reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 5 - REAL ESTATE COMMISSION › Subchapter 12 - CONTINUING EDUCATION › Section 11:5-12.15 - Denials, suspension or revocation of approvals

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commission may conduct investigations as may be necessary to enforce the provisions of 45:15-16.2a et seq. and this subchapter and may deny an application for approval and issue a reprimand to or suspend or revoke the approval of a real estate continuing education provider, instructor, including an instructor otherwise deemed approved pursuant to 11:5-12.1 0, or course, as applicable, if it is determined that:
1. An applicant, an instructor or a provider, individually or through any of the provider's employees, has failed to comply with applicable law or this subchapter;
2. A course submitted for approval or previously approved does not adequately reflect and present current and accurate information;
3. The provider or instructor or applicant for approval has engaged in misrepresentation in advertising or otherwise;
4. The provider or instructor has failed to timely and accurately download data on course completion;
5. The provider or instructor or applicant for approval has included false information in an application or reported false data to the Commission or its designee;
6. The provider or instructor is affiliated with a real estate broker or broker-salesperson licensee that has used or threatened to use a penalty or other form of coercion to compel a licensee to take a continuing education course from the affiliated provider or instructor;
7. A payment to the Commission was dishonored or, if made by credit card, reversed;
8. The provider or instructor has been disciplined by the Commission or any other occupational licensing agency in New Jersey or another jurisdiction;
9. The provider has collected money from licensees for a continuing education course, but refused or failed to provide the promised instruction; or
10. The provider or instructor has provided to a licensee any false or misleading information related to real estate licensing or education matters or to the licensee's education needs or license status.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 5 - REAL ESTATE COMMISSION › Subchapter 12 - CONTINUING EDUCATION › Section 11:5-12.16 - Appeals of initial denials of applications for continuing education course, instructor and provider approval and of applications for a waiver of the continuing education requirement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Complete applications for continuing education course, instructor and provider approval shall be reviewed by the Voluntary Advisory Committee. Should the Voluntary Advisory Committee recommend denial of the application, the Executive Director of the Commission shall so notify the applicant in writing, which notification shall include the specific grounds on the basis of which the Voluntary Advisory Committee determined to recommend the denial of the application. Such a notification shall constitute an initial denial of the application and shall advise the applicant of their opportunity to appeal the initial denial to the Real Estate Commission as set forth in this section.
(b) Applications for a waiver of the continuing education requirement shall be initially reviewed by the Commission staff. Should it be determined that an applicant does not qualify for such a waiver, the Executive Director of the Commission shall issue an initial denial in writing so notifying the applicant. The initial denial shall include the specific grounds on the basis of which it was determined that the applicant did not qualify for a waiver and shall advise the applicant of their opportunity to appeal the initial denial to the Real Estate Commission as set forth in this section.
(c) An applicant may appeal an initial denial as referenced in (a) or (b) above to the Commission by submitting an original and two copies of a written submission requesting such an appeal.
1. All appeal submissions shall include a copy of the initial denial of the Executive Director denying the application.
2. Appeal submissions may include any other relevant written material tending to support the appeal.
3. Appeals shall be filed within 30 days of the date of the initial denial issued by the Executive Director. A failure by the applicant to timely appeal an initial denial of an application shall result in the application being deemed withdrawn.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 5 - REAL ESTATE COMMISSION › Subchapter 12 - CONTINUING EDUCATION › Section 11:5-12.17 - Fees

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The fees for applications related to the requirements imposed by this subchapter are as follows:
1. Application for approval as a continuing education provider - $ 300.00.
2. Application for approval as a continuing education instructor - $ 150.00.
3. Application for approval of a continuing education course - $ 200.00.
4. Fee to process completion of continuing education requirement subsequent to May 1 in the second year of a biennial license term - $ 200.00.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 5 - REAL ESTATE COMMISSION › Subchapter 12 - CONTINUING EDUCATION › Section 11:5-12.18 - Voluntary Advisory Committee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Voluntary Advisory Committee created pursuant to 45:15-16.2a.b(1)(b) shall elect a chairperson and a vice-chairperson from among its members. Any member of the Committee shall be eligible for election to either position.
(b) The Voluntary Advisory Committee shall form committees and subcommittees to review complete applications for the approval of courses in the various core and elective topics set forth in 11:5-12.4 and 12.13 and complete applications for approval as a continuing education instructor or provider.
(c) The Voluntary Advisory Committee shall promptly report to the Commission's Executive Director its recommendations to approve or disapprove all of the complete applications it reviews. Each subcommittee of the Voluntary Advisory Committee shall report the results of its reviews of applications to the Voluntary Advisory Committee promptly upon completing such reviews and shall provide to the Executive Director copies of all recommendations for approval or disapproval contained in such reports. In the event that the Voluntary Advisory Committee fails to recommend approval or disapproval of a continuing education course, instructor or provider within 30 days of the completion of a subcommittee's review of such a complete application, the Commission may take action based upon the recommendation of the subcommittee.
(d) A majority of the appointed members of the Committee shall constitute a quorum and a majority vote by the members taken when a quorum is present shall constitute an action taken by the Committee.
1. The Voluntary Advisory Committee may meet in person or via teleconference, video conference or through the use of similar technologies.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to encourage the use of managed care to furnish injured workers with such medical, surgical and other treatment, and hospital service, as shall be necessary to cure and relieve the worker of the effects of the injury and to contain medical costs under workers' compensation coverage by providing eligible employers with a method whereby they may select a managed care alternative to traditional workers' compensation medical care at a reduced premium.
(b) Nothing in this subchapter is intended to revise, rescind or replace any statute under the New Jersey Workers' Compensation Law (34:15-1 et seq.) or any rules of the Division of Workers' Compensation promulgated thereunder.
(c) This subchapter applies to all persons subject to New Jersey's Workers' Compensation Law (34:15-1 et seq.), to all insurers authorized to provide workers' compensation coverage in the State of New Jersey and to all entities seeking approval as a workers' compensation managed care organization under this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.3 - Approval of workers' compensation managed care organizations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The completion by a WCMCO of the approval process conducted by the Department under this subchapter shall authorize the approved WCMCO to provide medical services under a workers' compensation policy after the insurer has filed an application with CRIB to obtain approval of a minimum five percent overall premium reduction for the insured's election to use a Department-approved managed care system for workers' compensation medical coverage. An approval issued under this subchapter shall not be used for any purpose except as set forth in this subchapter.
(b) The approval issued to a WCMCO under this subchapter by the Department shall continue in force excepting suspension, automatic expiration or revocation pursuant to this subchapter. If the WCMCO does not contract with any insurers during the initial two years of approval, the WCMCO's approval will automatically expire on the December 31st following the two-year anniversary of that initial approval.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.6 - Confidentiality of WCMCO application

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All data or information contained in a WCMCO's application for approval as set forth in
11:6-2.5(b)
is confidential, not subject to disclosure under the Open Public Records Act,
47:1A-1
et seq., and will not be disclosed by the Department to any person other than their employees and representatives, except the following items:
1. A description of the WCMCO's current and prior authority to do business in the State of New Jersey;
2. An organizational chart;
3. A listing and biographical affidavit of the WCMCO's officers and directors;
4. The address of the WCMCO's place of business;
5. The identity of the WCMCO's communication liaison;
6. WCMCO's audited financial reports, capitalization or projections, if otherwise available as filed with any other state or Federal government agency; and
7. Verification of the medical director's Board Certification.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.7 - Approval suspension and revocation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner shall approve an application if he or she finds that the applicant meets the following standards:
1. All of the materials required by this chapter or by the Commissioner have been filed;
2. The persons responsible for conducting the applicant's affairs are competent, trustworthy, possess good reputations, and have appropriate experience, training and education;
3. The applicant has demonstrated the ability to assure that its services will be performed in a manner which will ensure the efficient operation of its business, including appropriate financial controls;
4. The required programs to be used by the applicant are acceptable; and
5. The compensation arrangements made between the applicant and the benefits payer do not result in the assumption of financial risk by the applicant.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.8 - Monitoring; auditing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The WCMCO will ensure that it will continuously meet the requirements of this subchapter and any amendments thereto.
(b) The Department shall monitor and conduct periodic audits of the approved WCMCO as necessary to ensure compliance with the WCMCO approval criteria set forth in this subchapter.
(c) All records of the approved WCMCO and its individual participating physicians or providers shall be disclosed upon request of and in a format acceptable to the Commissioner. If such records are maintained in a coded or semi-coded manner, a legend for the codes shall be provided to the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.9 - Filing and review fees

Current through Register Vol. 56, No. 14, July 15, 2024
A non-refundable application fee in the amount of $ 1,500, payable to the "Treasurer, State of New Jersey," shall be submitted with the application.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.10 - WCMCO provider agreements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No provider agreement or amendment thereto may be used until a copy of the form of agreement has first been filed with the Department of Banking and Insurance. Thereafter, the form of agreement may be used until or unless a disapproval is received from the Department.
(b) All forms of agreements and amendments shall be filed at least 60 days prior to the planned date of use, and shall include a unique identifying form number in the bottom left hand corner.
(c) Submission of amended forms of agreements shall include two copies of the amended agreement(s) or page(s). One copy shall be marked to show changes to the existing form, and one copy shall be unmarked.
(d) Agreements with providers shall state:
1. The term of the agreement;
2. The services and supplies to be provided by the provider and a list of the contractual amounts or rates that will be paid to the provider for those services and supplies;
3. That providers shall not discriminate in their treatment of covered persons;
4. That the provider will hold the covered person harmless for the cost of any service or supply for which the carrier or intermediary provides benefits, whether or not the provider believes its compensation for the service or supply from the carrier or intermediary is made in accordance with the reimbursement provision of the provider agreement, or is otherwise inadequate; and
5. That the providers shall maintain malpractice insurance coverage in an amount not less than $ 1,000,000 per occurrence and $ 3,000,000 in the aggregate.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.11 - WCMCO fraud detection plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The WCMCO shall establish and implement a comprehensive fraud detection plan for identifying and reporting instances of possible fraud on the part of injured workers, employers, medical providers and others.
(b) The WCMCO fraud detection plan shall consist of a written plan that is reviewed at least annually and revised as necessary, and which shall include, but not be limited to:
1. Identification of items that trigger investigation into fraud and abuse;
2. Identification of frequent fraud areas and methods for detecting fraud;
3. Mechanisms for receiving input on worker, employer and provider problems and concerns regarding fraud or abuse; and
4. Procedures for investigating and reporting suspected fraud.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.12 - Minimal WCMCO treatment standards and protocols

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The WCMCO shall ensure that workers covered by the WCMCO are able to receive, at a minimum, the following services:
1. Initial treatment by a participating physician within 72 hours (depending on the nature of the injury or illness) of the WCMCO's knowledge of the necessity or request for treatment;
2. Initial treatment by a participating physician in the WCMCO within five working days or as soon thereafter as practicable, following treatment by a physician outside the WCMCO;
3. Screening and treatment, if necessary, by a WCMCO physician in cases requiring in-patient hospitalization;
4. Be directed to medical service providers within a reasonable distance from the worker's place of employment, considering the nature of care required and normal patterns of travel. To receive urgent care, the worker shall be assigned to a physician near the workplace. The assigned care coordinator physician will, in turn, arrange for necessary care through a provider closer to the worker's residence, if appropriate;
5. Treatment by a non-WCMCO medical service provider at the direction of the care coordinator physician when the worker resides outside the WCMCO's geographical service area. The care coordinator physician may only select a non-WCMCO provider who practices closer to the worker's residence than a WCMCO provider of the same category if that non-WCMCO provider agrees to the terms and conditions of the WCMCO;
6. Specialized medical services the WCMCO is not otherwise able to provide. The WCMCO's application shall include a description of the places and protocol of providing such specialized medical services; and
7. Emergency treatment in accordance with procedures that provide that in a potentially life threatening condition, the 911 emergency response system should be called or the worker should be taken to the nearest hospital emergency department.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.13 - Early return-to-work program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The WCMCO shall have an early return-to-work program to facilitate the return of an injured employee to the workplace in a timely manner. The program shall be coordinated by a case manager and be structured to ensure compliance with the provisions of the Americans With Disabilities Act, 42 U.S.C. §§
										12101 et seq.
(b) The Early Return-to-Work Program shall be based on a written plan which is reviewed annually and revised as necessary. The written plan shall include at a minimum:
1. The scope and purpose of the program;
2. Specification of back-to-work standards and procedures to facilitate an early return to work; and
3. Mechanisms to reduce the total claim costs of lost wages; medical costs; length of worker's disability; and lost work days.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.14 - Peer and utilization review programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The WCMCO shall have a program providing adequate methods of peer review and utilization review to prevent inappropriate or excessive treatment which shall include, but not be limited to, the following:
1. A pre-admission review program, which requires physicians to obtain prior approval from the WCMCO for all non-emergency admissions to the hospital and for all non-emergency surgeries prior to surgery being performed;
2. Individual case management programs, which search for ways to provide appropriate care at lower cost for cases which are likely to prove very costly, such as physical rehabilitation or psychiatric care;
3. Physician profile analysis, which shall include each physician's total charges, number and costs of related services provided, time loss of claimant, and total number of visits in relation to care provided by other physicians to persons with the same diagnosis;
4. Concurrent review programs, which periodically review the worker's care after treatment has begun, to determine if continued care is medically necessary;
5. Retrospective review programs, which examine the worker's care after treatment has ended, to determine if the treatment rendered was excessive or inappropriate; and
6. Second surgical opinion programs which describe the worker's ability to obtain the opinion of a second physician when non-emergency surgery is recommended.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.15 - Financial requirements for WCMCO

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to obtain initial approval, the WCMCO shall meet the following financial requirements:
1. A WCMCO applicant shall submit for approval an audited financial report for itself and all subcontracted entities for the year immediately preceding the application, completed on a generally accepted accounting principles (GAAP) basis, certified by an independent certified public accountant in accordance with N.J.A.C. 11:2-26.
2. If the financial affairs of the WCMCO'S parent company are audited on either a GAAP or statutory basis by an independent certified public accountant, but those of the WCMCO are not, then a copy of the audited financial statements of the parent company for the year immediately preceding the application may be submitted in lieu of the WCMCO filing audited financial statements.
3. The applicant shall submit for approval the following information with the audited financial report:
i. Disclosure of the source of all initial funding;
ii. Quarterly financial projections for the first three years of operations, which shall include a projected balance sheet, statement of revenue and expense, and statement of cash flows; and
iii. A description of the assumptions used in the financial projections which explain every major line item specifically and reasonably.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 7 - INSURANCE OF MUNICIPAL BONDS, ASSET-BACKED SECURITIES AND CONSUMER DEBT OBLIGATIONS › Subchapter 1 - GENERAL PROVISIONS › Section 11:7-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter sets forth requirements for insurers issuing contracts insuring municipal bonds, asset-backed securities and consumer debt obligations in this State.
(b) This subchapter shall apply to all insurers issuing contracts insuring municipal bonds, asset-backed securities or consumer debt obligations in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 7 - INSURANCE OF MUNICIPAL BONDS, ASSET-BACKED SECURITIES AND CONSUMER DEBT OBLIGATIONS › Subchapter 1 - GENERAL PROVISIONS › Section 11:7-1.4 - Limitations and restrictions-municipal bonds

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Policies insuring municipal bonds shall be issued to cover only bonds of the type defined in 11:7-1.1.
(b) For the purpose of complying with the provisions of 17:18-9, the total net liability of an insurer in respect to any one issue of municipal bonds insured shall be the average annual amount due for principal and interest on insured securities of such issue, net of appropriate allowance for reinsurance.
(c) In no event, shall the total net liability exceed an amount representing 10 percent of the surplus to policyholders of the insurer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 7 - INSURANCE OF MUNICIPAL BONDS, ASSET-BACKED SECURITIES AND CONSUMER DEBT OBLIGATIONS › Subchapter 1 - GENERAL PROVISIONS › Section 11:7-1.5 - Limitations and restrictions--asset-backed securities and consumer debt obligations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For purposes of this subchapter, "asset-backed securities" means:
1. Securities or other financial obligations of an issuer, provided that the issuer is a special purpose corporation, trust , or other entity, or (provided that the securities or other financial obligations constitute an insurable risk) is a bank, trust company , or other financial institution, deposits in which are insured by the Bank Insurance Fund or the Savings Association Insurance Fund (or any successor thereto), or, in the case of a bank, trust company , or other financial institution located outside the United States, deposits in which are insured by a national government-sponsored institution , such as the Bank Insurance Fund or the Savings Association Insurance Fund; and that:
i. A pool of assets has been conveyed, pledged or otherwise transferred to or is otherwise owned or acquired by the issuer;
ii. The pool of assets under (a)1i above backs the securities or other financial obligations issued; and
iii. No asset in the pool under (a)1i above, other than an asset directly payable by, guaranteed by or backed by the full faith and credit of the United States government (or in the case of an asset-backed security issued in a foreign country, backed by the full faith and credit of the national government or central bank of such foreign country) or that otherwise qualifies as collateral, has a value exceeding 20 percent of the pool's aggregate value; or
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 7 - INSURANCE OF MUNICIPAL BONDS, ASSET-BACKED SECURITIES AND CONSUMER DEBT OBLIGATIONS › Subchapter 1 - GENERAL PROVISIONS › Section 11:7-1.6 - Financial statements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The reserve for unearned premiums shall be computed as required by the provisions of 17:23-1.
(b) In addition to the contingency reserve required by 11:7-1.3(a), each insurer engaging in the issuance of policies insuring municipal bonds, asset-backed securities or consumer debt obligations shall provide a reserve for unpaid losses and loss adjustment expenses net of collateral as defined in 11:7-1.5(b)  on such policies in all financial statements filed by it with this Department. Such reserve shall be computed in a manner consistent with the provisions of 17:23-1.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 7 - INSURANCE OF MUNICIPAL BONDS, ASSET-BACKED SECURITIES AND CONSUMER DEBT OBLIGATIONS › Subchapter 1 - GENERAL PROVISIONS › Section 11:7-1.7 - Conflicts of interest prohibited

Current through Register Vol. 56, No. 14, July 15, 2024
No insurer authorized to transact the business of insuring municipal bonds shall pay any commission or make any gift of money, property or other valuable thing to any employee, agent or representative of any issuer of municipal bonds or to any employee, agent or representative of any underwriter of any issue of such bonds as an inducement to the purchase of, or at any time there is in force, a policy insuring such bonds, and no such employee, agent or representative of such issuer or underwriter shall receive any such payment or gift. However, violation of the provisions of this Section shall not have the effect of rendering void the insurance policy issued by the insurer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Dental Plan Organization Act (17:48D-1 et seq.) regulates persons and corporations which offer plans for the provision of dental services on other than a pure fee-for-service basis. The Act provides for the licensing and supervision of dental plan organizations to protect covered persons of the plan and to assure that the services contracted for are actually delivered.
(b) Section 23 of the Act authorizes the Commissioner to promulgate rules and regulations to effectuate its purposes. This subchapter establishes rules to implement the Act. These rules are designed to facilitate compliance with the Act by clarifying its requirements. Specific standards are also prescribed to ensure that the purposes of the Act are fulfilled.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.2 - Scope and application

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter applies to dental plan organizations as defined in N.J.S.A. 17:48D-2c and 11:10-1.3. Such organizations may offer group and individual dental plans on other than a pure fee-for-service basis.
(b) If the dental plan organization utilizes more than one full-time equivalent dentist to serve dental plan covered persons, it is subject to the Act and this subchapter.
(c) An individual dentist in solo practice is not required to comply with the Act or this subchapter.
(d) An individual dentist in solo practice may apply for a certificate of authority to act as a DPO, and shall comply with all the requirements of this subchapter.
(e) Supplemental dental plans as defined at 11:10-1.3 are subject to the Act and this subchapter. A DPO may not offer a supplemental dental plan unless it can be actuarially demonstrated that the capitation rate for such a plan is proportionate to the rate for an identical plan that provides 100 percent full coverage for the same services provided under the supplemental plan.
(f) An organization which provides coverage of dental services exclusively on a fee-for-service basis cannot qualify as a dental plan organization. Such organizations may not operate in this State without a certificate of authority as a health insurer or hospital, medical, dental or health service corporation, since fee-for-service coverage is either insurance or service benefits.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.4 - General rules

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any person desiring to establish, operate or administer a dental plan organization shall apply to the Commissioner for a certificate of authority. An application for a certificate of authority as a dental plan organization is available on the Department's website at
www.state.nj.us/dobi/division_insurance/managedcare/dpo_app.pdf
or can be obtained from:
New Jersey Department of Banking and Insurance
Valuation Bureau
Life and Health Division
20 West State Street
PO Box 325
Trenton, NJ 08625-0325
Phone: 609-292-5427
(b) Following the issuance of a Certificate of Authority, the DPO shall notify the Department in writing 60 days prior to any significant modification of information submitted with the application, or subsequently submitted, and shall include the document being modified and an explanation of the modification. Examples of modifications which are considered significant include, but are not limited to:
1. Changes in the DPO's organizational structure;
2. New officers, partners or members of the DPO's board of directors, board of trustees, executive committee or other governing board or committee;
3. Changes in the group or individual contract form issued by the DPO;
4. Adjustments to financial statements;
5. A change in ownership; and
6. Changes to provider agreements.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.5 - Written agreements with dentists

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every DPO shall enter into a written agreement with each dentist who will be providing dental services for plan covered persons, unless the dentist is employed by the DPO.
(b) DPOs shall file with the Commissioner at least 60 days prior to the planned date of use a copy of the form(s) of their provider agreement(s) and any amendments thereto. The agreement or amendment may be used 60 days after filing unless the Department notifies the DPO in writing within 60 days of filing of any insufficiency in the agreement or amendment. Submissions of amended forms shall include two copies of the revised or amended form(s). One copy shall be marked to show all additions or deletions to the previously approved form, and one copy shall be an unmarked final version of the form.
(c) Agreements and amendments shall include a contract form identifier on each page of the contract and/or amendment. The effective date of the form or amendment shall be part of the contract form identifier.
(d) Agreements with dentists shall include:
1. The amount and method of compensation and the services and supplies to be provided, including:
i. The capitation payment schedule(s), or the method by which the DPO will provide dentists with this information (for example, periodic member payment rosters);
ii. The method for calculating alternative payment, if applicable; and
iii. A provision stating the right of each provider to receive a periodic accounting (no less frequently than annually) of disbursements from the specialist pool, and/or the alternative payment methodology to the provider, including the method of calculation;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.6 - Evidence of coverage and group contracts

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The DPO shall prepare and issue the evidence of coverage to each enrollee within 60 days of the effective date of coverage or of a change in coverage. Covered groups may distribute the forms to covered persons on behalf of the DPO.
(b) The evidence of coverage must contain all the information required by N.J.S.A. 17:48D-9. A card containing only basic identifying information is not sufficient to meet these requirements.
(c) No evidence of coverage, or group contract, or amendment thereto, may be issued or delivered until a copy of the form has first been filed with, and has not been disapproved by, the Commissioner. A form or amendment, which differs from that previously filed with the Commissioner, may not be issued until it has first been filed with, and has not been disapproved by, the Commissioner. All forms and amendments shall be filed at least 60 days prior to the planned date of issuance, and shall include a unique identifying form number which reflects the effective date of the form or revision. Submissions of amended forms shall include two copies of the amended form(s) or page(s) only, if practicable. One copy shall be marked to show the changes from the prior approved form, and one copy shall be unmarked.
(d) All evidences of coverage shall clearly identify the name of the dental plan organization on its cover and in the text.
(e) All exclusions, exceptions, limitations, items not covered, and services not provided by the plan should be clearly identified in the evidence of coverage and group contract.
(f) Coordination of benefits provisions, which limit payment to 100 percent of allowable expenses when more than one dental plan covers a covered person, are permitted only if all of the following conditions are met:
1. Covered persons are covered under a group, not an individual contract;
2. The DPO follows the coordination of benefits rules set forth at N.J.A.C. 11:4-28; and
3. Both the group contract and evidence of coverage issued to group enrollees shall include the coordination of benefits provisions.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.8 - General surplus

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every DPO shall accumulate and maintain a minimum general surplus as set forth in this subsection, of which $ 50,000 shall be deposited with the Commissioner pursuant to N.J.A.C. 11:2-32 either within 90 days of the approval of the certificate of authority or by December 31, 2000, whichever is later:
1. For the reporting year ending December 31, 2000, the amount of the minimum general surplus shall be the greater of $ 50,000 or .5 percent of the current annual premium;
2. For the reporting year ending December 31, 2001, the amount of the minimum general surplus shall be the greater of $ 75,000 or .75 percent of the current annual premium;
3. For the reporting year ending December 31, 2002 and thereafter, the amount of the minimum general surplus shall be the greater of $ 100,000 or one percent of the current annual premium; and
4. For a newly-approved DPO, the initial amount of the minimum general surplus shall be calculated pursuant to (a)1 through 3 above based on the calendar year of approval.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.9 - Expense limitation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To achieve compliance with the expense limits set forth in 17:48D-14, every DPO shall:
1. Use at least 70 percent of its New Jersey premium in the first calendar year of operation, 75 percent in the second calendar year, and 80 percent in all subsequent calendar years for the direct provision of professional dental services to covered persons;
2. Set its per covered person retention in conformity with the statutory limits in constructing its schedule of premiums.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.10 - Complaints and other communications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Complaint systems required of every DPO (see 17:48D-12 ) shall provide that a written response shall be furnished to the covered person within 30 days after its receipt of a written complaint. The DPO's response shall, based on the information available to it at the time of response, be complete and accurate.
(b) Every DPO shall, based on the information available to it, provide the Department with a complete and accurate written response to any inquiry from the Department within 30 days after its receipt of such inquiry.
(c) Every DPO shall retain all written complaints and correspondence relating thereto for at least three years after the date of the last correspondence in file.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.11 - Fidelity bonds, crime and malpractice insurance

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The minimum amount of the fidelity bond, or crime insurance or its equivalent, on each director, officer, partner or employee of the DPO who receives, collects, reimburses or invests moneys in connection with the activities of the organization shall be $ 50,000.
1. Every DPO shall increase the bond amount, or its equivalent, as appropriate whenever its risk of loss for individual employee theft is greater than $ 50,000.
2. The fidelity bond or insurance policy shall name the DPO and the State of New Jersey as dual obligees or the State of New Jersey as an additional insured, as appropriate.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.12 - Schedule of premiums

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A DPO shall file a schedule of premiums at least annually. Every new or revised schedule of premiums shall be filed with the Commissioner at least 60 days prior to the effective date of coverage using that schedule of premiums. The Commissioner may disapprove a schedule of premiums at any time if the premiums provided thereunder are excessive, inadequate, or unfairly discriminatory, or if the filing does not substantially comply with the requirements of this section. A DPO shall not use a schedule of premiums which has not been filed, or which has been disapproved by the Commissioner.
(b) Every filing shall include all information to determine premiums, including the following:
1. A plan schedule and rate manual containing the following:
i. The rating period for which the filing is effective;
ii. A description of the plan of benefits, including deductibles, copays, and limits for each type of covered service;
iii. The basic premium or rate for each plan of benefits;
iv. The coverage period, if any, for which guaranteed premiums are guaranteed;
v. The numerical value of any classification factors used in the determination of premiums for a group, including age, gender, location, industry, prior coverage, and group size;
vi. A description of the rating methodology which will allow the determination of the premium for any group from group-specific information and the information in (b)1i, ii and iv above;
vii. A detailed example calculation of the premium for a sample group, giving all necessary group-specific information and using the methodology described in (b)1v above;
viii. An example that includes a sample of the rate proposal format using the sample premiums; and
ix. For a revision filing, the date and effective period of the filing that is being revised;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.13 - Enforcement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any DPO which violates any provision of this subchapter shall be subject to the appropriate penalty for violations of 17:48D-1 et seq., including suspension, nonrenewal or revocation of its certificate of authority.
(b) Any DPO that fails to reply to any inquiry of the Commissioner or fails to file quarterly or annual reports pursuant to this subchapter shall be subject to penalties pursuant to 17B:21-2.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 1 - DENTAL PLAN ORGANIZATIONS › Section 11:10-1.14 - Separability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provision of this subchapter, or its application to any person or circumstances, is held invalid, the remainder of this subchapter and its application to other persons or circumstances shall not be affected.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 2 - EMPLOYEE'S DENTAL BENEFIT PLANS; ALTERNATE COVERAGE › Section 11:10-2.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
P.L. 1983, Chapters 142 through 145, require that each employer or other organization subject thereto offer its employees or members the option of selecting alternate coverage which permits covered persons to obtain dental services from any dentist of their choice whenever the employer is contributing to a dental plan contract (as described in 11:10-2.2(a)  ). These statutes also direct the Commissioner to promulgate rules and regulations to effectuate their purposes. This subchapter is being promulgated to meet this statutory mandate and to implement the notification requirements of the statutes.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 2 - EMPLOYEE'S DENTAL BENEFIT PLANS; ALTERNATE COVERAGE › Section 11:10-2.2 - Scope and application

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter applies to each employer or other organization which:
1. Employs or has 25 or more employees or members during the full preceding calendar year; and
2. Contributes to a dental plan contract.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 2 - EMPLOYEE'S DENTAL BENEFIT PLANS; ALTERNATE COVERAGE › Section 11:10-2.3 - 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:
"Alternative coverage" means a plan that permits covered persons to obtain dental services from any licensed dentist.
"Dental plan contract" means any contract issued by a health insurer, dental plan organization, or dental service corporation which restricts covered persons in selecting the providers of dental services to a single provider or a limited number of providers.
"Enrollment period" means a period of time, of not less than one month's duration, prior to the renewal of a dental plan contract during which employees or members are afforded the option to be covered under the dental plan contract or alternative coverage.
"Other organization" means a group of 25 or more members to which a dental plan contract has been or is to be issued including, but not limited to, labor unions and associations.
"Renewal" means to begin a new term of the contract or to add an amendment to the contract.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 10 - DENTAL SERVICES › Subchapter 2 - EMPLOYEE'S DENTAL BENEFIT PLANS; ALTERNATE COVERAGE › Section 11:10-2.4 - Notification of affected parties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer, dental plan organization and dental service corporation shall provide to each employer or other organization to which this subchapter applies a copy of 17:48D-9.1 and 9.2 (as appropriate) and this subchapter at the time of offering a dental plan contract as defined in this subchapter.
(b) Every employer and other organization subject to this subchapter shall offer in writing to its employees or members and their eligible dependents the option of selecting coverage which permits dental services to be obtained from any licensed dentist as an alternative to the coverage provided under a dental plan contract. For new dental plan contracts being provided for the first time, this option shall be offered during the period for enrolling the employees or members in the new plan. For existing dental plan contracts, this option shall be offered during an enrollment period preceding the renewal date of the contract. Employers and other organizations which have offered this option to existing employees or members shall also offer this option to new employees or members at the time they are enrolled in a dental plan contract.
(c) Employers and other organizations to which this subchapter applies, shall post in a conspicuous manner, written notice of the coverage option and the text of P.L. 1983, Chapters 142-145, whichever chapter is applicable.