reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7A - LOSS RATIO REPORTS; DIVIDENDS AND CREDITS › Section 11:21-7A.3 - Filing of loss ratio reports

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each carrier having standard health benefits plan policy forms, open or closed nonstandard health benefits plan policy forms or HMO plans in force at any time during the preceding calendar year shall file with the Department an annual loss ratio report on the form appearing as Exhibit GG in the Appendix to this chapter, incorporated herein by reference. The annual loss ratio report, beginning with 1997 data reported in 1998, shall:
1. Aggregate standard health benefit plans, other than alliance plans, including all standard and nonstandard riders and endorsements thereto;
2. Aggregate open nonstandard health benefits plans, including all riders and endorsements thereto;
3. Aggregate closed nonstandard health benefits plans including all riders and endorsements thereto; and
4. Aggregate alliance health benefits plans, including all riders and endorsements thereto.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7A - LOSS RATIO REPORTS; DIVIDENDS AND CREDITS › Section 11:21-7A.4 - Contents of the loss ratio report

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A loss ratio report filed pursuant to 11:21-7A.3 shall include the following information:
1. The reporting carrier's name and address;
2. The carrier's earned premiums, before dividends or credits applicable to prior years, and claims for the preceding calendar year, calculated pursuant to the instructions of Exhibit GG;
3. The carrier's loss ratio determined by dividing the claims by the premiums;
4. The carrier's calculation of the dividends and credits to be issued pursuant to N.J.S.A. 17B:27A-25g(2). (A credit is a dividend paid in the form of a reduction in a current premium due, as distinguished from dividends paid in cash.);
5. An explanation of the carrier's plan to issue dividends and credits;
6. An explanation of the carrier's plan to distribute a dividend in the event of cancellation or termination by a policyholder;
7. Certification by a member of the American Academy of Actuaries that the information provided in the report is accurate and complete and that the carrier is in compliance with the requirements of N.J.S.A. 17B:27A-25g(2), N.J.A.C. 11:21-7A and instructions; and
8. Such other information as the Department may request.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7A - LOSS RATIO REPORTS; DIVIDENDS AND CREDITS › Section 11:21-7A.5 - Dividend or credit plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the preceding calendar year loss ratio for any of the classifications listed in 11:21-7A.3(a)  is less than 80 percent, the carrier shall include within the loss ratio report a plan to be approved by the Department for the distribution of all dividends and credits against future premiums for all policyholders with that classification in the preceding calendar year in an amount sufficient to assure that the claims in the preceding calendar year plus the amount of the dividends and credits shall equal 80 percent of the premiums for that classification in the preceding calendar year.
1. Carriers that issue health benefits plans through out-of-State trusts, associations or other multiple employer arrangements shall specify in the plan for distribution of dividends and credits that dividends and credits for such health benefits plans shall be paid or credited, as applicable, to the small employers covered under the health benefits plans, not the trust, association or other multiple employer arrangement.
2. Carriers that issue health benefits plans to small employers that are members of purchasing alliances shall specify in the plan for distribution of dividends and credits that dividends and credits for such health benefits plans shall be paid or credited, as applicable, to the small employers covered under the health benefits plans, not the trust, association or other multiple employer arrangement.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 9 - INFORMATIONAL RATE FILING REQUIREMENTS PURSUANT TO THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-9.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish informational rate filing requirements and procedures applicable to health benefits plans, including riders or endorsements, issued, renewed, reinstated or continued pursuant to 17B:27A-17 et seq.
(b) This subchapter applies to all carriers issuing, renewing, reinstating or continuing health benefits plans to small employers pursuant to 17B:27A-17 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 9 - INFORMATIONAL RATE FILING REQUIREMENTS PURSUANT TO THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-9.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
Words and terms, when used in this subchapter, shall have the meanings as defined at 17B:27A-17 or 11:21-1.2 unless defined below or the context clearly indicates otherwise.
"Classification factor" means a factor used to vary rates based upon characteristics of the employee, employer or policyholder.
"Closed nonstandard health benefits plan" means a closed nonstandard health benefits plan as defined at 11:21-11.2.
"Effective date" means the date on which coverage begins for the policyholder.
"Health benefits plan" means any standard health benefits plan or nonstandard health benefits plan including any rider or endorsement thereto.
"Nonstandard health benefits plan" means a health benefits plan policy or contract form under which policies or contracts were issued on or before December 31, 1993 to small employers or to one or more employees of a small employer by virtue of the employment arrangement, or a policy or contract form under which policies or contracts were issued on or before December 31, 1993 to an association, out-of-State trust or multiple employer arrangement and offered to a small employer or to one or more employees of a small employer.
"Nonstandard rider" means a rider or endorsement developed by a carrier to be offered with one or more of the standard health benefits plans.
"Open nonstandard health benefits plan" means an open nonstandard health benefits plan as defined at 11:21-11.2.
"Plan" means a policy or contract form under which policies, contracts or certificates are issued evidencing benefits for expenses incurred or coverage of services rendered when referring to a type of health benefits plan.
"Standard health benefits plan" means a health benefits plan promulgated by the SEH Board subject to the review and approval of the Commissioner.
"Standard rider" means a rider or endorsement promulgated by the SEH Board to be offered with one or more of the standard health benefits plans.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 9 - INFORMATIONAL RATE FILING REQUIREMENTS PURSUANT TO THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-9.3 - Informational rate filing requirements for small employer health benefits plans issued or renewed after December 31, 1993

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All carriers issuing policies, contracts or certificates under health benefit plans to small employers, including any standard or nonstandard rider option, prior to issuing any policy, contract or certificate under such plan, shall file with the Commissioner an informational rate filing which shall include the following data:
1. A plan schedule for each of the standard health benefits plans and nonstandard health benefits plans offered, outlining:
i. The benefit options available;
ii. The delivery system(s) for each plan;
iii. The in-network and out-of-network coinsurance percentages and/or copays for selective contracting arrangements or HMO point-of-service arrangements;
iv. The benefit differential for each nonstandard rider offered, separately specifying benefit increases and benefit decreases;
v. The basic premium rate or rating factors applicable for each option including the difference when Medicare is primary or secondary, based on actual employee or spouse Medicare coverage status. Reduced premium rates or rating factors must be provided when Medicare is primary for an employee eligible for Medicare by reason of age; and
vi. The coverage period, if any, for which the rates for a group are guaranteed;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 9 - INFORMATIONAL RATE FILING REQUIREMENTS PURSUANT TO THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-9.5 - Informational filing procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Informational filings submitted pursuant to this subchapter shall be sent to the Department at the following address:
Attention: SEH Informational Rate Filings
Life and Health Division
New Jersey Department of Banking and Insurance
20 West State Street
PO Box 325
Trenton, NJ 08625-0325
(b) If the Commissioner determines that an informational filing submitted pursuant to this subchapter is incomplete, the Commissioner shall provide written notice within 60 days to the carrier specifying those portions of the filing which are deficient and the information required to be submitted by the carrier. The notice shall specify whether or not the informational filing is deemed to be in substantial compliance with the requirements of 11:21-9.3. If the Commissioner takes no action with respect to the informational filing within 60 days of the date of submission thereof, the information filing shall be deemed complete.
(c) If the informational filing is incomplete but in substantial compliance with the requirements of N.J.A.C. 11:21-9.3, the carrier shall, within 30 days of receipt of written notice in (b) above, provide the Commissioner with the information required to complete the filing. Failure on the part of the carrier to comply with the provisions of this subsection may result in the imposition of a penalty pursuant to 11:21-9.6.
(d) If the informational filing is incomplete and not in substantial compliance with the requirements of N.J.A.C. 11:21-9.3, the Commissioner shall provide written notice to the carrier specifying the portions of the filing which are deficient and the information required to be submitted by the carrier. Upon receipt of notice from the Commissioner that the filing for any health benefits plan is not in substantial compliance, no contract, policy or certificate shall be entered into or renewed using the submitted rates until the Commissioner has determined that the informational filing is in substantial compliance or complete, and has provided written notice of that fact to the carrier. If the Commissioner takes no action within 30 days of the carrier's submission of information in an effort to render the filing in substantial compliance, the filing shall be deemed to be in substantial compliance.
(e) Any carrier aggrieved by a determination of the Commissioner pursuant to (b), (c) or (d) above may request a hearing on the Commissioner's determination, within 20 days of the receipt of notice of such determination, as follows:
1. A request for a hearing shall be in writing and shall include:
i. The name, address, and daytime telephone number of a contact person familiar with the matter;
ii. A copy of the notice involved;
iii. A statement requesting the hearing; and
iv. A concise statement specifying the reason(s) the carrier is aggrieved by the Commissioner's determination.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 9 - INFORMATIONAL RATE FILING REQUIREMENTS PURSUANT TO THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-9.6 - Errors in rate quotations and rate calculation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any carrier that quotes, bills or collects a premium to or from a small employer that is less than the rate shown in the carrier's informational SEH rate filing in effect at the time the premium is billed or collected shall:
1. Provide written notice to the small employer of the error as soon as possible but no later than 30 days after discovery of the error;
2. Be prohibited from charging, collecting, offsetting or otherwise recouping the amount of the undercharges; and
3. Continue to charge the erroneous rate for a period of at least 60 days from the date the written notice of the error is received by the small employer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 9 - INFORMATIONAL RATE FILING REQUIREMENTS PURSUANT TO THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-9.7 - Public disclosure of filed information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All data or information filed with the Department pursuant to 11:21-9.3(a)  are public records and may be disclosed in accordance with 47:1A-1 et seq., except that actuarial memoranda which contain confidential and proprietary information pursuant to 11:21-9.3(a)  3 shall not be disclosed by the Department to any person other than employees and representatives of the Department.
(b) A carrier shall separately identify in all informational rate filings the confidential actuarial information from all other information required by this regulation. If not so identified, all information shall be considered public information and subject to disclosure.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 9 - INFORMATIONAL RATE FILING REQUIREMENTS PURSUANT TO THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-9.8 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Failure to comply with the provisions of this subchapter may result in the imposition of fines or other penalties provided by 17B:27A-43.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 10 - THE MARKET SHARE REPORT › Section 11:21-10.1 - Scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter sets forth annual reporting requirements of market share data for the assessment of operational and administrative expenses of the SEH Program.
(b) This subchapter shall apply to all carriers that are, or become, members of the SEH Program for any portion of a calendar year for which reports under this subchapter are required to be filed, whether or not the carrier is a member on the report filing due date.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 10 - THE MARKET SHARE REPORT › Section 11:21-10.3 - Filing of the Market Share Report

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every member of the SEH Program shall file the Market Share Report set forth as Exhibit CC in the Appendix to this chapter, incorporated herein by reference, on or before April 1. Every member shall complete Parts A, B, C and D of the Market Share Report.
1. Affiliated carriers shall submit a combined Market Share Report, except as stated in (a)2 below. The combined Market Share Report shall be submitted under the name of one of the affiliated carriers' members.
2. Any insurance company, health service corporation, hospital service corporation, or medical service corporation that is an affiliate of a health maintenance organization located in the State, and any health maintenance organization located in the State that is affiliated with an insurance company, health service corporation, hospital service corporation, or medical service corporation shall submit separate Market Share Reports.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 10 - THE MARKET SHARE REPORT › Section 11:21-10.4 - Net earned premium

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every member's net earned premium for the preceding calendar year ending December 31 shall be set forth in Part C of the Market Share Report.
1. Net earned premium set forth in Part C of the Market Share Report shall include net earned premium resulting from health benefits plans issued, continued or renewed during the preceding calendar year for one or more small employers, less any refunds paid by the carrier during that calendar year as a result of the application of the minimum loss ratio requirement.
2. Net earned premium reported in Part C of the Market Share Report shall be based upon, if not the same as, the data set forth in the member's annual NAIC statement blank, adjusted to meet the definition of group health benefits plan and exclude refunds as described in (a)1 above, as necessary.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 10 - THE MARKET SHARE REPORT › Section 11:21-10.5 - Certification

Current through Register Vol. 56, No. 14, July 15, 2024
All reports shall be certified as accurate, complete and conforming with the requirements of this subchapter by the Chief Financial Officer or other duly authorized officer of the member.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 10 - THE MARKET SHARE REPORT › Section 11:21-10.6 - Failure to comply

Current through Register Vol. 56, No. 14, July 15, 2024
Failure to comply with the reporting provisions of this subchapter shall result in the Board determining that the premium set forth in the member's most recent Annual Statement filed with the Department is the premium based upon which that member's market share allocation of assessments shall be calculated by the Board.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter applies to nonstandard health benefits plans which were in effect on December 31, 1993 and have been renewed, continued or reinstated and filed with the Commissioner for informational purposes in accordance with N.J.S.A. 17B:27A-19j(6)(a) on or before January 31, 1994 which may continue to be renewed, amended and moved to another carrier by a small employer or an association, out-of-State trust and multiple employer arrangement subject to the approval of the Commissioner, but which are not subject to N.J.S.A. 17B:27A-19b, and the rating of which shall be segregated from the rating of all other health benefits plans.
(b) This subchapter defines the procedures for filing and standards for approval of nonstandard health benefits plans which were in effect on December 31, 1993 and have been renewed, continued or reinstated and filed with the Commissioner for informational purposes in accordance with N.J.S.A. 17B:27A-19j(6)(a) on or before January 31, 1994 which the carrier, association, out-of-State trust or other multiple employer arrangement shall continue to issue, and renew, and may amend and which may be moved from one carrier to another by a small employer or an association, out-of-State trust and multiple employer arrangement subject to the approval of the Commissioner.
(c) This subchapter establishes the procedures for making a complete filing of nonstandard health benefits plans with the Commissioner for renewal, amendment or movement to another carrier, and the standards for review of the filings submitted.
(d) This subchapter sets forth standards for renewal of a nonstandard health benefits plan, and standards for determining what constitutes a request for renewal by a small employer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.3 - General standards for continuing and renewing a nonstandard health benefits plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall continue and renew a nonstandard health benefits plan in accordance with this subchapter unless the carrier has:
1. Filed a request to withdraw the nonstandard health benefits plan in accordance with the requirements of N.J.A.C. 11:21-13, and the request has been approved by the Commissioner; or
2. The carrier has filed a notice of withdrawal from the small employer market in accordance with the requirements of N.J.A.C. 11:21-16 and N.J.S.A. 17B:27A-23e.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.4 - Certification of benefits coverage and actuarial value of nonstandard health benefits plans

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For nonstandard health benefits plans for which the carrier made an informational filing of a Certification of Prior Filing and Compliance with P.L. 1994, c.11, set forth as Part 3 of Exhibit BB in the Appendix to this chapter, on or before January 20, 1995 in accordance with 11:21-11.9, or made an informational filing of a Certification of Informational Filing and Compliance with P.L. 1994, c.11, as set forth as Part 4 of Exhibit BB in the Appendix to this chapter, on or before January 31, 1995 in accordance with 11:21-11.9, carriers shall file the nonstandard health benefits plan accompanied by a completed Checklist and Certification as set forth in Part 5 of Exhibit BB in the Appendix to this chapter, incorporated herein as part of this subchapter.
(b) Each such filing shall comply with N.J.A.C. 11:4-40, except that only one copy of the forms need be submitted. The forms submission shall include the nonstandard health benefits plan form, the form of all riders offered therewith, and the application for the nonstandard health benefits plan.
(c) Separate checklists and certifications and certified statements as set forth in Part 5 of Exhibit BB of the Appendix to this chapter shall be submitted for each nonstandard health benefits plan.
(d) A checklist and certification and statement certified to by an officer of the carrier submitted pursuant to this section shall not be accepted by the Commissioner until it is complete.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.5 - Closed books of business

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier seeking approval to treat a nonstandard health benefits plan as a closed nonstandard health benefits plan shall specify that on the Checklist and Certification required to be filed for that nonstandard health benefits plan pursuant to 11:21-11.4.
(b) Notwithstanding that a nonstandard health benefits plan may meet the definition of a closed nonstandard health benefits plan, if the carrier does not specify that the nonstandard health benefits plan is closed as set forth in (a) above, the carrier shall not treat the nonstandard health benefits plan as a closed nonstandard health benefits plan at any time in the future.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.6 - Obligation to market

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except with respect to nonstandard health benefits plans for which the carrier has filed a statement in accordance with 11:21-11.5, the carrier shall market the nonstandard health benefits plan to all small employers, their eligible employees and their eligible employees' dependents, as appropriate, within an association, out-of-State trust or other multiple employer arrangement, with all options and riders until such time as the carrier withdraws the nonstandard health benefits plan pursuant to N.J.A.C. 11:21-13, the carrier withdraws from the small employer market pursuant to N.J.A.C. 11:21-16, or, in the case of an association, the association terminates its sponsorship or endorsement of the nonstandard health benefits plan.
1. The obligation to market a nonstandard health benefits plan exists only with respect to an association's, trust's or other multiple employer arrangement's small employers, the small employers' eligible employees and the eligible employees' dependents, as appropriate; a carrier shall not newly issue a nonstandard health benefits plan to any other association, out-of-State trust or multiple employer arrangement (that will be offered to small employer members or participants of the association, multiple employer arrangement or out-of-State trust) except as 11:21-11.8 may apply.
2. The carrier shall similarly market every nonstandard health benefits plan that the carrier agrees to add to its portfolio in accordance with 11:21-11.8 at the request of a small employer or association, out-of-State trust or multiple employer arrangement.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.7 - Amendments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier may amend a nonstandard health benefits plan that has been approved or deemed approved by the Commissioner by submitting for approval the amendment together with a new, completed Checklist and Certification set forth in Part 5 of Exhibit BB of the Appendix to this chapter.
1. Each such filing shall comply with N.J.A.C. 11:4-40, except that only one copy of the form(s) need be submitted.
2. The carrier shall submit a separate Checklist and Certification for each nonstandard health benefits plan form being amended, clearly identifying the nonstandard health benefits plan form, and the date(s) previous certification(s) made in compliance with this subchapter were filed.
3. The carrier shall certify on the Checklist and Certification, for each plan being amended that the amendment to the nonstandard health benefits plan does not reduce the actuarial value or the benefits coverage of the nonstandard health benefits plan below the benefits coverage of Plan A and the actuarial value of the standard health benefits plan with the lowest actuarial value of the standard health benefits plans created by the Board.
4. The carrier simultaneously shall submit an explanation of the manner in which the amendment to the nonstandard health benefits plan affects the premiums for the health benefits plan, in accordance with N.J.A.C. 11:21-8.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.8 - Agreement by a carrier to add a nonstandard health benefits plan to its portfolio

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier may agree to add a nonstandard health benefits plan not currently being offered by the carrier to its portfolio of small employer health benefits plans at the request of either an association, multiple employer arrangement, trust or a single small employer if that nonstandard health benefits plan has been renewed by the current carrier in accordance with this subchapter and upon the new carrier filing the nonstandard health benefits plan with the Commissioner in accordance with N.J.A.C. 11:4-40 and submission of a completed Checklist and Certification as set forth in Part 5 of Exhibit BB of the Appendix to this chapter.
(b) The filing carrier simultaneously shall comply with 11:21-11.6, with initial date of marketing of the nonstandard health benefits plan specified in writing by the filing carrier, which date shall be no later than the effective date of the filing carrier's obligations pursuant to any contract transferred to the filing carrier under the nonstandard health benefits plan.
(c) Upon written request by the Department, the carrier currently marketing the nonstandard health benefits plan shall submit to the Department in writing for each nonstandard health benefits plan form being accepted by a filing carrier the current carrier's identification of the nonstandard health benefits plan form, and the date(s) the current carrier's checklists and certification(s) with appropriate statements made in compliance with this subchapter for the nonstandard health benefits plan form(s) were filed by the Department (including amendments thereto, if any).
(d) If the filing carrier is accepting the nonstandard health benefits plan upon the request of an association, trust or multiple employer arrangement, the filing carrier may amend the nonstandard health benefits plan form to be effective simultaneously with the effective date of the filing carrier's obligations pursuant to any contract transferred to the filing carrier under the nonstandard health benefits plan, subject to the filing carrier filing an amendment made in accordance with 11:21-11.7.
(e) If the filing carrier agrees to add a nonstandard health benefits plan to its portfolio at the request of a small employer, the filing carrier shall not amend the nonstandard health benefits plan for six months following the date that the filing carrier's obligations pursuant to the contract issued to the small employer under the nonstandard health benefits plan becomes effective.
1. Any amendment made subsequently shall be made by the filing carrier in accordance with 11:21-11.7.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.9 - Additional standards for certifications and standards for review of certifications by the Department

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to complying with the other requirements of this subchapter, certifications submitted by carriers in accordance with this subchapter shall comply with the requirements of 11:4-40.4, 40.5 and 40.11.
(b) All rate filings shall be submitted as specified in N.J.A.C. 11:21-9.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.10 - Informational filing of nonstandard health benefits plans (made in accordance with N.J.S.A 17B:27A-19j(6)(a) on or before January 31, 1995)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall submit a Certification of Prior Filing and Compliance with P.L. 1994, c.11, as set forth in Part 3 of Exhibit BB of the Appendix to this chapter, incorporated herein as part of this subchapter, for all nonstandard health benefits plans continued, renewed or reinstated pursuant to P.L. 1994, c.11, if the carrier has previously submitted the nonstandard health benefits plans to the Commissioner for filing and the nonstandard health benefits plans were so filed.
(b) A carrier shall submit a Certification of Informational Filing and Compliance with P.L. 1994, c.11, as set forth in Part 4 of Exhibit BB of the Appendix to this chapter, incorporated herein as part of this subchapter, for all nonstandard health benefits plans continued, renewed or reinstated pursuant to P.L. 1994, c.11, if those nonstandard health benefits plans were not previously submitted to the Commissioner for filing.
(c) A certification submitted pursuant to this section shall not be filed by the Commissioner until it is complete.
1. The Commissioner shall notify a carrier when a certification is determined by the Commissioner to be deficient, specifying the reasons therefor in writing.
2. The Commissioner shall determine a certification to be deficient if the certification in any way deviates from the forms as set forth in the Appendix, fails to provide answers to any of the questions contained therein, or the form fails to be certified by a duly authorized officer of the carrier. A certification shall continue to be considered deficient until the carrier submits information satisfactory to the Department to render the certification complete.
3. A carrier shall submit the information necessary to cure any deficiency(ies) or incompleteness specified within 30 days of the date of the notice, or shall become subject to fine.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 11 - NONSTANDARD HEALTH BENEFITS PLANS FILINGS WITH THE COMMISSIONER: REQUIREMENTS FOR MAINTAINING NONSTANDARD PLANS › Section 11:21-11.11 - Penalty and fines

Current through Register Vol. 56, No. 14, July 15, 2024
Pursuant to 17B:27A-43, a carrier failing to comply with the requirements of this subchapter shall be subject to payment of a fine of not less than $ 2,000 nor more than $ 5,000 per violation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 13 - NONSTANDARD PLANS: WITHDRAWAL OF PLANS › Section 11:21-13.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter sets forth the procedures by which a carrier may make a request to withdraw a nonstandard health benefits plan.
(b) This subchapter sets forth standards for review of a request to withdraw a nonstandard health benefits plan.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 13 - NONSTANDARD PLANS: WITHDRAWAL OF PLANS › Section 11:21-13.3 - Restricted withdrawal and marketing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier, association, multiple employer arrangement or out-of-State trust shall not withdraw a nonstandard health benefits plan without prior approval of the Commissioner if there was one or more policies or contracts inforce under that nonstandard health benefits plan on December 31, 1993, and one or more small employers continued to be covered under that nonstandard health benefits plan as of January 1, 1994, except as (b) below applies.
(b) A carrier may withdraw a nonstandard health benefits plan without obtaining prior approval pursuant to this subchapter if the carrier is effecting withdrawal from the small employer market in accordance with N.J.A.C. 11:21-16.
(c) A carrier shall market all open nonstandard health benefits plans made available through an association, trust or other multiple employer arrangement to all small employers members within that association, trust or other multiple employer arrangement, and the employees of such small employers.
(d) A carrier shall not market a closed nonstandard health benefits plan either directly or through an association, out-of-State trust or multiple employer arrangement.
(e) An association, multiple employer arrangement or out-of-State trust may market an open nonstandard health benefits plan, but if it does market an open nonstandard health benefits plan to its members' employees and dependents it shall offer coverage to all eligible employees and their dependents within the membership of the association, multiple employer arrangement or out-of-State trust, and in no instance shall actual or expected health status be used in determining membership.
1. An association, multiple employer arrangement or out-of-State trust that markets an open nonstandard health benefits plan shall also market at least one standard health benefits plan in accordance with 11:21-11.6.
2. In no instance shall a closed nonstandard health benefits plan be marketed.
3. No carrier shall be relieved of its obligation to market all of the standard health benefits plans by virtue of marketing at least one standard health benefits plan through an association, multiple employer arrangement or out-of-State trust.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 13 - NONSTANDARD PLANS: WITHDRAWAL OF PLANS › Section 11:21-13.4 - Request to withdraw nonstandard health benefits plans

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier may submit to the Commissioner a completed request to withdraw one or more closed and open nonstandard health benefits plan(s) at any time except that a carrier shall not:
1. Submit more than one request to withdraw at any one time, but may amend its request to withdraw, if necessary;
2. Submit a request to withdraw a nonstandard health benefits plan that the carrier added to its portfolio of health benefits plans in accordance with 11:21-11.8 within the first 12 month period following the effective date of the carrier's obligation pursuant to contracts issued under that nonstandard health benefits plan; or
3. Submit a request to withdraw while a request for relief pursuant to N.J.A.C. 11:20-11 or 11:21-15 is pending.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 13 - NONSTANDARD PLANS: WITHDRAWAL OF PLANS › Section 11:21-13.5 - Review and approval of a request to withdraw

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall deny a request to withdraw if the request fails to substantially comply with the filing format and information requirements set forth in 11:21-13.4. The Department shall notify the carrier in writing that its request to withdraw is deficient on such grounds. If the carrier intends to pursue its request to withdraw, the carrier shall submit the additional information specified or otherwise submit a filing in accordance with the format requirements specified in 11:21-13.4 within 30 days of receipt of the Department's notice of deficiency. Failure to submit within 30 days the required information shall result in the carrier's request being denied without prejudice.
(b) When the Commissioner determines that the requirement to continue servicing the nonstandard health benefits plan(s) specified in the request to withdraw is an unreasonable financial burden for the carrier, the Commissioner shall notify the carrier in writing that it may withdraw the specified nonstandard health benefits plan(s) subject to the standards of 11:21-13.6.
(c) If the Commissioner denies a carrier's request to withdraw made pursuant to the provisions of N.J.A.C. 11:21-13.4, the carrier may request a hearing on the Commissioner's determination within seven days from the date of receipt of such determination as follows:
1. A request for a hearing shall be in writing and shall include:
i. The name, address, and daytime telephone number of a contact person familiar with the matter;
ii. A copy of the Commissioner's determination;
iii. A statement requesting a hearing; and
iv. A statement describing in detail the basis for which the carrier believes that the Commissioner's denial is erroneous.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 13 - NONSTANDARD PLANS: WITHDRAWAL OF PLANS › Section 11:21-13.6 - Standards for the process of withdrawal of a nonstandard health benefits plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall effect the withdrawal of the specified nonstandard health benefits plan(s), if the request is granted by the Commissioner, through nonrenewal of the policies, contracts or certificates issued under the nonstandard health benefits plan(s) at the time of the 12-month anniversary date of each such policy, contract or certificate, provided that each policyholder, contractholder or certificateholder, and all covered persons and their dependents under the contract or certificate is given 90 days written notice prior to the date of the nonrenewal.
1. The carrier shall include in the notice the reasons for the nonrenewal (that is, that withdrawal of the health benefits plan has been approved by the Commissioner pursuant to this subchapter).
2. The carrier shall include in the notice an offer to obtain coverage under the standard health benefits plans issued by the carrier if the policyholder, contractholder, or certificateholder is a small employer (unless the carrier has been granted relief by the Commissioner pursuant to 17B:27A-26 ) or a statement that coverage may be available under an individual health benefits plan if the policyholder, contractholder or certificateholder is not a small employer.
3. The carrier shall include in the notice the name, address and telephone number of the employee or agent of the carrier who may be contacted for assistance and information concerning the withdrawal.
4. The carrier shall provide notice of the withdrawal to the producer of record for each policy, contract or certificate within 60 days of the date that the request to withdraw is granted.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 13 - NONSTANDARD PLANS: WITHDRAWAL OF PLANS › Section 11:21-13.7 - Other policyholder rights unaffected

Current through Register Vol. 56, No. 14, July 15, 2024
Except with respect to a right of guaranteed renewability, nothing in this subchapter shall be construed to contravene any rights of policyholders, contractholders or certificateholders concerning nonrenewal requirements or obligations set forth in a policy or contract of a health benefits plan that is the subject of a request to withdraw.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 15 - RELIEF FROM OBLIGATIONS IMPOSED UNDER THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-15.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter establishes the informational and procedural requirements for members requesting relief from obligations to pay assessments pursuant to 17B:27A-38 or to offer coverage or accept applications to a small employer, pursuant to 17B:27A-26.
(b) This subchapter applies to all members of the SEH Program.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 15 - RELIEF FROM OBLIGATIONS IMPOSED UNDER THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-15.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Words and terms defined at 17B:27A-17 and N.J.A.C. 11:21-1, when used in this subchapter, shall have the meanings as defined therein, unless more specifically defined in (b) below or unless the context clearly indicates otherwise.
(b) The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Applicant" means the member seeking a deferral of its obligation to pay assessments or a waiver of its obligation to offer coverage and accept applications pursuant to 17B:27A-17 et seq.
"Financially impaired" means a member which, after November 5, 1993, is not insolvent, but is deemed by the Commissioner to be potentially unable to fulfill its contractual obligations, or a member which is placed under an order of rehabilitation or conservation by a court of competent jurisdiction.
"Relief" means a deferral of obligations pursuant to 17B:27A-38 or a waiver of obligations pursuant to 17B:27A-26, as applicable.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 15 - RELIEF FROM OBLIGATIONS IMPOSED UNDER THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-15.3 - Application procedures and filing format

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any member seeking relief may submit such request to the Department at any time, except that requests for relief from payment of assessments pursuant to 17B:27A-38 shall be submitted to the Department no later than 15 days following the due date of payment of the assessment.
(b) All requests outlined in this subchapter shall be accompanied by a statement averring a need for relief from the obligation(s), as the case may be, including supporting documentation as set forth in 11:21-15.4, and shall specify the statutory and regulatory basis for such relief. A single filing may request relief from more than one obligation, but shall specify each obligation from which relief is sought.
(c) Each request shall be in loose leaf form inserted into standard two-ring or three-ring binders tabbed or otherwise indexed to correspond to the exhibits set forth in 11:21-15.4. The loose leaf sheets used in the request shall be eight and one-half inches wide and 11 inches long and punched for two-ring or three-ring binders, as appropriate.
(d) All members requesting relief pursuant to this subchapter shall submit five copies of each request in the format set forth in (c) above.
(e) If a request fails to materially comply with the filing format and information requirements set forth in 11:21-15.4 and this section, the Department shall notify the member that its request for relief is deficient and is denied on such grounds. The notice shall also set forth any information or other action required to cure the deficiency(s). If the member intends to pursue its request, the member shall submit the additional information specified or otherwise submit a filing in accordance with the format requirements specified in this section within 15 days of receipt of the Department's notice of deficiency. Failure to submit within 15 days the information necessary in the proper format to cure the deficiency shall result in the member's request being denied.
(f) All requests for relief or other information required pursuant to this subchapter shall be filed with the Department at the following address:
SEH Program
Request for Relief
New Jersey Department of Banking and Insurance
Division of Financial Solvency
20 West State Street
PO Box 325
Trenton, NJ 08625-0325
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 15 - RELIEF FROM OBLIGATIONS IMPOSED UNDER THE SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Section 11:21-15.4 - Informational filing requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When requesting relief from obligations pursuant to N.J.S.A. 17B:27A-26b or 17B:27A-38, the applicant shall provide with its request the following information in a clear, concise and complete manner:
1. A cover letter stating:
i. The name of the applicant;
ii. The form of relief and, if a deferral of less than the full amount, specific amount/percentage of relief which the applicant is requesting;
iii. A statement of facts relied upon as the basis under which relief is sought, including the specific factor(s) upon which the Commissioner may find that the member is or would be placed in a financially impaired position as set forth in 11:2-27.3(a)1  to 29; and
iv. The name, title, telephone number and telefax number of a contact person familiar with the filing to whom the Department may direct any additional questions;