 17B:27A-49 by clarifying the requirement that insured multiple employer arrangements (MEAs) notify the Commissioner of certain information on an annual basis.
(b) This subchapter applies to self-funded and partially self-funded multiple employer welfare arrangements as defined in 29 U.S.C. §
										1002(40), other than governmental plans as defined in 29 U.S.C. §
										1002(32) and church plans as defined in 29 U.S.C. §
										1002(33), that provide a health benefit plan or plans which cover the employees of at least one employer that is either domiciled in New Jersey or has its principal headquarters or principal administrative office located in New Jersey. This subchapter also applies to carriers providing health benefits coverage, stop-loss coverage or administrative services to multiple employer arrangements as defined at 17B:27A-17.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.3 - Initial registration of self-funded MEWAs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) By September 5, 2004, a self-funded MEWA operating in this State prior to June 7, 2004, shall file an application for initial registration with the Commissioner. A self-funded MEWA that was not operating in this State prior to June 7, 2004, shall not commence operations in this State until it submits an application for initial registration to the Commissioner, and said application is approved. The application for registration shall be on a form prescribed by the Commissioner available on the Department's website at
http://www.state.nj.us/dobi/division_insurance/mewaapps.htm
, and shall include the following:
1. A certification of an officer, director or trustee of the self-funded MEWA that states:
i. The name of the self-funded MEWA, which shall not include the terms "insurance," "mutual," "casualty," "surety," "indemnity," "HMO," "assurance" or any other name likely to mislead;
ii. The names and addresses of the employers who are members of the self-funded MEWA;
iii. The names and addresses of the trustees or other persons responsible for the operations of the self-funded MEWA;
iv. The mailing address and telephone number at which communications to the self-funded MEWA are to be received;
v. The eligibility requirements for membership in the association, if any, to which the self-funded MEWA provides a health benefit plan or plans; and
vi. The fees, if any, charged for membership in the association, if any, to which the self-funded MEWA provides a health benefit plan or plans;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.4 - Subsequent annual registration of self-funded MEWAs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An application for subsequent annual registration following the initial registration shall be filed annually. The application shall be due on the same date as the annual financial statements filed pursuant to 11:4-56.9(a). The application for the subsequent annual registration shall consist of the certification of an officer, director or trustee of the self-funded MEWA a form prescribed by the Commissioner, and shall include the certification of an officer, director or trustee of the self-funded MEWA that the MEWA continues to comply with the requirements of 17B:27C-1 et seq. and this subchapter.
(b) Filings described in (a) above shall be accompanied by a fee in the amount of $ 1,000 made payable to "State of New Jersey-General Treasury," and submitted to the following address:
Att: Self-funded MEWA Registration
NJ Department of Banking and Insurance
20 West State Street
PO Box 325
Trenton, NJ 08625-0325
(c) Within 90 days of receipt of the registration, the Commissioner shall issue a registration unless the Commissioner finds that the registrant is not in compliance with the requirements of 17B:27C-1 et seq. and this subchapter, or that the continued operations of the self-funded MEWA with respect to the provision of health benefits are hazardous to enrollees, members, providers or residents of this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.5 - Eligibility requirements for self-funded MEWA coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No self-funded MEWA, and no association that obtains health coverage from a self-funded MEWA, shall refuse to provide coverage or deny membership in the MEWA or association to any employer, employee or dependent based on any of the following characteristics of the employer, employee or dependent:
1. Health status;
2. Medical condition, including physical and mental illness;
3. Claims experience of the employer or any employee or dependent;
4. Receipt of health care;
5. Medical history;
6. Genetic information;
7. Evidence of insurability, including conditions arising out of acts of domestic violence;
8. Partial or total disability;
9. Group size;
10. Age;
11. Gender; or
12. Any other health status-related factor.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.6 - Rating requirements of self-funded MEWAs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior to issuing benefit plans to small employers, a self-funded MEWA shall prepare, maintain and make available to the Department upon request, an exhibit showing the methodology for calculating assessments for small employer members. The exhibit shall contain:
1. A plan schedule describing each plan of benefits offered, which shall specify:
i. The benefit options available for each plan;
ii. The delivery system for each plan; and
iii. The in-network and out-of-network deductibles, coinsurance, and/or copays;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.7 - Notice of change in documents of self-funded MEWAs

Current through Register Vol. 56, No. 14, July 15, 2024
A registered self-funded MEWA shall not modify any information or document furnished pursuant to this subchapter unless the MEWA files with the Commissioner a notice of the change or modification, together with any additional information to explain the change or modification, at least 60 days prior to the use or adoption of the change. If the Commissioner fails to affirmatively approve or disapprove the change or modification within 60 days of receipt of the notice, the notice of modification shall be deemed approved. The Commissioner may extend the 60-day review period for not more than 30 additional days by providing the MEWA with written notice of the extension before the expiration of the 60-day period. If a change or modification is disapproved, the Commissioner shall notify the MEWA in writing, and specify the reason for the disapproval.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.8 - Financial requirements of self-funded MEWAs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A self-funded MEWA shall establish and maintain a separate trust account with respect to that segment of its operations that provides for self-funded health benefits plans. The trust account shall reflect the income, disbursements, assets and liabilities associated with providing health benefits. At all times, the trust account shall contain assets in an amount at least equal to the sum of its liabilities, including the claim reserve account, plus the required RBC.
(b) The separate trust account described in (a) above shall maintain capital and surplus at the following minimum levels:
1. For the calendar year ending December 31, 2003, 90 percent of the regulatory action level RBC determined in accordance with the RBC instructions;
2. For the calendar year ending December 31, 2004, 95 percent of the regulatory action level RBC determined in accordance with the RBC instructions; and
3. For the calendar years ending on or after December 31, 2005, the regulatory action level RBC determined in accordance with the RBC instructions.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.9 - Financial reporting of self-funded MEWAs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A self-funded MEWA shall file with the Commissioner an annual report for the separate trust account established pursuant to 11:4-56.8 no later than May 15 of each calendar year, or four months and 15 days after the end of each fiscal year of the self-funded MEWA for the immediately preceding year.
1. The annual report shall be completed as prescribed by the National Association of Insurance Commissioners (NAIC) Health Annual Statement Instructions, and completed on a statutory accounting principles basis, in accordance with the NAIC Accounting Practices and Procedures Manual, effective January 1, 2001, both incorporated herein by reference as amended and supplemented (NAIC, 2301 McGee Street, Kansas City, MO 64108).
2. The annual report shall include a certification of, and an opinion by, a qualified actuary that the reserves required by 11:4-56.8(f), and included on the self-funded MEWA's annual report, are sufficient.
i. The actuarial certification shall identify the specific methodology used to determine the reserves, and shall specify whether and how the methodology has changed since the last report.
ii. The actuarial opinion shall include the workpapers prepared by the actuary in support of the certification.
3. The annual report shall be submitted using the NAIC health blank in effect at the time of the year reported, and submitted to the following address:
New Jersey Department of Banking and Insurance
Office of Solvency Regulation
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.10 - Financial examinations of self-funded MEWAs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may, upon reasonable notice, conduct an examination of a registered self-funded MEWA as often as he or she deems necessary in order to protect the interests of enrollees, members, providers and the residents of this State. A registered self-funded MEWA shall make its books and records available for examination by the Commissioner, and retain its records for not less than seven years.
(b) The Commissioner may commission and employ such persons to conduct or assist in conducting the examination as he or she may deem advisable.
(c) The self-funded MEWA being examined shall bear the reasonable cost of the examination.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.11 - Notification to the Department by carriers of contracts with MEAs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall notify the Department by December 31 of each year of all health insurance contracts, health maintenance organization contracts, stop-loss contracts and administrative services only (ASO) contracts it issued, renewed, or had in force at any time during the 12-month period ending on September 30 of that calendar year, that covered a multiple employer arrangement (MEA) with employees and dependents in New Jersey.
(b) Such notice shall include:
1. The name and address of each MEA with whom the carrier contracted;
2. The state in which the health insurance contract, health maintenance organization contract, stop-loss contract or ASO contract was issued to the MEA;
i. If the issue state was New Jersey, the unique identifying form number of the health insurance contract, health maintenance organization contract or stop-loss contract issued to the MEA, and the date such form was approved by the Department;
3. The names and addresses of all employers covered by the MEA with employees or dependents in New Jersey and, for each such employer, the number of employees eligible for coverage; and
4. A copy of the health insurance contract, health maintenance organization contract, stop-loss contract or ASO contract between the carrier and the MEA in force at any time during the calendar year.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Section 11:4-56.12 - Violations and penalties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Persons failing to comply with any of the requirements of this subchapter shall be subject to revocation or suspension of a certificate of registration and/or a penalty of not more than $ 1,000 for a first offense, and not more that $ 5,000 for each subsequent offense pursuant to 17B:27C-10.
(b) A self-funded MEWA that fails to submit an application for registration, and covers employers domiciled in New Jersey or who have their principal headquarters or principal administrative offices in New Jersey, shall terminate coverage of such employers by February 7, 2005, and shall provide 180 days notice of termination to affected employers.
(c) A self-funded MEWA whose application for initial or subsequent annual registration is denied or withdrawn, but that covers employers domiciled in New Jersey or who have their principal headquarters or principal administrative office in New Jersey, shall terminate coverage of such employers within eight months of the date of withdrawal or denial and shall provide 180 days notice of termination to affected employers.
(d) If the Commissioner rejects a complete initial registration application filed pursuant to 11:4-56.3, or a subsequent annual registration application filed pursuant to 11:4-56.4, the Department shall advise the applicant in writing that the registration request is denied; shall specify the reasons for the denial; and shall advise the applicant of the right to request a contested case hearing as defined at 1:1-2.1, and of the procedures for filing the request.
1. A request for a hearing shall be filed within 20 days of receipt of the letter denying the request for registration, and shall be forwarded to:
Assistant Commissioner
Life and Health
New Jersey Department of Banking and Insurance
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 56 - SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENTS AND INSURED MULTIPLE EMPLOYER ARRANGEMENTS › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
Self-Funded MEWA Loss Ratio Report Form
Small Employer Business
Reporting Year (Year in which this report was prepared) ............
For Preceding Calendar Year Ending December 31, ....................
Name of MEWA: ...............................................
Address of MEWA: ............................................
1. Premiums ...................
2. Claims (a. + b.-c. + d.-e.) ...................
a. ...................
b. ...................
c. ...................
d. ...................
e. ...................
3. Loss Ratio (2./1.) ...................
4. Dividends (.75 x 1.)- 2. ...................
Signature of Preparer Date ........................
Date ................
Name of Preparer Title ............................
Title ...............
Address ....................................................................
Telephone Number ...........................................................
1.
Premiums are total earned premiums for small employer business, before
any dividends or credits applicable to prior year's Loss Ratio Reports.
2.
Claims for small employer business are equal to:
a.
claims paid in the preceding calendar year regardless of year
incurred; plus
b.
claims paid from January 1 to June 30 of the reporting year for
claims incurred prior to January 1 of the reporting year; less
c.
claims paid from January 1 through June 30 of the
preceding calendar year for claims incurred prior to January 1 of
the preceding calendar year (as reported in the preceding
year's Loss Ratio Report); plus
d.
a residual reserve equal to 3.3 percent of a. + b.-c.; less
e.
a residual reserve (as reported in the preceding year's Loss
Ratio Report).
3.
Loss Ratio is the quotient, to the nearest. 1 percent, of the Claims
dividend by the Premiums (2. divided by 1.)
4.
Dividends are 0 if the amount on Line 3 is 75.0% or greater. Otherwise,
dividends are equal to (75% of Line 1.) minus Line 2.