reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 2 - INDIVIDUAL HEALTH COVERAGE PROGRAM PLAN OF OPERATION › Section 11:20-2.12 - Assessments for administrative expenses and organizational and operating expenses

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as described in (a)4 below, every member shall be liable for a portion of the administrative expenses of the IHC Program. Within 90 days of approving a final audited statement of the IHC Program financial statements and the conclusion of all appeals of assessments for administrative expenses, the IHC Program Board shall notify each member by separate invoice of the dollar amounts being assessed against the member for its portion of the final administrative expense total for the applicable fiscal year or years. To the extent that an interim assessment has been made for that period, the notice shall provide reconciliation between the original invoice and the final invoice.
1. Such notice shall include a brief summary of the final administrative expenses and shall credit the member for any interim administrative expense assessments paid.
2. If a member has advanced a sum or sums of money to the IHC Program to cover some portion of the IHC Program's administrative expenses, those sums advanced shall be credited against the member's assessment amounts.
3. Each member's final assessment for administrative expenses shall be reduced by any deferral assessment paid by assessed carriers in proportion to the original assessment made to cover the deferred amount.
4. A member shall not be liable for an assessment that is less than the minimum assessment set forth in N.J.A.C. 11:20-2.18.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 2 - INDIVIDUAL HEALTH COVERAGE PROGRAM PLAN OF OPERATION › Section 11:20-2.14 - Failure to pay assessments

Current through Register Vol. 56, No. 14, July 15, 2024
If a member determined liable for an assessment fails to pay the full amount of the assessment and applicable interest, if any, within 60 days of the date of the invoice, and has neither submitted notice that it is seeking a deferral from the Commissioner, nor requested a hearing, the IHC Program Board may provide to the Commissioner a notice of the member's failure to make payment along with a recommendation to revoke the member's authority to write any health benefits plans or other health coverage in this State. A copy of this notice shall be sent to the member by registered mail at the same time that the notice is sent to the Commissioner. In accordance with the Act, failure to pay assessments shall be grounds for removal of a member's authority to write health coverage of any kind in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 2 - INDIVIDUAL HEALTH COVERAGE PROGRAM PLAN OF OPERATION › Section 11:20-2.15 - Penalties/adjustments and dispute resolutions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A member seeking to challenge the amount of an assessment must do so within 20 days of receiving the notice of the assessment pursuant to the procedures for appeals set forth at 11:20-20.2.
(b) If the Board determines that the nature or extent of errors or conduct by a member evidence activity for which penalties or sanctions are appropriate, the Board shall refer the matter to the Commissioner, Attorney General, and/or other appropriate enforcement agency, for appropriate action including the assessment of any penalties and sanctions as provided by the Act, as well as any other penalties permitted by law. Nothing herein shall be construed to limit the authority of the Commissioner, the Attorney General or any law enforcement agency to take appropriate regulatory or enforcement action with respect to violations of law and regulations.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 2 - INDIVIDUAL HEALTH COVERAGE PROGRAM PLAN OF OPERATION › Section 11:20-2.16 - Indemnification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The participation in the IHC Program as a member, the establishment of rates, forms or procedures, or any other joint or collective action required by the Act shall not be the basis of any legal action, criminal or civil liability, or penalty against the IHC Program, member of the Board of Directors, employee of the Board, or any member carrier either jointly or separately except as otherwise provided in the Act.
(b) The Board shall not be liable for any obligation of the IHC Program. No Director, officer or employee of the Board shall be individually liable and no cause of action of any nature may arise against them, for any action taken or omission made by them unless their conduct was outside the scope of their employment or constituted a crime, actual fraud, actual malice or willful misconduct.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 2 - INDIVIDUAL HEALTH COVERAGE PROGRAM PLAN OF OPERATION › Section 11:20-2.18 - Minimum assessment

Current through Register Vol. 56, No. 14, July 15, 2024
If the total amount of a member's assessment invoice would be less than $ 5.00, the member shall not be liable for that amount and that amount shall be reapportioned pursuant to N.J.A.C. 11:20-2.12. This provision shall apply to an invoice for administrative expenses issued pursuant to N.J.A.C. 11:20-2.12.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 3 - BENEFIT LEVELS AND POLICY FORMS › Section 11:20-3.1 - The standard health benefits plans

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The standard individual health benefits plans established by the Board contain the benefits, limitations and exclusions set forth in the Appendix to this chapter as follows:
1. Plan A/50, Appendix Exhibit A with pages identified as unique to Plan A/50;
2. Plan B, Appendix Exhibit A with pages identified as unique to Plan B;
3. Plan C, Appendix Exhibit A with pages identified as unique to Plan C;
4. Plan D, Appendix Exhibit A with pages identified as unique to Plan D; and
5. HMO Plan, Appendix Exhibit B.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 3 - BENEFIT LEVELS AND POLICY FORMS › Section 11:20-3.2 - Sample schedule page text

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The standard plans set forth in Appendix Exhibits A and B include sample schedule page text. The sample schedule pages highlight some covered services. Carriers may include additional covered services on the schedule. Features included on one sample schedule page may be included on any schedule page, as appropriate to the plan design being offered.
(b) The standard plans set forth in Appendix Exhibit A may be issued to a covered person who qualifies for a cost sharing reduction. Carriers may include cost sharing amounts on the schedule that are appropriate to the cost sharing reduction a covered person receives.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 3 - BENEFIT LEVELS AND POLICY FORMS › Section 11:20-3.3 - Compliance and variability rider

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Members may incorporate regulatory changes required to be made to the standard policy forms, standard HMO contract, and standard riders through the use of the Compliance and Variability Rider as set forth as Exhibit D of the Appendix, incorporated herein by reference, if the Board has indicated in the rule adoption of the regulatory changes to the standard policy forms that Compliance and Variability Riders may be used. Carriers may only use the Compliance and Variability Rider to incorporate Board designated text for the period of time specified by the Board in the rule adoption of the regulatory changes to the standard policy forms.
(b) Members may make any changes to the standard policy forms, standard HMO contract, or standard riders promulgated by the Board consistent with the permitted as variable text set forth in Exhibits A and B of the Appendix to this Chapter, as described in the Explanation of Brackets, Exhibit C, through the use of the Compliance and Variability Rider as set forth as Exhibit D of the Appendix.
(c) Members may incorporate text for benefits required to be offered to the Policyholder through the use of the Compliance and Variability Rider as set forth as Exhibit D of the Appendix, if the Board has indicated in the rule adoption of the regulatory changes to the standard policy forms to address the mandated offer that carriers may issue the optional coverage by rider in lieu of including the coverage in the standard policy forms. For example, coverage for autologous bone marrow transplant, as required to be offered pursuant to P.L. 1995, c. 100, may be included using the Compliance and Variability Rider.
(d) Members may address the cost sharing reduction amounts referred to in 11:20-3.2(b)  on the Compliance and Variability Rider.
(e) Members may not use the Compliance and Variability rider to accomplish benefit modifications as outlined in 11:20-3.6.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 3 - BENEFIT LEVELS AND POLICY FORMS › Section 11:20-3.7 - Plan or plan option withdrawal by IHC Board

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the IHC Board promulgates rules withdrawing a plan, plan option, or deductible/copayment option, a carrier shall cease issuing that plan, plan option, or deductible/copayment option within the timeframe established by the IHC Board by regulation.
(b) If the IHC Board promulgates rules withdrawing a plan, plan option, or deductible/copayment option, a carrier shall nonrenew that individual plan, plan option, or deductible/copayment option pursuant to the procedures set forth in (c) and (d) below.
(c) Not more than 60 days after the Board has promulgated rules withdrawing a plan, plan option, or deductible/copayment option, and not less than 90 days in advance of the effective date of the nonrenewal on the anniversary date of the plan, a carrier shall mail a notice of nonrenewal by mail to every policy or contractholder. Following the initial notice of nonrenewal to each policy or contractholder, the carrier shall send a subsequent notice of the nonrenewal to each policy or contractholder which notice shall be included with a monthly premium bill or premium notice issued prior to the date of nonrenewal, or, where no monthly premium statement is transmitted, send a notice at least 30 days prior to nonrenewal. Nonrenewal notices for policy or contractholders shall contain the following information:
1. A statement that the IHC Board has withdrawn the plan, plan option, or deductible/copayment option from the individual health benefits market;
2. The date upon which the plan, plan option, or deductible/copayment option shall be nonrenewed;
3. A statement that the plan, plan option, or deductible/copayment option is being nonrenewed under the authority of N.J.A.C. 11:20-3.7;
4. A notice that the carrier shall make available a replacement plan, plan option, or deductible/copayment option;
5. A statement that the policy or contractholder may contact his or her producer, if any, for additional information regarding the plan, plan option, or deductible/copayment option withdrawal; and
6. The name, address and telephone number of the employee of the carrier who may be contacted for assistance and information regarding the withdrawal.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 3A - POLICY FORMS › Section 11:20-3A.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish the requirements and procedures by which carriers seeking to enter the individual plan market and carriers issuing plans in the individual plan market shall file individual policy or contract forms with the Commissioner and certify to the Commissioner that the health benefit plans to be used by the carrier are in substantial compliance with provisions in the approved individual plans, as required by N.J.S.A. 17B:27A-7d.
(b) This subchapter applies to all carriers, whether or not affiliated with other carriers doing business in the individual plan market in New Jersey, that seek to offer and are offering individual plans pursuant to the IHC Act.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 3A - POLICY FORMS › Section 11:20-3A.2 - Certification of Compliance

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Before marketing, issuing or renewing any of the standard policy forms, a member shall file with the Department, the Certification of Compliance set forth in the Appendix to this subchapter as Exhibit E, incorporated herein by reference. Each affiliated carrier must file a separate Certification of Compliance. A Certification of Compliance must be filed upon entry into the individual market and annually on or before March 1.
(b) Carriers that submit an Exhibit E Certification of Compliance may issue and make effective individual health benefits plans upon filing such Certification with the Department and may continue to do so until such time as the filing is disapproved in writing by the Department. The Department may disapprove an Exhibit E Certification of Compliance if the Certification is inaccurate or incomplete.
(c) Any carrier whose Certification of Compliance is disapproved may file an appeal of the Department's determination and request a hearing within 20 days of receipt of written notification of the Department's final determination.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 3A - POLICY FORMS › Section 11:20-3A.3 - Basic and essential health care services plan policy form

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Before a member may offer or issue the basic and essential health care services plan policy form, the member shall submit the information set forth below to the Department at Department of Banking and Insurance, Life and Health, Basic and Essential Health Care Services Plan Form Filing, 20 West State Street, P.O. Box 325, Trenton, New Jersey 08625.
1. One copy of the policy form for the basic and essential health care services plan, unless filing a certification as set forth in (b)1 below; and
2. A certification signed by a duly authorized officer of the member that states that:
i. The member will make the basic and essential health care services plan available to eligible persons and will make a good faith effort to market the plan;
ii. Rates for the basic and essential health care services plan have been submitted pursuant to the requirements of N.J.A.C. 11:20-6; and
iii. The benefits in the policy form being submitted include all of the coverages enumerated in section 2.a. of P.L. 2001, c. 368, but do not include any additional benefits.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 6 - INDIVIDUAL HEALTH BENEFITS CARRIERS INFORMATIONAL RATE FILING REQUIREMENTS › Section 11:20-6.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this subchapter is to establish informational rate filing requirements and procedures for members issuing or renewing individual health benefits plans pursuant to section 3 of the Act (17B:27A-4 ) as well as the basic and essential health care services plan pursuant to P.L. 2001, c. 368.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 6 - INDIVIDUAL HEALTH BENEFITS CARRIERS INFORMATIONAL RATE FILING REQUIREMENTS › Section 11:20-6.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
Words and terms, when used in this subchapter, shall have the meanings defined by the Act, 11:20-1.2, or as further defined below, unless the context clearly indicates otherwise.
"Informational filing" means a submission by a carrier of rate manuals which specify the plans offered, premium rates, all factors to be used in the calculation of premium rates, and a detailed actuarial memorandum supporting the calculation of the rates including a certification by a qualified member of the American Academy of Actuaries, the Society of Actuaries, or the Casualty Actuarial Society, all supporting data for the premium rates and such other information as specified in this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 6 - INDIVIDUAL HEALTH BENEFITS CARRIERS INFORMATIONAL RATE FILING REQUIREMENTS › Section 11:20-6.4 - Informational rate filing procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A member shall file one copy of the informational rate filing with the Department pursuant to 11:20-6.3(a) or (b) at the following address: New Jersey Dept. of Banking and Insurance
Life & Health Actuarial: IHC Rate Filings
PO Box 325
20 West State Street
Trenton, NJ 08625
(b) If the Commissioner determines that an informational filing filed pursuant to 11:20-6.3(a) or (b) is incomplete but in substantial compliance with 17B:27A-2 et seq., the Commissioner shall provide written notice to the member specifying those portions of the filing which are deficient and the information required to be submitted or resubmitted by the member.
(c) Within 30 days of receipt of a written notice as referenced in (b) above, the member shall provide the Department with the information required to complete the filing. Failure to provide this information may result in the imposition of penalties specified in 17B:27A-43 and/or revision of rates to the last filed rate.
(d) If the Commissioner determines that a filing is incomplete and not in substantial compliance, that the rates are inadequate, or that the rates are unfairly discriminatory, the Commissioner shall provide written notice to the member specifying the information required to be submitted, and specifying in addition the basis for the finding that the filing is not in substantial compliance, or, if applicable, that the rates are inadequate or unfairly discriminatory. The rate filing shall not become effective until the Commissioner has confirmed in writing that the basis for disapproval is cured.
(e) Upon the issuance of a notice as set forth in (d) above, the member shall submit any additional information required to make the filing complete in accordance with (c) above. A carrier may appeal the Commissioner's determination that the filing is not in substantial compliance or that the rates are inadequate or unfairly discriminatory and request a hearing within 20 days of receipt of the written notice set forth in (d) above.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 6 - INDIVIDUAL HEALTH BENEFITS CARRIERS INFORMATIONAL RATE FILING REQUIREMENTS › Section 11:20-6.5 - Permissible rate classification factors

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier shall not differentiate premium rates charged to different individuals except on the basis of age (in the case of standard plans and riders) and age, gender, and geography (in the case of basic and essential plans and riders) in accordance with the following restrictions:
1. Age factor categories shall be limited to the following increments: 19 and under; 20-24; 25-29; 30-34; 35-39; 40-44; 45-49; 50-54; 55-59; 60-64; and 65 and over.
2. Geographic categories shall be limited to six territories, each consisting of the areas covered by the first three digits of the U.S. Postal Service zip codes or the counties listed below. A carrier shall determine which territory applies to a policyholder on the basis of the address of the policyholder's place of residence. The six territories are the following:
i. Territory A consists of zip codes 070-073 or Essex, Hudson and Union counties;
ii. Territory B consists of zip codes 074-076 or Bergen and Passaic counties;
iii. Territory C consists of zip codes 077-079 or Monmouth, Morris, Sussex and Warren counties;
iv. Territory D consists of zip codes 088-089 or Hunterdon, Middlesex and Somerset counties;
v. Territory E consists of zip codes 081, 085-086 or Burlington, Camden and Mercer counties; and
vi. Territory F consists of zip codes 080, 082-084 and 087 or Atlantic, Cape May, Ocean, Salem, Cumberland and Gloucester counties.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 7 - LOSS RATIO AND REFUND REPORTING REQUIREMENTS › Section 11:20-7.1 - 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 the Act.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 7 - LOSS RATIO AND REFUND REPORTING REQUIREMENTS › Section 11:20-7.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
Words and terms, when used in this subchapter, shall have the meanings defined by the Act,
11:20-1.2
, or as further defined below, unless the context clearly indicates otherwise.
"Claims paid" means a dollar amount determined in accordance with statutory annual statement reporting , adjusted as required by this subchapter.
"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 Board.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 7 - LOSS RATIO AND REFUND REPORTING REQUIREMENTS › Section 11:20-7.3 - Filing of Loss Ratio Report

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each member that had a standard health benefits plan or a basic and essential health care services plan in force during the preceding calendar year shall file with the Commissioner an annual Loss Ratio Report on the form appearing as Exhibit J in the Appendix to this chapter, incorporated herein by reference. Affiliated carriers shall file a separate report for each carrier that had standard health benefits plans or the basic and essential health care services plans in force during the preceding calendar year plus a combined report reflecting the combined data for all affiliated carriers.
(b) The Report shall be filed on the basis of the combined total of the standard health benefits plans and the basic and essential health care services plans written by the member.
(c) The Report shall be completed and filed with the Board on or before August 15 of the reporting year for the preceding calendar year.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 7 - LOSS RATIO AND REFUND REPORTING REQUIREMENTS › Section 11:20-7.4 - Contents of the Loss Ratio Report

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Loss Ratio Report form set forth at Appendix Exhibit J shall be completed by August 15 of each year by each member and shall include the following information with respect to standard health benefits plans and basic and essential health care services plans:
1. The reporting member's name and address;
2. The member's net earned premium for the preceding calendar year; and
3. A statement of the member's total losses incurred consisting of:
i. Claims paid during the preceding calendar year, regardless of the year incurred;
ii. Less residual reserve set on June 30 of the preceding calendar year for claims incurred prior to January 1 of the preceding calendar year;
iii. Less claims paid from January 1 through June 30 of the preceding calendar year for claims incurred prior to January 1 of the preceding calendar year as reported in the preceding calendar year's Loss Ratio Report;
iv. Plus claims paid from January 1 through June 30 of the reporting year for claims incurred prior to January 1 of the reporting year;
v. Plus residual reserve for claims incurred prior to January 1 of the reporting year, not paid as of June 30 of the reporting year;
4. The member's loss ratio (determined by dividing the total losses incurred in (a)3 above by the net earned premium as determined in (a)2 above) calculated as a percentage to one decimal place (for example, 81.2 percent); and
5. Certification by a member of the Society of Actuaries, Casualty Actuarial Society, or American Academy of Actuaries that the information provided in the Loss Ratio Report is accurate, complete and that the carrier is in compliance with the requirements of 17B:27A-9 in accordance with this section.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 7 - LOSS RATIO AND REFUND REPORTING REQUIREMENTS › Section 11:20-7.5 - Refund plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the loss ratio determined in 11:20-7.4 is less than 80 percent, the member shall include with the Report a plan to be approved by the Commissioner for a refund to policy and contractholders of an amount equal to the difference between 80 percent of reported premiums and reported claims.
(b) The refund plan shall conform with the following:
1. Refunds shall be made to all contractholders who were covered for any period during the preceding calendar year whose refund is $ 5.00 or greater.
2. The refund amount per contractholder may be determined by multiplying the earned premium from each contractholder's standard health benefits plan and rider or basic and essential health care services plan and rider by the percentage resulting from dividing the total refund calculated in accordance with (a) above by the carrier's total net earned premium from the standard health benefits plans and basic and essential health care services plans, or on the basis of a practical and equitable alternative formula proposed by the carrier and approved by the Commissioner.
3. Refund payments shall be made within 60 days of written approval of the refund plan by the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 7 - LOSS RATIO AND REFUND REPORTING REQUIREMENTS › Section 11:20-7.6 - Unclaimed loss ratio refunds

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any loss ratio refund issued by a carrier to a policy or contractholder pursuant to this subchapter which remains unclaimed by that policy or contractholder shall be deemed abandoned two years from the date upon which the Commissioner approves the refund plan as set forth in 11:20-7.5(b).
(b) Refunds deemed abandoned pursuant to (a) above shall be subject to all applicable provisions of the Uniform Unclaimed Property Act, 46:30B-1 et seq., including, but not limited to, 46:30B-30, 46, 47, 49, 50 and 57. All carriers shall follow the procedures set forth in the Uniform Unclaimed Property Act with respect to the disposition of refunds deemed abandoned.
(c) Carriers which comply with the applicable provisions of the Uniform Unclaimed Property Act and this subchapter shall be relieved of liability to the extent of any unclaimed refunds upon payment of any unclaimed refunds to the State administrator designated pursuant to the Uniform Unclaimed Property Act.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 7 - LOSS RATIO AND REFUND REPORTING REQUIREMENTS › Section 11:20-7.7 - Certification of loss ratio refunds

Current through Register Vol. 56, No. 14, July 15, 2024
Within 30 days of issuing refunds to all policy or contractholders for a specific calendar year, any carrier required to provide a loss ratio refund pursuant this subchapter shall provide a certification to the Commissioner at the address in 11:20-6.4(a), stating the following: "The loss ratio refund, as set forth in the Loss Ratio Report, was issued by (name of company) to all policy or contractholders eligible for reimbursement with refund checks mailed, or premiums credited, on (date)."
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 8 - THE IHC PROGRAM ASSESSMENT REPORT › Section 11:20-8.1 - Scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter sets forth reporting and certification requirements for premium data of Program members and other carriers with reportable accident and health premium in New Jersey.
(b) This subchapter shall apply to all carriers with reportable accident and health premium in New Jersey for any portion of the period for which reports under this subchapter are required to be filed.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 8 - THE IHC PROGRAM ASSESSMENT REPORT › Section 11:20-8.2 - Filing of the assessment report form

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier with reportable accident and health premium in New Jersey shall file the N.J.A.C. 11:20 Appendix Exhibit K Assessment Report form and a copy of the N.J.A.C. 11:20 Appendix Exhibit K Part C Premium Data Worksheet, which are set forth as N.J.A.C. 11:20 Appendix Exhibit K, incorporated herein by reference, on or before April 1 of the year immediately following every two-year calculation period through the 2017-2018 calculation period. Thereafter, N.J.A.C. 11:20 Appendix Exhibit K shall be filed on or before April 1 of the year immediately following each calendar year.
(b) If a carrier with reportable accident and health premium in New Jersey is an affiliated carrier, the N.J.A.C. 11:20 Appendix Exhibit K Assessment Report and the Part C Premium Data Worksheet shall be filed as follows:
1. Each affiliated carrier shall file one copy of the N.J.A.C. 11:20 Appendix Exhibit K Part C Premium Data Worksheet whether or not that affiliated carrier reported accident and health premium in New Jersey during the two-year calculation period or one-year period, as applicable.
2. The combined affiliated carriers, identified using a single carrier name, shall file one copy of the Exhibit K Assessment Report. The information specified on the Exhibit K Assessment Report shall be the aggregated information supplied on the Premium Data Worksheets for all affiliated carriers.
3. The Exhibit K Assessment Report along with the Premium Data Worksheet(s) shall be filed together. For example, a carrier with three affiliates with reportable accident and health premium in New Jersey but only two of which issue non-group coverage, shall file one Exhibit K Assessment Report with the aggregated information for all affiliated carriers and three copies of the Exhibit K Part C Premium Data Worksheet.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 8 - THE IHC PROGRAM ASSESSMENT REPORT › Section 11:20-8.3 - Calculation of net earned premium and determination of program membership

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In Part C of the N.J.A.C. 11:20 Appendix Exhibit K Assessment Report, each member shall set forth its total net earned premium from plans issued, continued, or renewed for all affiliated carriers during the preceding two-year calculation period through the 2017-2018 calculation period. Thereafter, each member shall set forth its total net earned premium from plans issued, continued, or renewed for all affiliated carriers during the preceding calendar year on Part C of the N.J.A.C. 11:20 Appendix Exhibit K. Net earned premium reported in Part C of N.J.A.C. 11:20 Appendix Exhibit K shall be consistent with the data set forth on the N.J.A.C. 11:20 Appendix Exhibit K Part C Premium Data Worksheet(s).
(b) In Part C of the N.J.A.C. 11:20 Appendix Exhibit K Assessment Report, each carrier with no net earned premium in the preceding two-year calculation period or preceding calendar year, as appropriate, shall assert its status as a non-member by checking the box designated for non-members on the N.J.A.C. 11:20 Appendix Exhibit K Assessment Report. Carriers either with no net earned premium or whose Section 3 Calculation of Net Earned Premium on the N.J.A.C. 11:20 Appendix Exhibit K Part C Premium Data Worksheet is equal to 0 are non-members.
(c) Through the 2017 and 2018 two-year calculation period, every carrier, whether a member or not, shall complete an N.J.A.C. 11:20 Appendix Exhibit K Part C Premium Data Worksheet for each affiliate and shall attach each Worksheet to its N.J.A.C. 11:20 Appendix Exhibit K Assessment Report.
1. In Section 1 of the Premium Data Worksheet, the carrier shall report the total accident and health premium reported on its annual statement blank for each calendar year of the two-year calculation period.
2. In Section 2 of the Premium Data Worksheet, the carrier shall report the total net earned premium in each calendar year of the two-year calculation period for each of the excepted types of coverage which are specifically identified in Section 2 of the Worksheet.
3. In Section 3 of the Premium Data Worksheet, the carrier shall calculate the affiliate's net earned premium by subtracting the total excepted premium totals reported in Section 2 from the accident and health premium totals reported in Section 1 of the Worksheet.
4. The carrier shall report the aggregated two-year net earned premium on Exhibit K Part C by taking the sum of each affiliate's two-year net earned premium total as calculated on the Exhibit K Part C Premium Data Worksheet.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 8 - THE IHC PROGRAM ASSESSMENT REPORT › Section 11:20-8.6 - Certifications

Current through Register Vol. 56, No. 14, July 15, 2024
In Part D of the Exhibit K Assessment Report, the Chief Financial Officer, or other duly authorized officer of the carrier, shall certify that the Exhibit K Assessment Report and all Exhibit K Part C Premium Data Worksheets filed with the IHC Board are accurate and complete and conform with the requirements of this subchapter. Every duly authorized officer who provides a certification for the reporting required under this subchapter shall be responsible for errors contained therein.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 8 - THE IHC PROGRAM ASSESSMENT REPORT › Section 11:20-8.7 - Failure to file Exhibit K Assessment Report

Current through Register Vol. 56, No. 14, July 15, 2024
Failure to file in a timely manner the Exhibit K Assessment Report and certification required by this subchapter shall result in the Board's using the premium set forth in the member's most recent Annual Statements filed with the Department as the premium base to calculate that member's market share allocation of assessments for that calculation period.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.1 - 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-12 (including assessments for IHC Program losses and administrative expenses), or to offer coverage or accept applications to provide a standard health benefits plan to eligible persons, pursuant to 17B:27A-8.
(b) This subchapter applies to all members of the IHC Program.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Words and terms defined at 17B:27A-2 and N.J.A.C. 11:20-1, 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-2 et seq.
"Financially impaired" means a member that 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 imposed pursuant to 17B:27A-12, or a waiver of obligations pursuant to 17B:27A-8, as applicable.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.3 - 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 N.J.S.A. 17B:27A-12a(3) 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 11:20-11.4, 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 11:20-11.4. 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 11:20-11.4 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:
IHC Program
Request for Relief
New Jersey Department of Banking and Insurance
Office of Solvency Regulation
PO Box 325
Trenton, NJ 08625-0325
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.4 - Informational filing requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When requesting relief from obligations imposed pursuant to
17B:27A-4
or
17B:27A-12
, 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 34; and
iv. The name, title, telephone number, telefax number, and email address of a contact person familiar with the filing to whom the Department may direct any additional questions;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.5 - Confidentiality of request for relief

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All data or information contained in the request for relief filed pursuant to this subchapter shall be confidential and shall not be subject to public disclosure or copying pursuant to the "Right to Know" law, 47:1A-1 et seq., or the common law right to know, except for the following items, but only upon written, specified request and following 10 days written notice by the Department to the member/applicant:
1.
										11:20-11.4(a)1  i and ii--cover letter with name of applicant and describing relief sought;
2.
										11:20-11.4(a)1  iv--name, title, telephone number and telefax number of person familiar with the filing;
3.
										11:20-11.4(a)3  --most recent financial examination report;
4.
										11:20-11.4(a)5  i and ii--list of members of holding company system and intercompany transactions for period preceding date of filing;
5.
										11:20-11.4(a)8  --annual statement filed immediately preceding date of filing;
6.
										11:20-11.4(a)12  --non-refundable filing fee; and
7.
										11:20-11.4(a)13  --additional information required by the Commissioner to evaluate a particular filing.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.6 - Disposition of request for relief

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When the Commissioner determines pursuant to 17B:27A-8 or N.J.S.A. 17B:27A-12a(3), as applicable, that the member does not have the financial reserves necessary to underwrite additional coverage or is or would be placed in a financially impaired condition through fulfillment of a coverage or assessment obligation or obligations, the Commissioner shall notify the member that its duty to fulfill the applicable obligation shall be waived, or deferred in whole or in part, as appropriate. If the Commissioner defers in whole or in part a member's obligation to pay assessments pursuant to N.J.S.A. 17B:27A-12a(3), the member shall remain liable to the IHC Program for the amount deferred.
(b) The Commissioner shall find that a member is or would be financially impaired if:
1. The member has been placed in rehabilitation or conservation pursuant to 17B:32-31 et seq. or such similar law of the member's state of domicile;
2. The Commissioner finds that the member is in a hazardous financial condition, as determined pursuant to N.J.A.C. 11:2-27; or
3. The Commissioner finds that fulfillment of the obligation(s) from which relief is sought would place the member in a hazardous financial condition, as determined pursuant to N.J.A.C. 11:2-27.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.7 - Hearings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A member may request a hearing on a determination by the Commissioner within 20 days from the date of receipt of such determination as expressly permitted by the chapter as follows:
1. A request for a hearing shall be in writing and shall include:
i. The name, address, daytime telephone number, fax number and e-mail address 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 concise statement listing the disputed adjudicative facts warranting a hearing and describing the basis for the member's contention that the Commissioner's findings of fact are erroneous.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.8 - Notice to the IHC Program

Current through Register Vol. 56, No. 14, July 15, 2024
Members requesting relief pursuant to this subchapter shall concurrently provide written notice of all such requests to the IHC Program through the Executive Director. Members shall also provide written notice to the IHC Program of all dispositions of such requests by the Commissioner, within 15 days of such disposition. All such notices shall be sent to the address set forth at 11:20-2.1(h).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.9 - Exceptions for health maintenance organizations due to lack of capacity

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any member health maintenance organization (HMO) asserting that it is not required to offer coverage or accept applications pursuant to the requirements of the Act because it does not have the capacity to enroll additional members, pursuant to N.J.S.A. 17B:27A-8a, shall file the following information with the Commissioner:
1. A cover letter stating:
i. The name of the member HMO;
ii. A statement that the member is not required to offer coverage or accept applications pursuant to the Act because it does not have the capacity in its facilities to enroll additional members, and the basis for that assertion, with supporting documentation, certified by the president or duly authorized officer of the member;
iii. The number of the member's current individual and group members, listed by provider and classified by the provider's specialty, which shall be updated annually each year the member asserts a waiver pursuant to N.J.S.A. 17B:27A-8a; and
iv. A certification signed by the president or duly authorized officer that the member, pursuant to N.J.S.A. 17B:27A-8a:
(1) Will not offer coverage to or accept any new group members. Individual additions to existing groups shall not be considered new group members; and
(2) Upon denying individual health benefits coverage, will not offer such coverage in the individual market for a period of 180 days after the date the coverage is denied.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 20 - INDIVIDUAL HEALTH COVERAGE PROGRAM › Subchapter 11 - RELIEF FROM OBLIGATIONS IMPOSED BY THE INDIVIDUAL HEALTH INSURANCE REFORM ACT › Section 11:20-11.10 - Other actions by the Commissioner

Current through Register Vol. 56, No. 14, July 15, 2024
Nothing in this subchapter shall be construed as limiting the Commissioner's authority to take such action with respect to insurers, health service corporations or health maintenance organizations as may be authorized by law, including, but not limited to, placing an insurer, health service corporation or health maintenance organization in rehabilitation, liquidation or conservation pursuant to 17B:32-31 et seq.