reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 1 - GENERAL PROVISIONS › Section 11:21-1.6 - Mission statement

Current through Register Vol. 56, No. 14, July 15, 2024
The mission of the New Jersey Small Employer Health Benefits Program Board is to administer the New Jersey Small Employer Health Benefits Program in a manner aimed at increasing access to coverage, protecting consumers, educating key stakeholders in the marketplace and other interested parties, and promoting carrier participation in the market. This includes establishment and modification of standard plans for marketing to small employers and establishing and administering assessment mechanisms. It also includes the regulation of small employer health coverage carriers in conjunction with the New Jersey Department of Banking and Insurance and New Jersey Department of Health.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The words and terms used in this Plan shall have the meanings set forth at 17B:27A-17 and 11:21-1.2 or as further defined below:
"Administrator" or "Executive Director" means that person, persons, or entity selected by the Board to effectuate the administrative functions of the Program.
"Deferral" means a deferment, in whole or in part, of payments by a member of any assessment issued by the SEH Program Board, granted by the Commissioner pursuant to 17B:27A-38 and N.J.A.C. 11:21-15.
"Earned premiums" means the premium earned in New Jersey on health benefits plans less returned premiums thereon.
"Executive Director" means that person, persons, or entity selected by the Board to effectuate the administrative functions of the Program.
"Plan of Operation" means the plan of operation of the Program, including articles, by-laws and operating rules approved by the Board pursuant to the Act.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.3 - Powers of the Board

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Board has the specific authority pursuant to the Act to:
1. Adopt rules and regulations to establish a voluntary risk pooling arrangement.
2. Enter into contracts as are necessary or proper to carry out the provisions and purposes of the Act;
3. Sue or be sued, including taking any legal actions as may be necessary for recovery of any assessments due to the Program or to avoid paying any improper claims;
4. Establish benefit levels, deductibles and copayments, exclusions, and limitations for the standard health benefits plans in accordance with applicable law;
5. Assess members in accordance with the provisions of the Act, including such interim assessments as may be reasonable and necessary for organization and reasonable operating expenses. Such interim assessments shall be credited as offsets against any regular assessments due following the close of the fiscal year;
6. Establish rules, conditions and procedures pertaining to the assessment of the members of the Program;
7. Establish standard policy forms for the standard health benefits plans and rider packages, as provided in the Act;
8. Appoint from among the members appropriate legal, actuarial, and other committees as necessary to provide technical and other assistance in the operation of the Program, policy and other contract design, and any other functions within the authority of the Program;
9. Employ or retain such persons, firms or corporations to perform such functions as are necessary for the Board's performance of its duties. The Board may use the mailing address of such person, firm or corporation as the official address of the Program. Such persons may include an Executive Director with such authority as may be delegated by the Board to implement and carry out broad directives of the Board made pursuant to statutory powers. Such persons may include actuaries, accountants, auditors, insurance producers and such other specialists or persons whose advice or assistance is deemed by the Board to be necessary to the discharge of its duties under the Act. The Board may agree to compensate such persons so as best to serve the interests of the Program and the public. Such persons, firms or corporations shall keep and maintain such records of their activities as may be required by the Board.
10. Develop a method of handling and accounting for assets and moneys of the Program and an annual fiscal reporting to the Commissioner;
11. Develop a means of providing for the filling of vacancies on the Board, subject to the approval of the Commissioner;
12. Address any additional matters which are appropriate to effectuate the provisions of this Act; and
13. Develop a buyers' guide or other informational material for the Program.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.4 - Plan of Operation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Board shall perform its function under this Plan, and in accordance with the Act. The Plan is intended to assure the fair, reasonable and equitable administration of the Program and shall constitute a public record and accordance with the Act.
(b) The Plan does not, nor is it intended to, create any contractual or other rights or obligations between the Program and any entity or any person insured by any carrier. It does not provide any benefits or create any obligation, contractual or otherwise, to any person or entity.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.6 - Committees

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Appointments to Standing and other committees shall be approved by a majority of the Board present. A written record of the proceedings of each committee shall be maintained by the Executive Director. Committee members are responsible for providing staff support, but may recommend that the Board provide funding for outside contractors. Committees may not take final action; however, within the scope of their mission and duties, Committees may make recommendations and reports to the Board for its decision and action.
(b) Standing Committees shall include the following:
1. A Finance and Audit Committee which shall make recommendations to the Board with respect to:
i. The methods and rules for calculating assessments;
ii. Assessment of members in accordance with the provisions of the Act, including such interim assessments as may be reasonable and necessary for organizational and reasonable interim operating expenses;
iii. Independent consulting actuaries who may be approved by the Board;
iv. Establishment of rules, conditions, and procedures pertaining to the registry of multiple employer arrangements in accordance with the provisions of the Act; and
v. The selection of an independent auditor for the annual audit of the Program operations;
vi. The review of reports prepared by independent auditors and other audit-related matters the Board deems necessary;
vii. Contracts which are necessary or proper to carry out the provisions and purposes of the Act;
viii. Developing the means to select an Executive Director, a statement of the powers and duties of the Executive Director, the compensation of the Executive Director, and a statement of the efficiency standards an Executive Director must meet; and
ix. Recommendations for employing or retaining persons, firms or corporations to perform the functions necessary for the Board's performance of its duties, including retention of an Executive Director for the Program;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.7 - Executive Director selection and duties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Executive Director shall be selected by the Board.
(b) The Executive Director shall perform the administrative functions required under the Act and the Plan. The Executive Director is responsible, along with the Board, for the fair, equitable and reasonable administration of the Program.
(c) The Executive Director shall perform all administrative functions developed by the Board including the following:
1. Preparing and submitting an annual report to the Board and the Commissioner no later than September 1;
2. Establishing the procedures and installing the systems needed to properly administer the operations of the Program;
3. Establishing with Board approval, one or more depository accounts for the transaction of Program business;
4. Collecting assessments due to the Program on a timely basis;
5. Depositing all moneys collected on behalf of the Program on a timely basis in the State Treasury in an account established for that purpose;
6. Issuing checks or drafts on and/or approving charges against bank accounts of the Program;
7. Keeping all accounting, administrative and financial records of the Program;
8. Acting as a resource for carriers in complying with the Program;
9. Calculating all assessments in accordance with the methodology approved by the Board; notifying members of amounts due; tracking the amount of assessments in dispute or subject to deferral request; coordinating with the Department and other appropriate parties, including State agencies, regarding fiscal administrative matters;
10. Preparing an annual estimate of the operating and administrative expenses of the Program; and
11. Performing other functions as agreed between the Board and the Executive Director.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.8 - Assessments for administrative and operating expenses

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Following approval of a final audited Program statement, the Board shall determine the final administrative expense total for the fiscal year, if any.
1. Each member's final assessment shall be reduced by any interim assessment paid by the member or credited to the member by the Board.
2. Each member's final assessment shall be reduced by any deferred assessments paid by assessed carriers in proportion to the original additional assessment made to cover the deferred amount.
3. Members shall be assessed for a proportionate share of the final administrative expenses for the fiscal year on the basis of health benefits plan earned premiums for the calendar year that includes the first six months of the fiscal year. The administrative expense assessment for each member shall be equal to the total of all administrative expenses for the fiscal year multiplied by the ratio of that member's earned premium for health benefits plans to the earned premium for health benefits plans of all members of the calendar year that includes the first six months of the fiscal year.
i. Beginning in Fiscal Year 2005, if a member's proportionate share of the interim assessment or final administrative assessment is less than $ 5.00, the member shall not be assessed and the amounts uncollected will be reapportioned proportionally, based on market share, among the member carriers.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.9 - Reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
Carriers shall submit statements, assessments and other reports as may be required by the Board pursuant to the Act and this chapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.10 - Financial administration

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Board shall maintain the books and records of the Program so that financial statements can be prepared to satisfy the Act. Further, these books shall satisfy any additional requirements of the Board and outside auditors.
1. The receipt and disbursement of cash by the Program shall be recorded as it occurs.
2. Non-cash transactions shall be recorded when assets or liabilities should be realized by the Program in accordance with generally accepted accounting principles.
3. Assets and liabilities of the Program, other than cash, shall be accounted for and described in itemized records.
4. The net balance due to or from the Program shall be calculated for each carrier and confirmed as deemed appropriate by the Board or when requested by the respective carrier. These balances should be supported by a record of each individual carrier's financial transactions with the Program. These records include:
i. Any adjustments to assessments as explained in this Plan;
ii. Adjustments to the amount due to/from the Program based upon corrections to carrier submissions;
iii. Interest charges due from a carrier for late payment of amounts due to the Program; and
iv. Other records required by the Board.
5. The Board shall maintain a general ledger which balances are used to produce the Program's financial statements in accordance with generally accepted accounting principles. The balances in the general ledger shall agree with the corresponding balances in subsidiary ledgers or journals.
6. The Board's fiscal year shall begin on July 1 and end on June 30.
7. Assessments shall be paid when billed. If the assessment is not received by the Board within 45 days of the invoice date, the carrier shall pay interest on the assessment from the invoice date at the rate of 1.5 percent per month except if the carrier is granted a deferral.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.11 - Records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Board shall provide for the maintenance and retention of its official records in accordance with the Destruction of Public Records law (
47:3-15
through 32) and all other applicable laws.
(b) The Board's records shall include the following:
1. Minutes of all Board meetings;
2. Written reports and recommendations of committees to the Board;
3. Informational and other filings made by carriers with the Board pursuant to the Act or the Board's rules;
4. Riders proposed or adopted by the Board, including all comments received;
5. The Plan of Operation and any amendments thereto;
6. Records concerning the election of Directors and appointment of committees and committee members;
7. Regulations or actions proposed or adopted by the Board, including all comments received; and
8. Such other specific records as the Board may from time to time direct or as may be required by law.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.12 - Audit functions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Program shall have an annual audit of its operations conducted by an independent certified public accountant approved by the Board. This audit shall encompass at least the following items:
1. The handling and accounting of assets and money for the Program; and
2. The annual fiscal report of the Program.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.14 - Indemnification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A member or employee of the Board, including the Executive Director and staff, shall not be liable in an action for damages to any person for any action taken or recommendation made by him or her within the scope of his or her functions as a member or employee, if the action or recommendation was taken or made without malice.
(b) The members of the Board shall be indemnified and their defense of any action provided for in the same manner and to the same extent as employees of the State under the "New Jersey Tort Claims Act," P.L. 1972, c.45, on account of acts or omissions in the scope of their employment.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 2 - NEW JERSEY SMALL EMPLOYER HEALTH BENEFITS PROGRAM PLAN OF OPERATION › Section 11:21-2.15 - Amendment and termination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This Plan may be amended by a majority vote of the entire Board, subject to approval of the Commissioner as provided hereinafter. A vote on an amendment may be taken at any meeting called, in whole or in part, for the purpose of considering a proposed amendment. Written notice of any meeting at which an amendment to the Plan is to be considered shall be sent to each Director by mail, electronic mail, or facsimile transmission at least 10 days (exclusive of the meeting day) prior to the date of the meeting. Such notice shall state that an amendment to the Plan is to be considered at the meeting and shall set forth the substance of any amendments which have been proposed or a description of the section or sections which are proposed to be amended. Notice to a Director shall be deemed sufficient if mailed, postage prepaid, to the most recent address provided by the Director to the Board or sent by facsimile transmission to the most recent facsimile reception number provided by the Director or sent by e-mail to the e-mail address provided by the Director. At any meeting for the consideration of an amendment to the Plan, for which proper notice has been given pursuant to this section, the Board may vote on any amendment proposed by a Director prior to, or during the meeting. Any amendment adopted by the Board shall be submitted to the Commissioner for approval. Any such amendment submitted to the Commissioner shall be deemed approved no later than 90 days after receipt by the Commissioner unless expressly disapproved in writing by the Commissioner before expiration of the approval period. Amendments to the Plan must be adopted pursuant to P.L. 1993, c.162.
(b) The Program shall continue in existence subject to termination in accordance with the laws of this State or the United States of America. In case of enactment of a law or laws which, in the determination of the Board and the Commissioner, shall result in the termination of the Program, the Program shall terminate and conclude its affairs. Any funds or assets held by the Program following the payment of all claims and expenses of the Program shall be distributed to the members at that time in accordance with the then-existing assessment formula.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 3 - STANDARD BENEFIT PLANS AND RIDERS › Section 11:21-3.1 - Benefits provided

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The standard health benefits plans established by the Board contain the benefits, limitations, exclusions and other terms set forth in exhibits in the Appendix to this chapter, which is incorporated herein by reference.
1. Plan B, "The Small Group Health Benefits Policy B," set forth in Exhibits F and W features carrier coinsurance of 50 percent or 60 percent.
2. Plan C, "The Small Group Health Benefits Policy C," set forth in Exhibits F and W features carrier coinsurance of 70 percent.
3. Plan D, "The Small Group Health Benefits Policy D," set forth in Exhibits F and W features carrier coinsurance of 80 percent.
4. Plan E, "The Small Group Health Benefits Policy E," set forth in Exhibits F and W features carrier coinsurance of 90 percent.
5. Exhibit F contains those items of Plans B, C, D, and E which are common among the plans as well as text which is unique to Plans B, C, D, and E, where such Plan-unique text is clearly identified and Exhibit W contains corresponding certificate text for each of the plans.
6. HMO Plan, "The Small Group Health Maintenance Organization Contract," is set forth in Exhibits G and Y.
7. HMO-POS Plan, "The Small Group Health Maintenance Organization Point of Service ("POS") Contract," is set forth in Exhibits HH and II.
8. Exhibits G and HH contain the group contract text for the HMO Plan and the HMO-POS Plan. Exhibits Y and II contain the evidence of coverage text for the HMO Plan and the HMO-POS Plan.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 4 - POLICY FORMS › Section 11:21-4.1 - Policy forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Members shall use the standard policy forms for Plans B, C, D, and E which are set forth in the Appendix to this chapter as Exhibits F, and W subject to the "Explanation of Brackets" set forth in Exhibit K of the Appendix, incorporated herein by reference. Members shall not make any changes to the text of the standard policy forms, except as permitted consistent with the explanation of brackets set forth as Exhibit K.
(b) Members shall use the standard policy form for HMO Plan which is set forth in the Appendix to this chapter as Exhibit G and Y, subject to the "Explanation of Brackets" set forth in Exhibit K of the Appendix, incorporated herein by reference.
(c) Members shall use the standard policy form for HMO-POS Plan, which is set forth in the Appendix to this chapter as Exhibit HH and II, subject to the "Explanation of Brackets" set forth in Exhibit K of the Appendix, incorporated herein by reference.
(d) All health benefits plans and optional benefits riders issued to small employers on and after January 1, 1994, shall be issued in accordance with this subchapter.
(e) Members shall use the standard small group health benefits certificate for Plans B, C, D and E which is set forth in the Appendix to this chapter as Exhibit W, subject to the "Explanation of Brackets" set forth in Exhibit K of the Appendix, incorporated herein by reference.
(f) Members shall use the standard employee evidence of coverage for HMO Plan which is set forth in the Appendix to this chapter as Exhibit Y, subject to "Explanation of Brackets" set forth in Exhibit K of the Appendix, incorporated herein by reference.
(g) All small group health benefits certificates and employee evidences of coverage issued to employees covered under small employer health benefits plans on and after January 1, 1994, shall be issued in accordance with this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 4 - POLICY FORMS › Section 11:21-4.2 - Certification or filing of forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a)No carrier shall issue any health benefits plan certificate or evidence of coverage to a small employer or the employees of a small employer or use any application form, employer or employee certification, waiver or enrollment form or make any amendments thereto until the carrier has certified that its health benefits plans and forms are in compliance with the small employer health benefits plans and all provisions of N.J.A.C. 11:21-4 and 6.
1. A carrier shall submit completed Certification of Compliance forms, set forth in Parts 1 and 2 of Exhibit BB of the Appendix to this chapter and incorporated herein by reference upon entering the small employer market, on or before 45 days of the date amendments to the standard policy forms are effective, and on or before March 1 of each year thereafter. The market entry filing and the filing upon amendments being made to the standard policy forms shall address the plans the carrier will be marketing and issuing. The March 1 filing shall address the plans the carrier issued or renewed at anytime during the prior calendar year.
2. A carrier shall submit completed Certification of Compliance forms to the Board, at the address set forth at 11:21-1.3.
3. Certification of Compliance forms shall be certified by a duly authorized officer of the carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 4 - POLICY FORMS › Section 11:21-4.4 - Compliance and variability rider

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Notwithstanding the requirements of
11:21-4.1
, members may incorporate regulatory changes required to be made to the standard policy forms, standard HMO and HMO POS contracts, certificates, and evidences of coverage for Plans B, C, D, E, HMO, and HMO POS through the use of the Compliance and Variability Rider as set forth as Exhibit DD of the Appendix, incorporated herein by reference, subject to the following:
1. If expressly permitted by the Board, the Compliance and Variability Rider may be issued by Members to incorporate changes to the standard policy forms Plans B-E, HMO, and HMO POS contracts, certificates, or evidences of coverage. Nothing contained herein shall prevent a Member from issuing a standard policy form Plans B-E, HMO, or HMO POS contract, certificate, or evidence of coverage which has incorporated Board-promulgated changes.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 6 - STANDARD EMPLOYER AND EMPLOYEE APPLICATION AND SMALL EMPLOYER CERTIFICATION FORMS › Section 11:21-6.1 - Standard application form

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All small employer carriers offering small employer health benefits plans with an effective date on or after January 1, 1994, shall use the standard application form approved by the Board and available on the Board's website at
www.state.nj.us/dobi/division_insurance/ihcseh/sehforms.html
.
(b) Small employer carriers shall require any small employer applying for a small employer health benefits plan to be issued by that small employer carrier to complete, as part of the application, the New Jersey Small Employer Certification form approved by the Board and available on the Board's website at
www.state.nj.us/dobi/division_insurance/ihcseh/sehforms.html
.
(c) The application requires the following types of information:
1. The policyholder name and contact information;
2. The Federal Tax ID Number;
3. The type of business and nature of the business;
4. The number of employees, classes of employees, and coverage type;
5. The status with respect to COBRA and Medicare as secondary payor;
6. The waiting period;
7. The contribution percentage;
8. Affiliates;
9. Benefit options;
10. Replacement information;
11. Continued coverage;
12. Agent/producer information; and
13. A signature section.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 6 - STANDARD EMPLOYER AND EMPLOYEE APPLICATION AND SMALL EMPLOYER CERTIFICATION FORMS › Section 11:21-6.2 - Annual Small Employer Certification Form

Current through Register Vol. 56, No. 14, July 15, 2024
Small employer carriers shall require each small employer covered by a small employer health benefits plan issued by the small employer carrier to that small employer to complete each year the New Jersey Small Employer Certification form approved by the Board and available on the Board's website at
http://www.state.nj.us/dobi/division_insurance/ihcseh/sehforms.html
. This form shall be sent to the small employer for completion no earlier than 150 days prior to the renewal of the small employer's health benefits plan. The information requested on the certification form is set forth at 11:21-6.1(d).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 6 - STANDARD EMPLOYER AND EMPLOYEE APPLICATION AND SMALL EMPLOYER CERTIFICATION FORMS › Section 11:21-6.4 - Waiver

Current through Register Vol. 56, No. 14, July 15, 2024
Any full-time employee who declines coverage under the small employer health benefits plan shall complete the employee waiver form approved by the Board and specified in Exhibit T of the Appendix to this chapter incorporated herein by reference.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter sets forth the standards all carriers must meet in offering, issuing and renewing all health benefits plans to any small employer, the small employer's full-time employees, and the dependents of those full-time employees.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.2 - Determination of small employer status

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To determine whether an employer qualifies as a small employer, as defined in
11:21-1.2
, a carrier shall evaluate whether an employer satisfies the requirements of the definition.
(b) A small employer carrier shall add the number of full-time employees (where full-time means 30 or more hours per week for purposes of the determination of small employer status) to the number that results from the part-time employee calculation in subsection 2 below, and if the sum is at least one but not more than 50, the employer shall be considered to be a small employer.
1. Employees working 30 or more hours per week are full-time employees and each full-time employee counts as one.
2. Employees working fewer than 30 hours per week are part-time and counted as the sum of the hours each part-time employee works per week multiplied by four and the product divided by 120 and rounded down to the nearest whole number.
3. Small employer carriers shall not include an individual and his or her spouse when the business is owned by the individual or by the individual and his or her spouse, sole proprietors, partners of partnerships, or two percent or more owners of Subchapter S corporations, or their immediate family members as employees even if such persons will be covered under the employer's plan.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.3 - Eligibility and issuance

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A small employer carrier shall issue a health benefits plan to any small employer which requests it, pays the premiums therefor, and meets the contribution and participation requirements, if any, of the small employer carrier. All health benefits plans shall provide coverage for all full-time employees and their dependents who elect to participate regardless of health status-related factors and without exclusionary riders.
1. -2. (No change.)
1. A small employer carrier shall not refuse to issue coverage, or discriminate in the issuance of coverage, to a small employer based upon the geographical location of the employees of the small employer, except that an HMO carrier or other carrier issuing a network-based plan may refuse to issue coverage to an employer to cover an employee that does not live, work, or reside in the small employer carrier's service area.
2. Every small employer carrier except small employer carriers that are HMOs, shall, as a condition of transacting business in this State, actively offer to small employers at least three of standard health benefits Plans B, C, D, and E, including all riders it has elected to write, except as such riders may be restricted to specific standard health benefits plans. Small employer carriers that are HMOs shall, as a condition of transacting business in this State, actively offer to small employers every standard health benefits plan it writes, including all riders it has elected to write, except as such riders may be restricted to specific standard health benefits plans.
3. A small employer carrier shall consider the number of all employees of all affiliated companies of a small employer in determining whether an employer is a small employer and in determining participation levels.
4. At the time of application, the determination of whether an employer is a small employer shall be based upon the small employer's completed New Jersey Small Employer Certification form.
i. If an employer qualifies as a small employer in the immediately preceding calendar year, the employer shall be considered a small employer regardless of the status of the employer on the date of application or the effective date of coverage so long as it employs at least one employee on the first day of the plan year.
ii. If an employer did not qualify as a small employer in the immediately preceding calendar year, the employer shall not be considered a small employer, regardless of the status of the employer on the date of application or the proposed effective date of coverage, if any.
iii. In the case of an employer that was not in existence during the preceding calendar year, refer to 11:21-7.2(e).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.4 - Limitations on purchase by small employers of health benefits plans with different actuarial value than existing plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A small employer who purchases a health benefits plan pursuant to the Act shall not be permitted to purchase a health benefits plan with a greater actuarial value until the first anniversary date of the small employer's existing health benefits plan.
(b) When a small employer replaces a health benefits plan with a health benefits plan of greater actuarial value, the small employer shall not be permitted to change the health benefits plan to one of less actuarial value until the anniversary date of the small employer's health benefits plan.
(c) A small employer who has purchased a health benefits plan pursuant to the Act may purchase a health benefits plan of lesser actuarial value prior to the anniversary date of the existing health benefits plan, provided that the existing health benefits plan was purchased at least 12 months prior to the latest anniversary date of the health benefits plan.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.5 - Participation requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A small employer carrier shall require a minimum participation under the small employer's health benefits plan of 75 percent of full-time employees (where full-time means 25 or more hours per week for purposes of eligibility for coverage and participation requirements) who are not serving under a waiting period as permitted under
11:21-7.8(d)
, except as set forth in (b) below. This participation requirement shall be applied by the small employer carrier uniformly among all health benefits plans and all small employers. A carrier shall count as covered under the small employer's health benefits plan, for the purpose of satisfying employee participation requirements, a full-time employee who:
1. Is covered as an employee or dependent under any fully insured health benefits plan offered by the small employer;
2. Is covered under Medicare;
3. Is covered under Medicaid or NJ FamilyCare;
4. Is covered under another group health benefits plan;
5. Is covered under a spouse's group health benefits plan;
6. Is covered under Tricare; or
7. With respect to Small Business Health Options Program coverage only, is covered under an individual plan.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.6 - Contribution requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A small employer carrier shall not require a minimum small employer contribution of more than 10 percent of the annual cost of the small employer's health benefits plan. This contribution requirement shall be applied by the small employer carrier uniformly among all health benefits plans and all small employers.
(b) A small employer carrier may, upon approval of the Board, require a minimum contribution of less than 10 percent provided that the small employer carrier:
1. Notifies the Board in writing of its contribution requirement;
2. Explains why the lesser requirement is reasonable; and
3. Applies the requirement uniformly to all small employer health benefits plans and to all small employers.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.7 - Employee open enrollment period

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each small employer shall designate a 30-day period each year as the employee open enrollment period. Such period shall begin no more than 90 days prior to the start of the plan year.
(b) Employees and dependents who are eligible under the small employer's plan but who are late enrollees may enroll for coverage under the small employer's plan during the employee open enrollment period.
(c) Employees and dependents who are covered under the small employer's plan who wish to elect coverage under a different policy, if any, offered by the small employer, may enroll for coverage under the alternate plan during the employee open enrollment period.
(d) The effective date of coverage applied for during the employer open enrollment period shall be the start of the plan year.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.7A - Special enrollment period

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The special enrollment period means a period of time that is no less than 30 days following the date of a triggering event listed in (b)1 through 5 below and no less than 60 days following a triggering event listed in (b)6 below during which:
1. Full-time employees and dependents who are late enrollees are permitted to enroll under the small employer's plan; and
2. Full-time employees and dependents who already have coverage are allowed to replace current coverage with a different plan, if any, offered by the small employer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.8 - Effective date of employer's coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A small employer carrier, prior to issuing a health benefits plan, may require the following:
1. A completed small employer standard application form including the small employer certification form in accordance with 11:21-6.1(a) and (b);
2. Complete employee enrollment forms and waiver forms; and
3. An advance premium payment not to exceed one month's premium, which shall be refunded to the employer if the health benefits plan is not issued by the small employer carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.9 - Price quotes; disclosures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A small employer carrier shall provide a price quote to a small employer, directly or through an authorized third party, within 10 working days of receiving a request for a quote and such information as is reasonable and necessary to provide the quote. A small employer carrier shall notify a small employer, directly or through an authorized producer, within five working days of receiving a request for a price quote of any additional information needed by the small employer carrier to provide the quote.
(b) Each small employer carrier shall make reasonable disclosure in price quotes provided to small employers of the provisions concerning the small employer carrier's right to change premiums and the criteria in the small employer carrier's rate filing which affect changes in premium rates.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.10 - Tie-ins

Current through Register Vol. 56, No. 14, July 15, 2024
A small employer carrier that does not embed pediatric dental benefits in the health benefits plans offered to small employers shall obtain a reasonable assurance that the small employer has purchased a stand-alone pediatric dental benefit plan from a carrier that offers a qualified pediatric dental benefit plan. A small employer carrier shall not require, as a condition to the offer or sale of a health benefits plan to a small employer, that the small employer purchase or qualify for any other insurance products or services.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.11 - Guaranteed renewal

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All health benefits plans that are issued or renewed on or after January 1, 1994, must be guaranteed renewable at the option of the policy or contract holder or small employer, except that a carrier may discontinue a health benefits plan pursuant to (b) below or nonrenew a health benefits plan pursuant to (c) below.
(b) A carrier may discontinue a health benefits plan only if:
1. The policyholder, contract holder, or employer has failed to pay premiums or contributions in accordance with the terms of the health benefits plan or the carrier has not received timely premium payments; or
2. The policyholder, contract holder, or employer has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.12 - Reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A small employer carrier shall file with the Board, quarterly no later than 60 days after the end of the fiscal quarter, the following information reported with respect to standard health benefits plans:
1. The number of small employers, covered employees, and dependents that were issued health benefits plans in the previous calendar quarter, reported separately as to newly issued plans and renewals, and separately for standard health benefits plans B, C, D, and E; plans B, C, D, and E sold through or in conjunction with a selective contracting arrangement; HMO; and HMO POS; and
2. The total number of health benefits plans in force at the end of the quarter, and the total number of employees and dependents covered, reported separately for each standard health benefits plan B, C, D, and E; plans B, C, D, and E sold through or in conjunction with a selective contracting arrangement; HMO; and HMO POS.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.14 - Permissible rate classification factors

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For health benefits plans issued or renewed on or after January 1, 2014, a carrier shall not differentiate premium rates charged to different small employers for the same health benefits plan except on the basis of age and geography in accordance with the following restrictions:
1. Rates shall vary by age for each covered person age 21 or older. There shall be a per child rate for children under age 21 with a limit applied to the number of children rate equal to three times the child rate.
2. Geographic categories shall be limited to six territories, each consisting of the areas covered by the counties listed below. A carrier shall determine which territory applies to a small employer on the basis of the address of the small employer's principal place of business. The six territories are the following:
i. Territory A consists of Essex, Hudson, and Union counties;
ii. Territory B consists of Bergen and Passaic counties;
iii. Territory C consists of Monmouth, Morris, Sussex, and Warren counties;
iv. Territory D consists of Hunterdon, Middlesex, and Somerset counties;
v. Territory E consists of Burlington, Camden, and Mercer counties; and
vi. Territory F consists of Atlantic, Cape May, Ocean, Salem, Cumberland, and Gloucester counties.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.15 - Employer waiting period

Current through Register Vol. 56, No. 14, July 15, 2024
A small employer carrier shall not be required to modify the waiting period provision of a health benefits plan except as of an anniversary date of the plan, and upon the request of a small employer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Subchapter 7 - PROGRAM COMPLIANCE › Section 11:21-7.16 - Obligation to offer individual health benefits plans

Current through Register Vol. 56, No. 14, July 15, 2024
Members that offer small employer health benefits plan in this State shall offer and make a good faith effort to market individual health benefits plans pursuant to 17B:27A-2 et seq. and 11:20-24.6. Such requirement may be satisfied by the member or the member's affiliate since the definition of "carrier" at 17B:27A-2 says carriers that are affiliated companies shall be treated as one company.
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.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this subchapter is to implement the loss ratio and refund reporting requirements of 17B:27A-19.3 and 25.
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.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following terms, when used in this subchapter, shall have the following meanings:
"Closed nonstandard health benefits plan" means a closed nonstandard health benefits plan as defined at 11:21-11.2.
"Open nonstandard health benefits plan" means an open nonstandard health benefits plan as defined at N.J.A.C. 11:21-11.2.
"Preceding calendar year" means the calendar year immediately preceding the reporting year.
"Reporting year" means the year in which the loss ratio report is required to be filed with the Department.
"Small employer purchasing alliance," "purchasing alliance" or "alliance" means a small employer purchasing alliance as established pursuant to 17B:27A-25.3.