New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 1 - GENERAL PROVISIONS › Section 11:20-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
Words and terms contained in the Act, when used in this chapter, shall have the meanings as defined in the Act, unless the context clearly indicates otherwise, or as such words and terms are further defined by this chapter.
"Act" means the New Jersey Individual Health Insurance Reform Act, P.L. 1992, c.161 (N.J.S.A. 17B:27A-2 through 16.5), as it may be amended and supplemented from time to time.
"Affiliated carriers" means two or more carriers that are treated as one carrier for purposes of complying with the Act because the carriers are subsidiaries of a common parent or one another.
"Annual open enrollment period" means the Federally-designated period of time each year during which:
1. Individuals are permitted to enroll in a standard health benefits plan or standard health benefits plan with rider; and
2. Individuals who already have coverage may replace current coverage with a different standard health benefits plan or standard health benefits plan with rider.
"Board" means the Board of Directors of the New Jersey Individual Health Coverage Program established by the Act.
"Carrier" means any entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital or health service corporation, or any other entity providing a plan of health insurance, health benefits or health services. For purposes of this chapter, carriers that are affiliated carriers shall be treated as one carrier.
"Catastrophic plan" means a standard health benefit plan that is designed and offered in accordance with the requirements of Federal regulations at 45 CFR 156.155.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Conversion health benefits plan" means a group conversion contract or policy issued on or after August 1, 1993 that is not subsidized by either:
1. A single charge or ongoing increase in premium rates chargeable to the group policy or contract, identifiable as an excess morbidity charge in the group rating formula to cover group conversion excess morbidity costs; or
2. A reduction in dividends or returns paid to a group policy or contract holder, identifiable as a charge to or reduction in the group dividend or return formula to cover group conversion excess morbidity costs.
"Deferral" means a deferment, in whole or in part, of payment by a member of any assessment issued by the IHC Program Board, granted by the Commissioner pursuant to N.J.S.A. 17B:27A-12a(3) and N.J.A.C. 11:20-11.
"Department" means the New Jersey Department of Banking and Insurance.
"Dependent" means:
1. The applicant's spouse;
2. The applicant's same-gender domestic partner as that term is defined in P.L. 2003, c. 246;
3. The applicant's civil union partner pursuant to P.L. 2006, c. 103 as well as same sex relationships recognized in other jurisdictions if such relationships provide substantially all of the rights and benefits of marriage;
4. The applicant's child, legally-adopted child, step child, foster child including a child placed in foster care, or child under a court-appointed guardianship;
5. A child of the applicant's domestic partner subject to applicable terms of the individual health benefits plan;
6. A child of the applicant's civil union partner subject to applicable terms of the individual health benefits plan; or
7. With respect to coverage that is not issued through the Marketplace, any other child over whom the applicant has legal custody or legal guardianship or with whom the applicant has a legal relationship or a blood relationship provided the child depends on the applicant for most of the child's support and maintenance and resides in the applicant's household.
"Director" means a Director of the Individual Health Coverage Program Board who, in accordance with N.J.S.A. 17B:27A-10 as amended by P.L. 1993, c.164, § 5:
1. Has been elected by the members of the Individual Health Coverage Program and approved by the Commissioner;
2. Has been appointed by the Governor and confirmed by the Senate; or
3. Sits ex officio on the Board of Directors.
"Eligible person" means a person who is a resident of New Jersey who is not covered under Part A or Part B of Title XVIII of the Federal Social Security Act (42 U.S.C. §§
										1395 et seq.), commonly referred to as "Medicare."
"Essential health benefits" or "EHB" means the categories of health care services required to be covered in accordance with 45 CFR 156.110.
"Fiscal year" means the time period beginning on July 1st of each year and ending on June 30th of the following calendar year.
"Group health benefits plan" means a health benefits plan covering at least one employee.
"Group health plan" means an employee welfare benefit plan, as defined in Title I , section 3 of Pub.L. 93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C. §
										1002(1)) , to the extent that the plan provides medical care, and including items and services paid for as medical care to employees or their dependents directly or through insurance, reimbursement, or otherwise.
"Health benefits plan" means a hospital and medical expense insurance policy; health service corporation contract; hospital service corporation contract; medical service corporation contract; health maintenance organization subscriber contract; or other plan for medical care delivered or issued for delivery in this State. For purposes of this chapter, health benefits plan shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; stop loss or excess risk insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefits plans shall not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in Federal regulations. Health benefits plan shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. Health benefits plan shall not include the following if it is offered as a separate policy, certificate, or contract of insurance: Medicare supplemental health insurance as defined under section 1882(g)(1) of the Federal Social Security Act (42 U.S.C. §
										1395ss(g)(1)) ; coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (10 U.S.C. §§
										1071 et seq.); and similar supplemental coverage provided to coverage under a group health plan. The term "health benefits plan" specifically includes:
1. Standard health benefits plans as defined in this section;
2. Closed blocks of business otherwise meeting the definition of health benefits plan;
3. Executive medical plans;
4. Student coverage which provides more than accident-only coverages;
5. All prescription drug plans whether or not written on a stand-alone basis;
6. Plans that cover both active employees and retirees eligible for Medicare for which separate statutory reporting is not made by the carrier; and
7. All other health policies, plans or contracts not specifically excluded.
"HMO" means a health maintenance organization authorized in accordance with N.J.S.A. 26:2J-1 et seq.
"Hospital confinement indemnity coverage" means coverage that is provided on a stand-alone basis, contains no elimination period greater than three days, provides coverage for no less than 31 days during one period of confinement for each person covered under the policy, and provides no less than $ 40.00 but no more than $ 250.00 in daily benefits except that the benefit for the first day of hospital confinement may exceed $ 250.00 as long as the following formula is satisfied:
1st day benefit--2nd day benefit / 5 + 2nd day benefit <$ 250.00
"IHC Program" means the New Jersey Individual Health Coverage Program.
"Individual health benefits plan" means:
(a) a health benefits plan for eligible persons and their dependents; and (b) a certificate issued to an eligible person which evidences coverage under a policy or contract issued to a trust or association, regardless of the situs of delivery of the policy or contract, if the eligible person pays the premium and is not being covered under the policy of contract pursuant to continuation of benefits provisions applicable under Federal or State law. The term "individual health benefits plan" shall include a policy, contract, or certificate evidencing coverage by a policy or contract issued to a trust or association, issued to an eligible person described in, but not limited to, the following examples: a student, except coverage issued to an institution of higher education for coverage of students and their dependents in New Jersey if such policy has been filed by the Commissioner as a discretionary group pursuant to N.J.S.A. 17B:27-49, an unemployed individual or part-time employee, except as may be provided pursuant to N.J.S.A. 17B:27A-17 et seq. and N.J.A.C. 11:21-7.3; a self-employed person; an employer, when he or she (and dependents) is the sole employee seeking coverage by a health benefits plan, except as may be provided pursuant to N.J.S.A. 17B:27A-17 et seq. and N.J.A.C. 11:21-7.6; any person who is the sole employee seeking coverage by a health benefits plan, except as may be provided pursuant to N.J.S.A. 17B:27A-17 et seq. and N.J.A.C. 11:21-7.6; and an employee who is one of several employees of the same employer who are covered by certificates, contracts or policies issued by the same carrier, trust or association, if the employer does not contribute to, and remit payment for, the coverage of such employees.
The term "individual health benefits plan" shall not include a certificate issued under a policy or contract issued to a trust, or to the trustees of a fund, which trust or fund is an employee welfare benefit plan as defined by the "Employee Retirement Income Security Act of 1974" (29 U.S.C. §§
										1001 et seq.), to the extent that the Employee Retirement Income Security Act preempts the application of the Act to that plan.
"Marketplace" means the Federally facilitated Exchange as defined in Federal regulations at 45 CFR 155.20, through which qualified individuals can purchase qualified health plans and obtain a determination of eligibility for a premium tax credit, cost-sharing reduction, or exemption from the requirement to purchase health insurance.
"Medicaid" means the program administered by the New Jersey Division of Medical Assistance and Health Services Program in the New Jersey Department of Human Services, providing medical assistance to qualified applicants, in accordance with P.L. 1968, c.413 (N.J.S.A. 30:4D-1 et seq.) and amendments thereto.
"Medical care" means amounts paid:
1. For the diagnosis, care, mitigation, treatment, or prevention of a disease, illness, or medical condition or for the purpose of affecting any structure or function of the body; and
2. Transportation primarily for and essential to medical care referred to in paragraph 1 above.
"Medicare" means coverage provided pursuant to Part A or Part B of Title XVIII of the Federal Social Security Act, Pub.L. 89-97 (42 U.S.C. §§
										1395 et seq.) and amendments thereto.
"Medicare Advantage" means policies and contracts issued by carriers pursuant to a contract between the carrier and the Federal government under Section 1853 of the Federal Social Security Act (42 U.S.C. §§
										1395 et seq.) and any amendments thereto.
"Member" means a carrier that issues or has in force health benefits plans in New Jersey. A member shall not include a carrier whose combined average Medicare, Medicaid, and NJ FamilyCare enrollment represents more than 75 percent of its average total enrollment for all health benefits plans or whose combined Medicare, Medicaid, and NJ FamilyCare net earned premium for the reporting year represents more than 75 percent of its total net earned premium for the reporting year. The average Medicare, Medicaid, and NJ FamilyCare enrollment and average enrollment for all health benefits plans shall be calculated by taking the sum of these enrollment figures, as measured on the last day of each calendar quarter during the reporting year, and dividing by four.
"Minimum essential coverage" means any of the following types of coverage:
1. Government sponsored programs. Coverage under:
i. The Medicare program under Part A of Title XVIII of the Social Security Act;
ii. The Medicaid program under Title XIX of the Social Security Act;
iii. The Children's Health Insurance Program (CHIP) program under Title XXI of the Social Security Act;
iv. Medical coverage under Chapter 55 of Title 10, United States Code, including coverage under the TRICARE program;
v. A health care program under Chapter 17 or 18 of Title 38, United States Code, as determined by the Secretary of Veterans Affairs, in coordination with the Secretary of Health and Human Services and the Secretary;
vi. A health plan under section 2504(e) of Title 22, United States Code (relating to Peace Corps volunteers); or
vii. The Nonappropriated Fund Health Benefits Program of the Department of Defense, established under section 349 of the National Defense Authorization Act for Fiscal Year 1995 ( Public Law 103-337; 10 U.S.C. §
										1587 note);
2. Employer-sponsored plan. Coverage under an eligible employer-sponsored plan;
3. Plans in the individual market. Coverage under a health plan offered in the individual market within a state;
4. Grandfathered health plan. Coverage under a grandfathered health plan; and
5. Other coverage. Such other health benefits coverage, such as a state health benefits high risk pool, as the Secretary of Health and Human Services, in coordination with the Secretary, recognizes.
Minimum essential coverage shall also include those additional types of coverage designated by the Secretary of the United States Department of Health and Human Services at 45 CFR 156.602, including, but not limited to: self-funded student health coverage offered by an institution of higher education; Refugee Medical Assistance supported by the Administration for Children and Families; and Medicare Advantage plans.
"Modified community rated" means, with respect to coverage under standard health benefit plans, a rating system in which the premium for all persons covered under a policy or contract for a specific health benefits plan and a specific date of issue of that plan is the same without regard to sex, health status, occupation, geographical location, or any other factor or characteristic of covered persons, other than age.
The rating system provides that the premium rate charged by a carrier for the highest rated individual or class of individuals shall not be greater than 300 percent of the premium rate charged for the lowest rated individual or class of individuals purchasing the same individual health benefits plan. The rate differential among the premium rates charged to individuals covered under the same individual health benefits plan shall be based on the actual or expected experience of persons covered under that plan; provided, however, that the rate differential may also be based upon age. The factors upon which the rate differential is applied shall be consistent with rules promulgated by the Commissioner, which include age classifications.
"Net earned premium" means the premiums earned in this State on health benefits plans, less return premiums thereon, and dividends paid or credited to policy or contract holders on the health benefits plan business. Net earned premium shall include the aggregate premiums earned on the carrier's insured group and individual business and health maintenance organization business, including premiums from any Medicare, Medicaid, or NJ FamilyCare contracts with the State or Federal government, but shall not include any premium associated with the benefits enumerated in Section 2 of Part C of the Premium Data Worksheet, which is set forth at N.J.A.C. 11:20 Appendix Exhibit K, incorporated herein by reference.
"NJ FamilyCare" means the FamilyCare Health Coverage Program established pursuant to P.L. 2005, c. 156 (N.J.S.A. 30:4J-8 et al.).
"Open enrollment" means the offering of a health benefits plan to any eligible person on a guaranteed issue basis during the annual open enrollment period.
"Plan" means the Plan of Operation of the IHC Program, an individual health benefits plan, or a group health benefits plan, as the context indicates.
"Plan sponsor" shall have the meaning given that term under Title I , section 3 of Pub.L. 93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C. §
										1002(16)(B)) .
"Premium earned" means premium received, adjusted for the changes in premium due and unpaid, and paid in advance, and unearned premium, net of refunds or dividends paid or credited to policyholders, but not reduced by dividends to stockholders or by active life reserves.
"Program" means the New Jersey Individual Health Coverage Program established pursuant to the Act.
"Qualified health plan" or "QHP" means a health benefits plan certified to meet the requirements specified at 45 CFR Subpart 156.200 for participation on a Marketplace in accordance with 45 CFR Subpart 155.1000.
"Renewal date" means January 1 of the year immediately following the effective date of a policy and each succeeding January 1 thereafter.
"Resident" means a person whose primary residence is in New Jersey or, in the case of a person who has moved to New Jersey who intends to establish a primary residence in New Jersey.
"Special enrollment period" means a period of time that is no less than 60 days following the date of a triggering event during which:
1. Individuals are permitted to enroll in a standard health benefits plan or standard health benefits plan with rider; and
2. Individuals who already have coverage are allowed to replace current coverage with a different standard health benefits plan or standard health benefits plan with rider.
With respect to a loss of coverage, the special enrollment period also includes the 60 days preceding the loss of coverage.
"Standard health benefits plan" means a health benefits plan, including riders, if any, each of which is adopted by the IHC Program Board.
"Standard health benefits plan with rider" means a standard health benefits plan as amended with one or more optional benefit riders as permitted by N.J.A.C. 11:20-3.6. Note that the inclusion of a rider with a standard health benefits plan results in a unique plan, but does not create another standard health benefits plan.
"Stop loss" or "excess risk insurance" means an insurance policy designed to reimburse a self-funded arrangement for catastrophic, excess or unexpected expenses wherein neither the employees nor other individuals are third party beneficiaries under the insurance policy. In order to be considered stop loss or excess risk insurance for purposes of the Individual Health Insurance Reform Act, the policy shall establish a per person attachment point or retention or aggregate attachment point or retention, or both, which meet the following requirements:
1. If the policy establishes a per person attachment point or retention, that specific attachment point or retention shall not be less than $ 20,000 per covered person per plan year; and
2. If the policy establishes an aggregate attachment point or retention, that aggregate attachment point or retention shall not be less than 125 percent of expected claims per plan year.
"Subsidy" means a premium tax credit or a cost sharing reduction pursuant to 26 CFR 1.36B, 45 CFR 156.410, and 45 CFR 156.425.
"Triggering event" means an event that results in an individual becoming eligible for a special enrollment period. Triggering events are:
1. The date the eligible person loses eligibility for minimum essential coverage, or the eligible person's dependent loses eligibility for minimum essential coverage, including a loss of coverage resulting from the decertification of a QHP by the Marketplace;
2. The date a dependent child's coverage ends as a result of attaining age 26 whether or not the dependent is eligible for continuing coverage in accordance with Federal or State laws;
3. The date a dependent child's coverage under a parent's group plan ends as a result of attaining age 31;
4. The effective date of a Marketplace redetermination of an eligible person's subsidy, including a determination that an eligible person is newly eligible or no longer eligible for a subsidy with respect to Marketplace coverage, and for off-Marketplace coverage, the effective date of a Marketplace redetermination that an eligible person is no longer eligible for a subsidy;
5. The date an eligible person gains or becomes a dependent due to birth, adoption, placement for adoption, or placement in foster care with respect to the eligible person and new dependent(s);
6. The date an eligible person gains or becomes a dependent due to marriage, provided at least one spouse demonstrates having minimum essential coverage for one or more days during the 60 days preceding the date of marriage;
7. The date NJFamilyCare determines an applicant whose application was submitted during the open enrollment period or during a special enrollment period is ineligible if that determination is made after the open enrollment period or special enrollment period ends;
8. The date an eligible person and his or her dependent child(ren) who are victims of domestic abuse or spousal abandonment need to enroll for coverage apart from the perpetrator of the abuse or abandonment;
9. The date an eligible person gains access to plans in New Jersey as a result of a permanent move provided the eligible person demonstrates having minimum essential coverage for one or more days during the 60 days preceding the permanent move;
10. The date of a Marketplace or carrier finding that it erroneously permitted or denied an eligible person enrollment in a QHP;
11. The date of the court order that requires coverage of a dependent; and
12. The date the eligible person demonstrates to the Marketplace or State regulatory agency that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.
Exception: A loss of coverage resulting from nonpayment of premium, fraud, or misrepresentation of material fact shall not be a triggering event.
"Two-year calculation period" means a two-calendar-year period, the first of which shall begin January 1, 1997, and the last shall end December 31, 2018.