New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 3 - STANDARD BENEFIT PLANS AND RIDERS › Section 11:21-3.2 - Optional benefit riders to standard plans and administrative functions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Members may offer riders that increase the coverage offered by Plans B, C, D, E, HMO, and HMO POS plan subject to the provisions set forth in (a)1 through 6 below.
1. Before a member may sell a rider that increases any benefits or increases the actuarial value of Plans B, C, D, E, HMO, or HMO POS, the member shall file the rider with the Board for informational purposes.
2. "Coverage" offered by the four plans, the HMO plan, and the HMO POS plan for purposes of optional benefit riders filed pursuant to (a)2 above includes, but is not limited to:
i. The types and extent of services and supplies described in the "Covered Charges," and "Exclusions" sections of Plans B, C, D, and E the "Covered Services and Supplies" and "Non-Covered Services and Supplies" sections of the HMO plan, and the "Covered Services and Supplies," "Covered Charges," and "Non-Covered Services and Supplies and Non-Covered Charges" sections of the HMO POS plan;
ii. Deductibles, coinsurance, copayments, maximum out of pocket, network maximum out of pocket and non-network maximum out of pocket of Plans B, C, D, E, HMO, and HMO POS as applicable (including, but not limited to, deductible provisions such as deductible waiver, year-end deductible carry-over, and first dollar coverage), and their applicability in situations involving common accident; and
iii. Eligibility as set forth in the "Employee coverage," "Dependent coverage," and "Continuation rights" sections of Plans B, C, D, and E, the "Eligibility" and "Continuation Provisions" of sections of the HMO plan, and the "Eligibility" and "Continuation Rights" sections of the HMO POS plan.
3. "Coverage" offered by the four plans, the HMO plan, and the HMO POS plan for purposes of optional benefit riders filed pursuant to (a)2 above does not include:
i. Provider networks;
ii. Coverage which is specifically excluded from the definition of "health benefits plan" in 11:21-1.2, except for dental coverage for persons age 19 or older where the additional dental coverage is subject to the standard plan's deductible and coinsurance or copayment schedule, as applicable; or
iii. Benefits which are other than those provided under a "health benefits plan" as defined at 11:21-1.2.
4. In addition to (a)1, 2, and 3 above, any benefit rider shall be subject to the provisions of Sections 2, 3(b), 6, 7, 8, 9, and 11 of P.L. 1992, c.162, as amended.
5. A member making an informational filing shall:
i. Submit one copy of the filing and any related materials to the Board at the address specified at 11:21-1.3 through paper or electronic means;
ii. Submit one copy of the rider or riders which amend the standard group policy and certificate forms, which rider or riders shall include cross-references to the standard group policy and certificate provisions or sections and/or pages which are being modified;
iii. Specify whether the rider or amendment thereof is to be used in connection with standard health benefit Plans B, C, D, E, HMO, or HMO POS plan and provide clear and conspicuous notice of such on the forms submitted for each rider;
iv. The standard group policy and employee certificate language shall not be altered, and the benefit modifications shall appear only on the rider or riders; and
v. For riders of increasing value only, submit copies of a certification signed by a duly authorized officer of the member that states clearly:
(1) That the rider increases a benefit or benefits and does not include a decrease of any benefits or decrease in the actuarial value of standard health benefits Plan B, C, D, E, HMO, or HMO POS;
(2) That the filing is complete and in accordance with all the requirements of this subsection and applicable New Jersey statutes and regulations;
(3) That the member will offer all small employers the health benefits plan the rider modifies as a plan including the rider and as a plan without the rider;
(4) That a rate filing for plans including and without the rider has been made with the Commissioner pursuant to N.J.A.C. 11:21-9;
(5) If amending a plan, or a plan and a rider or riders, sold through or in conjunction with a selective contracting arrangement or the HMO POS contract, that the plan including the rider continues to comply with the requirements set forth in
11:4-37.3(b)
6 and 11:24-14.4(c), as applicable.
(6) That the premium or percentage change for a ridered standard plan shall be listed separately from the premium or percentage change for the unridered standard plan when rates are illustrated on rate quotes prepared by the carrier.
6. The Board shall notify a member in writing of its determination of whether an informational filing is complete and in compliance with this subsection, within 60 days of the Board's receipt of the member's submission of a rider or amendment thereof. If the Board does not notify a member of its determination with respect to an informational filing within 60 days of the Board's receipt of the submission, the informational filing shall be deemed complete.
i. If an informational filing is incomplete and not in compliance with the requirements of this subchapter, the notification shall provide the reasons the filing is incomplete and what additional information needs to be submitted by the member. The member shall provide the Board with the information required to complete the filing. Upon receipt of notice from the Board that a filing is incomplete and not in substantial compliance with the requirements of this subchapter, the member shall not sell the rider or amendment thereof until the member has received written notice from the Board that the informational filing is complete.
ii. If the Board takes no action within 60 days of receipt by the Board of a member's submission of information requested by the Board to complete an informational filing, the filing shall be deemed to be complete.