New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.2A - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Health benefits plan" means a hospital and medical expense insurance policy, health service corporation contract, hospital service corporation contract, medical service corporation contract, health maintenance organization subscriber contract, or other plan for medical care delivered or issued for delivery in this State. For purposes of this subchapter, health benefits plan shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; stop loss or excess risk insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefits plan shall not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in Federal regulations. Health benefits plan shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. Health benefits plan shall not include the following if it is offered as a separate policy, certificate, or contract of insurance: Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Federal Social Security Act ( 42 U.S.C. §
										1395ss(g)(1) ); and coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code ( 10 U.S.C. §§
										1071 et seq.); and similar supplemental coverage provided to coverage under a group health plan.
"Spouse" means an individual legally married under the laws of this State, or under the laws of another jurisdiction; a domestic partner, pursuant to New Jersey law at P.L. 2003, c. 246; a civil union partner, pursuant to New Jersey law at P.L. 2006, c. 103; and a person legally joined in a same sex relationship in another jurisdiction if such relationship provides substantially all of the rights and benefits of marriage.