Title 17B — Insurance

Chapter 17

§ 17B:17-1 Scope of act

This Subtitle 3 of Title 17B shall be known as the "Life and Health Insurance Code," sometimes referred to herein as this "Code," and shall have application only to life insurance, health insurance and annuities as herein defined. No part of Subtitle 3 of Title 17 and no other part of Title 17B as they now exist or may hereafter be constituted shall have any application to such insurance or annuities unless specifically otherwise provided in the act enacting this Code or in an act enacted subsequent to such act.

a. Any insurance company, domestic, alien or foreign, now or hereafter organized which in addition to doing the business of health insurance as defined in section 17B:17-4, is licensed to make, or shall hereafter become licensed to make, kinds of insurance other than those defined hereinafter in this chapter, shall be subject only to the hereinafter enumerated provisions of this Code but only in connection with such health insurance business:

(1) All the provisions of the following chapters:

Chapters 22, 26, 29, 34 and 35.

(2) All the provisions of the following sections:

17B:17-1, 17B:17-2, 17B:17-4, and 17B:17-6 through 17B:17-14; 17B:18-1, 17B:18-35 through 17B:18-40, 17B:18-63, 17B:18-66; 17B:19-5; 17B:24-1 through 17B:24-5, 17B:24-8 and 17B:24-9;

(3) All of the provisions of the following articles of the designated chapter.

Articles 2 and 3 of Chapter 27.

b. The provisions of the following chapters and sections shall not be applicable to those insurance companies described in subsection "a" above:

(1) Chapters 21, 23, 30 and 33.

(2) 17B:18-41, 17B:18-42, 17B:18-47, 17B:18-56, 17B:18-57, 17B:18-58, 17B:18-64, 17B:18-65 and 17B:19-1.

All such companies will remain subject to subtitle 3 of Title 17 except as above provided.

c. Any insurer now licensed under R.S. 17:17-1, d. solely to do the business of health insurance shall be subject to every provision of this Code as a health insurer.

d. An insurer may be organized under the provisions of section 17B:18-4 to do the business of health insurance as defined in section 17B:17-4 and in addition kinds of insurance other than those kinds defined in this chapter, and in such case, it shall have all the obligations, powers and privileges of a health insurer organized under this Code and shall to the extent not inconsistent herewith be subject to all the provisions of Subtitle 3 of Title 17.

e. Except as otherwise specifically provided no provision of this Code shall apply to:

(1) Fraternal benefit societies as defined in Part 5A of Subtitle 3 of Title 17.

(2) Mutual benefit associations as defined in Part 6 of Subtitle 3 of Title 17.

(3) Hospital and medical service corporations as defined in Part 9 of Subtitle 3 of Title 17.

§ 17B:17-2 Insurer defined

"Insurer" includes every person engaged as indemnitor or contractor in the business of life insurance, health insurance or of annuity.

§ 17B:17-3 Life insurance defined

"Life insurance" is a policy or contract whereby an insurer is obligated to pay or allow a benefit of pecuniary value with respect to the cessation of human life. Life insurance includes also the granting of endowment benefits and optional modes of settlement of proceeds of life insurance as well as provisions for a. additional benefits in event of death by accident or accidental means or in event of dismemberment or loss of sight, or b. safeguarding such insurance against lapse or giving a special surrender value or special benefit or an annuity in the event that the insured shall become totally and permanently disabled, whether such provisions are incorporated in a policy or contract of life insurance or in a policy or contract supplemental thereto. Life insurance does not include workmen's compensation coverages.

§ 17B:17-4 Health insurance defined

"Health insurance" is a contract or agreement whereby an insurer is obligated to pay or allow a benefit of pecuniary value with respect to the bodily injury, disablement, sickness, death by accident or accidental means of a human being, or because of any expense relating thereto, or because of any expense incurred in prevention of sickness, and includes every risk pertaining to any of the enumerated risks. Health insurance does not include workmen's compensation coverages.

§ 17B:17-5 Annuity defined

"Annuity" is a contract not coming within the definition of life insurance as set forth in section 17B:17-3, or health insurance as set forth in section 17B:17-4, under which an insurer obligates itself to make periodic payments for a specified period of time, such as for a number of years, or until the happening of an event, or for life, or for a period of time determined by any combination thereof. Such a contract which includes extra benefits of the kinds set forth in sections 17B:17-3 or 17B:17-4 shall nevertheless be deemed to be an annuity if such extra benefits constitute a subsidiary or incidental part of the entire contract.

§ 17B:17-5.1 Definitions; funeral insurance policies

24. a. As used in this section:

"At need funeral arrangements" means funeral arrangements made with the survivors or personal representative of a person who has already died for that person's funeral.

"Funeral arrangements" means funeral and burial plans made through a mortuary, including the selection of plans for the furnishing of funeral goods and services pursuant to a completed plan of bodily disposition and the act of offering the opportunity to purchase or to enroll in a prepaid funeral agreement by the mortuary.

"Funeral insurance policy" means any insurance policy or annuity contract that, at the time of issue, was intended to provide, or which was explicitly marketed for the purpose of providing, funds to the provider, whether directly or indirectly, at the time of the insured's death in connection with a prepaid funeral agreement.

"Intended funeral recipient" means the person named in a prepaid funeral agreement for whose bodily disposition the prepaid funeral agreement is intended to provide. The intended funeral recipient may or may not be the purchaser.

"Preneed funeral arrangements" means funeral arrangements made with an intended funeral recipient or his guardian, agent or next of kin, for the funeral of the intended funeral recipient.

"Prepaid funeral agreement" means a written agreement and all documents related thereto made by a purchaser with a provider prior to the death of the intended funeral recipient, with which there is connected a provisional means of paying for preneed funeral arrangements upon the death of the intended funeral recipient by the use of a funeral trust or funeral insurance policy, made payable to a provider and in return for which the provider promises to furnish, make available or provide the prepaid funeral goods or services, or both, specified in the agreement, the delivery of which occurs after the death of the intended funeral recipient.

"Prepaid funeral goods" means personal property typically sold or provided in connection with a funeral, or the final disposition of human remains, including, but not limited to, caskets or other primary containers, cremation or transportation containers, outer burial containers, vaults, as defined in N.J.S.8A:1-2, memorials as defined in N.J.S.8A:1-2, funeral clothing or accessories, monuments, cremation urns, and similar funeral or burial items, which goods are purchased in advance of need and which will not be delivered until the death of the intended funeral recipient named in a prepaid funeral agreement. Prepaid funeral goods shall not mean the sale of interment spaces and related personal property offered or sold by a cemetery company as provided for in N.J.S.8A:1-1 et seq.

"Prepaid funeral services" means those services typically provided in connection with a funeral, or the final disposition of human remains, including, but not limited to, funeral directing services, embalming services, care of human remains, preparation of human remains for final disposition, transportation of human remains, use of facilities or equipment for viewing human remains, visitation, memorial services or services which are used in connection with a funeral or the disposition of human remains, coordinating or conducting funeral rites or ceremonies and similar funeral or burial services, including limousine services provided in connection therewith, which services are purchased in advance of need and which will not be provided or delivered until the death of the intended funeral recipient named in a prepaid funeral agreement. Prepaid funeral services shall not mean the sale of services incidental to the provision of interment spaces or any related personal services offered or sold by a cemetery company as provided for in N.J.S.8A:1-1 et seq.

"Provider" means a person, firm or corporation duly licensed and registered pursuant to the "Mortuary Science Act," P.L.1952, c.340 (C.45:7-32 et seq.) to engage in the business and practice of funeral directing or mortuary science, or an individual serving as an agent thereof and so licensed:

(1) Operating a duly registered mortuary in accordance with P.L.1952, c.340 (C.45:7-32 et seq.) and the regulations promulgated thereunder;

(2) Having his or its business and practice based within the physical confines of the registered mortuary; and

(3) Engaging in the practice of making preneed funeral arrangements, including, but not limited to, offering the opportunity to purchase or enroll in prepaid funeral agreements.

"Purchaser" means the person named in a prepaid funeral agreement who purchases the prepaid funeral goods and services to be provided thereunder. The purchaser may or may not be the intended funeral recipient. If the purchaser is different than the intended funeral recipient, it is understood that the relationship of the purchaser to the intended funeral recipient includes a means to provide administrative control over the agreement on behalf of the intended funeral recipient.

b. The issuance and marketing of any funeral insurance policy shall meet all of the terms and conditions specified by the Department of Insurance as would apply to any life insurance or annuity contract, and shall in addition meet the standards and requirements specified in sections 1 through 13 of P.L.1993, c.147 (C.45:7-82 to 45:7-94).

c. Any insurance policy or annuity contract used as a funeral insurance policy on or after the effective date of P.L.1993, c.147 (C.45:7-82 et al.), whether issued within the State or outside of the State, whether on a group or individual basis, and any certificates, policies, contracts, applications, forms and related material, shall be subject to all the laws and regulations of this State and the terms and conditions of the Department of Insurance, as though issued in this State, and shall at the time of filing be designated as being intended for use as a funeral insurance policy.

d. The Commissioner of Insurance shall adopt rules and regulations to implement the provisions of this section, including a regulation establishing the loss ratio for funeral insurance policies.

§ 17B:17-6 Person defined

"Person" includes any individual, insurer, company, association, organization, society, partnership, syndicate, trust, business trust, corporation and every legal entity.

§ 17B:17-7 Domestic insurer, foreign insurer, alien insurer defined

a. A "domestic" insurer is one formed under the laws of this State.

b. A "foreign" insurer is one formed under the laws of a jurisdiction of the United States of America other than this State.

c. An "alien" insurer is one formed under the laws of any country other than the United States of America, its States, districts, territories, commonwealths, possessions and the Panama Canal Zone.

§ 17B:17-8 State defined

When used in context signifying a jurisdiction other than the State of New Jersey, "State" means any State, district, territory, commonwealth, or possession of the United States of America, and the Panama Canal Zone.

§ 17B:17-9 Domicile defined

The "domicile" of an insurer means:

a. As to Canadian insurers, the province in which the insurer's head office is located.

b. As to other alien insurers authorized to transact insurance in one or more States, as provided in section 17B:23-5c.

c. As to alien insurers not authorized to transact insurance in one or more States, the country under the laws of which the insurer was formed.

d. As to all other insurers, the State under the laws of which the insurer was formed.

§ 17B:17-10 Principal office defined

"Principal office" means:

a. As to Canadian insurers, the office in Canada from which the general affairs of the insurer are directed or managed.

b. As to other alien insurers authorized to transact insurance in one or more States, the office in the United States from which the general affairs of the insurer in the United States are directed or managed.

c. As to all other insurers, the office from which the general affairs of the insurer are directed or managed.

§ 17B:17-11 Authorized insurer, unauthorized insurer defined

a. An "authorized insurer" is one duly authorized by a current certificate of authority issued by the commissioner pursuant to this code to act as an insurer in this State.

b. An "unauthorized insurer" is an insurer not so authorized.

§ 17B:17-12 Certificate of authority; license defined

a. A "certificate of authority is a certificate issued by the commissioner evidencing the authority of an insurer to transact insurance in this State.

b. A "license" is authority granted by the commissioner pursuant to this code authorizing the licensee to engage in a business or operation of insurance in this State as an agent, broker, or solicitor, as the case may be, and the written evidence of such authority.

§ 17B:17-12.1 Change of domicile for insurers

2. a. An insurer that is formed under the laws of another state and is admitted to transact the business of insurance in this State may become a domestic insurer upon the commissioner's determination that the company has complied with all applicable requirements of Title 17B of the New Jersey Statutes relating to the formation of a domestic insurer of the same type. If the commissioner approves the domestication of a foreign insurer pursuant to this section, the insurer shall be entitled to a certificate of authority equivalent to that which was previously held as a foreign insurer and the insurer shall be subject to the authority and jurisdiction of this State. The newly domesticated insurer shall amend its articles of incorporation to provide that the corporation is a continuation of the corporate existence of the original foreign corporation through the adoption of this State as its corporate domicile, and that the original date of incorporation in its original domiciliary state is the date of incorporation of such domestic insurer. For purposes of the premium tax laws, pursuant to P.L.1945, c.132 (C.54:18A-1 et seq.), however, the date of licensure shall be the date on which the commissioner approves the domestication in this State.

b. Any domestic insurer may, upon the written approval of the commissioner, transfer its domicile to any other state in which it is admitted to transact the business of insurance. The company shall cease to be a domestic insurer as of the effective date of the transfer approved by the commissioner. Such a company shall be admitted to transact the business of insurance in this State if the company is otherwise qualified as a foreign insurer pursuant to the applicable requirements of Title 17B of the New Jersey Statutes.

c. Every insurer authorized to transact business in the State shall notify the commissioner of the details of any proposed transfer of domicile at least 60 days prior to the effective date of the proposed transfer, however, the commissioner may approve a shorter period for providing such notice. Such an insurer shall file promptly any resulting amendments to corporate documents filed or required to be filed with the commissioner.

d. Prior to granting approval for any foreign insurer to become a domestic insurer, or for a domestic insurer to transfer its domicile to another state, the commissioner may conduct whatever investigations, examinations or hearings he deems necessary, and may subject the issuance of his approval to the conditions and restrictions that he determines are reasonable and necessary for the protection of the company's policyholders or the public.

e. The transfer of domicile of an insurer pursuant to the provisions of this section shall not be construed to alter either the existing rights, franchises and interests, or the duties, obligations and liabilities of the insurer transferring domicile, except as otherwise provided by law. Insurers who transfer domicile shall continue to be subject to all the liabilities, claims and demands against the company which were in existence prior to the transfer of domicile. Any action or proceeding pending at the time of the consummation of the process by which the domicile is transferred in which the company is a party shall not abate or discontinue by reason of the transfer of domicile, but shall be prosecuted to a final resolution in the same manner as if the transfer of domicile had not taken place.

f. The certificate of authority, insurance producer appointments and licenses, rating systems and other documents required to be maintained for regulatory purposes, which are in existence and approved for use in this State at the time any insurer licensed to transact the business of insurance in this State transfers its corporate domicile to this or any other state by merger, consolidation, transfer, or any other lawful method, shall continue in full force and effect upon such transfer if the commissioner is satisfied that the insurer remains duly qualified to transact the business of insurance in this State. All outstanding policies of any transferring insurer shall remain in full force and effect and need not be endorsed as to the new name of the company or its new location unless so ordered by the commissioner. To the extent required by law, every transferring insurer shall file new policy forms with the commissioner on or before the effective date of the transfer, but may use existing policy forms with appropriate endorsements if allowed by, and under such conditions as approved by, the commissioner.

§ 17B:17-13 Misdemeanor to do business unless authorized

a. No person shall act as an insurer in this State without complying with the applicable provisions of this Code.

b. No person by himself, or by his brokers, agents, solicitors, surveyors, canvassers or other representatives of whatever designation, nor any such broker, agent, solicitor, surveyor, canvasser, or other representative, shall solicit, negotiate or effect any contract of insurance of any kind or sign, deliver or transmit, by mail or otherwise, any policy or annuity contract or receive any premium, commission, fee or other payment thereon, or maintain or operate any office in this State for the transaction of the business of insurance, or in any manner, directly or indirectly, transact the business of insurance of any kind whatsoever, within this State, unless specifically authorized under the laws of this State.

c. Specific authorization under the laws of this State shall not be required with respect to the following:

(1) Investigation, settlement, or litigation of claims under an insurer's policies lawfully written in this State, or liquidation of such insurer's assets and liabilities (other than the collection of new premiums) all as resulting from its former authorized operation in this State.

(2) Transactions involving a policy subsequent to issuance thereof lawfully solicited, written, or delivered outside this State.

(3) Reinsurance when transacted as authorized under section 17B:18-62.

(4) The continuation and servicing of life or health insurance policies or annuity contracts remaining in force as to residents of this State when the insurer is not transacting new insurance therein.

(5) Group life or health insurance or annuity contracts covering residents of this State under a group policy or contract lawfully issued in another State.

d. Any person violating any of the provisions of this section shall be guilty of a misdemeanor.

§ 17B:17-13.1 Charitable annuities.

a. The commissioner may, in his discretion, issue a special permit to a qualified nonprofit domestic or foreign corporation or association organized without capital stock or not for profit, engaged solely in bona fide charitable, religious, missionary, educational or philanthropic activities and which shall have been in active operation for at least ten years authorizing any such corporation or association to enter into annuity agreements with donors. Before issuing any such special permit the commissioner shall promulgate rules and regulations governing such annuity agreements and permit holders with respect to such annuity agreements. Such rules and regulations shall, in addition to such other provisions as the commissioner may determine to be necessary or desirable to protect the public, provide that each applicant for a special permit shall submit to the commissioner copies of its form of agreements with donors, and a schedule of its maximum annuity rates, which rates shall be so computed, on the basis of the standard valuation law, as to return to the special permit holder, upon the death of the annuitant, a residue at least equal to one-half of the original gift or other consideration for such annuity.

b. Each such special permit holder shall have and maintain segregated assets at least equal to the sum of the reserves on its outstanding agreements calculated in accordance with the provisions of Chapter 19 of this Code, and a surplus of ten per centum of such reserves or the amount of $100,000, whichever is higher, and such assets shall be segregated as separate and distinct funds, independent of all other funds of such special permit holder and shall not be applied for the payment of the debts and obligations of the special permit holder other than with respect to annuity agreements. In determining the reserves of any such special permit holder, a deduction shall be made for all or any portion of an annuity risk which is lawfully reinsured by an authorized insurer. Segregated assets herein required to be maintained shall be invested in accordance with the provisions of the "Prudent Investor Act," P.L.1997, c.26 (C.3B:20-11.1 et seq.).

c. Any corporation or association defined in subsection a. hereof which, prior to the effective date of this Code, has entered into annuity agreements shall obtain a special permit as herein provided prior to entering into any new or additional annuity agreements provided, however, that the commissioner shall by regulation allow a period of time, which shall not be more than five years following the effective date of this Code for any such corporation or association to comply with the provisions of subsection b. of this section with respect to any annuity agreement entered into prior to the effective date of this Code. The commissioner, in his discretion may extend such time for a reasonable period.

d. If the commissioner finds that any special permit holder has failed to comply with the requirements of this section or of any rule or regulation of the commissioner issued hereunder, he may by appropriate order, subject to the provisions of the Administrative Procedure Act (P.L.1968, c.410), Chapter 34 of this Code and any rules adopted thereunder suspend or revoke any such special permit and he may take such other action to restrain or enjoin any such violation as may be otherwise provided by law. In addition the commissioner may make such orders as he deems desirable and necessary to afford appropriate financial security to the annuitants. The commissioner may require that special permit holders submit periodically such reports as he may deem desirable or necessary to ascertain compliance with requirements of this section and the commissioner may, whenever he deems it expedient, make or cause to be made an examination of the assets and liabilities and other affairs of any such special permit holder as the same pertains to annuity agreements entered into pursuant to this section. The reasonable expenses of any such examination shall be fixed and determined by the commissioner, and he shall collect them from the special permit holder examined, who shall pay them on presentation of a detailed account of the expenses.

e. No special permit holder shall be deemed an insurer as defined in this Code.

§ 17B:17-14 General penalty

Each violation of this Code as to which a penalty is not provided by another provision of this Code or by other applicable laws of this State shall be a misdemeanor, and may in addition to any prescribed applicable denial, suspension, or revocation of certificate of authority, license, or permit be punishable upon conviction in the manner prescribed for misdemeanors under the provisions of Title 2A of the statutes of this State. Each instance of such violation may be considered a separate offense.

§ 17B:17-15 Conflict with other laws

All laws and parts of laws of this State inconsistent with this Code are hereby superseded with respect to matters covered by this Code.

§ 17B:17-16 Separability of provisions

If any provision of this Code or the application thereof to any person or circumstance is held invalid, the invalidity shall not affect other provisions or applications of this Code which can be given effect without the invalid provision or application, and for this purpose the provisions of the Code are separable.

§ 17B:17-17 Short title

This act shall be known and may be cited as the "Life and Health Insurance Policy Language Simplification Act."

§ 17B:17-18 Purpose

The purpose of this act is to establish minimum standards for language used in policies, contracts and certificates of life insurance, health insurance, annuity, credit life insurance and credit health insurance, delivered or issued for delivery in this State, to facilitate ease of reading by insureds.

This act is not intended to increase the risk assumed by insurance companies or other entities subject to this act or to supersede their obligation to comply with the substance of other insurance legislation applicable to life, health, credit life or credit health insurance or annuity policies. This act is not intended to impede flexibility and innovation in the development of policy forms or content or to lead to the standardization of policy forms or content.

§ 17B:17-19 Definitions

As used in this act:

a. "Policy" or "policy form" means any policy, contract, certificate, or agreement of life or health insurance, including credit life insurance and credit health insurance, or annuity, delivered or issued for delivery in this State by any company subject to this act; any certificate, contract, or policy issued by a fraternal benefit society; and any certificate issued pursuant to a group insurance policy delivered or issued for delivery in this State.

b. "Company" or "insurer" means any life or health insurance company, fraternal benefit society, nonprofit health service corporation, nonprofit hospital service corporation, nonprofit medical service corporation, nonprofit dental service corporation, mutual benefit association, and all similar type organizations.

c. "Commissioner" means the Commissioner of Insurance.

§ 17B:17-20 Application of act; exclusions

a. This act shall apply to all policies delivered or issued for delivery in this State by any company on or after the dates such forms must be filed or approved under this act, but nothing in this act shall apply to:

(1) Any policy which is a security subject to Federal jurisdiction;

(2) Any group policy covering a group of 50 or more lives at date of issue, other than a group credit life insurance policy or a group credit health insurance policy; however, this shall not exempt any certificate issued pursuant to a group policy delivered or issued for delivery in this State;

(3) Any group annuity contract which serves as a funding vehicle for pension, profit-sharing, or deferred compensation plans;

(4) Any form used in connection with, as a conversion from, as an addition to, or in exchange pursuant to a contractual provision for, a policy delivered or issued for delivery on a form filed, approved or permitted to be issued prior to the dates such forms must be filed or approved under this act; or

(5) The renewal of a policy delivered or issued for delivery prior to the dates such forms must be filed or approved under this act.

b. No other law of this State setting language simplification standards shall apply to any policy form.

c. Any non-English language policy delivered or issued for delivery in this State shall be deemed to be in compliance with this act if the insurer certifies that such policy is translated from an English language policy which does comply with this act.

§ 17B:17-21 Policy forms

a. In addition to any other requirements of law, no policy forms, except as stated in section 4, shall be delivered or issued for delivery in this State on or after the dates such forms must be filed or approved under this act, unless:

(1) The text achieves a minimum score of 40 on the Flesch reading ease test or an equivalent score on any other comparable test as provided in subsection c. of this section;

(2) It is printed, except for specification pages, schedules and tables, in not less than ten point type, one point leaded;

(3) The style, arrangement, and overall appearance of the policy give no undue prominence to any portion of the text of the policy or to any endorsements or riders; and

(4) It contains a table of contents or an index of the principal sections of the policy, if the policy has more than 3,000 words printed on three or fewer pages of text, or if the policy has more than three pages regardless of the number of words.

b. For the purposes of this section, a Flesch reading ease test score shall be measured by the following method:

(1) For policy forms containing 10,000 words or less of text, the entire form shall be analyzed. For policy forms containing more than 10,000 words, the readability of two 200 words samples per page may be analyzed instead of the entire form. The samples shall be separated by at least 20 printed lines.

(2) The number of words and sentences in the text shall be counted and the total number of words divided by the total number of sentences. The figure obtained shall be multiplied by a factor of 1.015.

(3) The total number of syllables shall be counted and divided by the total number of words. The figure obtained shall be multiplied by a factor of 84.6.

(4) The sum of the figures computed under paragraphs (2) and (3) subtracted from 206.835 equals the Flesch reading ease score for the policy form.

(5) For purposes of paragraphs (2), (3), and (4), the following procedures shall be used:

(a) A contraction, hyphenated word, or numbers and letters, when separated by spaces, shall be counted as one word;

(b) A unit of words ending with a period, semicolon, or colon, but excluding headings and captions, shall be counted as a sentence; and

(c) A syllable means a unit of spoken language consisting of one or more letters of a word as divided by an accepted dictionary. Where the dictionary shows two or more equally acceptable pronunciations of a word, the pronunciation containing fewer syllables shall be used.

(6) The term "text" as used in this section shall include all printed matter except the following:

(a) The name and address of the insurer; the name, number, or title of the policy; the table of contents or index; captions and subcaptions; specification pages, schedules, or tables; and

(b) Any policy language which is drafted to conform to the requirements of any Federal law, regulation, or agency interpretation; any policy language required by any collectively bargained agreement; any medical terminology; any words which are defined in the policy; and any policy language required by law or regulation; provided, however, the insurer identifies the language or terminology excepted by this subparagraph (b) and certifies, in writing, that the language or terminology is entitled to be excepted by subparagraph (b).

c. Any other reading test may be approved by the commissioner for use as an alternative to the Flesch reading ease test if it is comparable in result to the Flesch reading ease test.

d. Filings subject to this section shall be accompanied by a certificate signed by an officer of the insurer stating that it meets the minimum reading ease score on the test used or stating that the score is lower than the minimum required but should be approved in accordance with section 7 of this act. To confirm the accuracy of any certification, the commissioner may require the submission of further information to verify the certification in question.

e. At the option of the insurer, riders, endorsements, applications, and other forms made a part of the policy may be scored as separate forms or as part of the policy with which they may be used.

§ 17B:17-22 Issuance of policy forms after filing; construction with other laws

Nothing in this act shall be construed to negate any law of this State permitting the issuance of any policy form after it has been on file for the time period specified.

§ 17B:17-23 Flesch reading ease score; authorization of lower score

The commissioner may authorize a lower score than the Flesch reading ease score required in section 5a. (1) whenever, in his sole discretion, he finds that a lower score: a. will provide a more accurate reflection of the readability of a policy form; b. is warranted by the nature of a particular policy form or type or class of policy forms; or c. is caused by certain policy language which is drafted to conform to the requirements of any State law, regulation, or agency interpretation.

§ 17B:17-24 Content of policy forms; construction with other laws

A policy form meeting the requirements of section 5a. shall be filed or approved notwithstanding the provisions of any other law which specifies the content of policies, if the policy form provides the policyholders and claimants protection no less favorable than they would be entitled to under such law.

§ 17B:17-25 Date of application

a. Except as provided in section 4, this act applies to all policy forms filed on or after 2 years after the effective date of this act. No policy form shall be delivered or issued for delivery in this State on or after 5 years after the effective date of this act unless filed or approved by the commissioner or permitted to be issued under this act. Any policy form which has been filed or approved or permitted to be issued prior to 5 years after the effective date of this act and which meets the standards set by this act need not be resubmitted for filing or approval but may continue to be lawfully delivered or issued for delivery in this State upon the filing with the commissioner of a list of such forms identified by form number and accompanied by a certificate as to each such form in the manner provided in section 5d.

b. The commissioner may, in his sole discretion, extend the dates in subsection a. of this section.

§ 17B:17-26 Definitions relative to life insurance.

1. As used in this act:

"Account" means any mechanism, whether denoted as a retained asset account or otherwise, whereby the settlement of proceeds payable to a beneficiary under a policy is accomplished by the insurer or an entity acting on behalf of the insurer where the proceeds are retained by the insurer pursuant to a supplementary contract not involving annuity benefits other than death benefits.

"Commissioner" means the Commissioner of Banking and Insurance.

"Death index" means the death master file maintained by the United States Social Security Administration or any other database or service that is at least as comprehensive as the death master file maintained by the United States Social Security Administration and that is acceptable to the commissioner.

"Insured" means an individual covered by a policy or an annuitant when the annuity contract provides for benefits to be paid or other monies to be distributed upon the death of the annuitant.

"Insurer" means a life insurance company or fraternal benefit society that is required to file an annual financial audit pursuant to N.J.A.C.11:2-26.4.

"Policy" means a life insurance policy, an annuity contract, a certificate under a life insurance policy, or a certificate issued by a fraternal benefit society, under which benefits are to be paid upon the death of the insured, and which is issued on or after the effective date of this act.

§ 17B:17-27 Applicability of act.

2. a. This act shall apply to:

(1) every policy issued by a domestic insurer in this State and any account established under or as a result of that policy; and

(2) every policy delivered or issued for delivery in New Jersey by an authorized foreign insurer and any account established under or as a result of that policy.

b. Notwithstanding subsection a. of this section, with respect to a policy delivered or issued for delivery outside this State, a domestic insurer may, in lieu of the requirements of this act, implement procedures that meet the minimum requirements of the state in which the policy was delivered or issued, provided that the commissioner concludes that those other requirements are no less favorable to the policy owner and beneficiary than those required by this act.

§ 17B:17-28 Use of death index by insurer.

3. a. Every insurer shall use the death index to cross-check every policy and account subject to this act no less frequently than on a semi-annual basis, except as specified in section 6 of this act. An insurer may perform the cross-check using the updates made to the death index since the date of the last cross-check performed by the insurer, provided that the insurer performs the cross-check using the entire death index at least once. The commissioner may promulgate rules and regulations that allow an insurer to perform the cross-checks less frequently than semi-annually.

b. The cross-checks shall be performed using the social security number, the name, and date of birth of the insured or account holder.

c. If an insurer only has a partial name, social security number, date of birth, or combination thereof, of the insured or account holder under a policy or account, the insurer shall use the available information to perform the cross check.

d. Every insurer shall implement reasonable procedures to account for common variations in data that would otherwise preclude an exact match with a death index.

§ 17B:17-29 Action of insurer upon receiving notice of death.

4. Upon receiving notification of the death of an insured or account holder or in the event of a match made by a death index cross-check pursuant to section 3 of this act, an insurer shall search every policy or account subject to this act to determine whether the insurer has any other policies or accounts for the insured or account holder.

§ 17B:17-30 Procedures to confirm death, location, notification of beneficiaries.

5. a. An insurer shall establish procedures to reasonably confirm the death of an insured or account holder and begin to locate beneficiaries within 90 days after the identification of a potential match made by a death index cross-check or by a search conducted by the insurer pursuant to section 4 of this act. For those potential matches identified as a result of a death index match, the insurer shall, within 90 days of a death index match, complete a good faith effort, which shall be documented by the insurer, to locate the beneficiary or beneficiaries.

b. Once the beneficiary or beneficiaries under the policy or account have been located, the insurer shall provide to the beneficiary or beneficiaries the information necessary to make a claim pursuant to the terms of the policy or account. The insurer shall process all claims and make prompt payments and distributions in accordance with all applicable laws, rules, and regulations.

c. Nothing in this act shall be construed to prevent an insurer from requiring satisfactory proof of loss, such as a death certificate, for the purpose of verifying the death of the insured.

§ 17B:17-31 Inapplicability of act.

6. This act shall not apply to:

a. any account or policy issued to a group master policyholder in which the insurer does not maintain records on its administrative systems containing the information necessary to comply with the requirements of this act;

b. any account, policy, or certificate that provides a death benefit under an employee benefits, government or church plan subject to or as defined under the Employee Retirement Income Security Act of 1974 (29 U.S.C. s.1002) or any other federal employee benefit program;

c. any policy or certificate of life insurance that is used to fund a preneed funeral contract or prearrangement;

d. any policy or certificate of credit life or accidental death insurance; or

e. any other circumstance as determined to be appropriate by the commissioner.

Chapter 18

§ 17B:18-1 Scope of chapter

This chapter shall be applicable only to domestic stock and domestic mutual insurers, authorized to do one or more of the kinds of business defined in sections 17B:17-3, 17B:17-4 and 17B:17-5, except as otherwise stated in section 17B:17-1.

§ 17B:18-2 Stock insurer defined

A domestic stock insurer is an insurer incorporated in accordance with the laws of this State with its capital divided into shares and owned by its stockholders.

§ 17B:18-3 Mutual insurer defined

A domestic mutual insurer is an insurer incorporated in accordance with the laws of this State without permanent capital stock, the governing body of which, except while temporary capital stock is outstanding as provided in section 17B:18-9 and except as provided in section 17B:18-20, is elected by its policyholders.

§ 17B:18-4 Organization of stock or mutual insurer

a. Ten or more persons may form a domestic stock or domestic mutual insurer to engage in the business of writing any or all of the kinds of insurance defined in sections 17B:17-3, 17B:17-4 and 17B:17-5 by signing a certificate stating their intention to form a corporation pursuant to this Code setting forth:

(1) The name of the insurer, which shall contain the words "insurance company" or words of similar connotation which shall not so closely resemble that of any existing insurer or other corporation as to be likely to mislead the public, and shall be approved by the commissioner;

(2) The place where its principal office in this State is to be located and the name of its agent at that office upon whom process may be served;

(3) The kind or kinds of insurance proposed to be written by the insurer, stating the section of this code defining the same;

(4) Whether the insurer is to be a stock or mutual insurer;

(5) If a stock insurer, the amount of its capital stock which shall not be less than that required by section 17B:18-35, the classes and number of shares of each into which it is divided and the par value of each share, which shall not be less than $5.00;

(6) The period, if any, limited for the duration of the insurer.

b. The certificate may contain such other particulars as may be necessary to explain and make manifest or limit the objects and purposes of the insurer, and such other provisions not inconsistent with this Code, or the Constitution or laws of this State, which the corporators may choose to insert for the conduct of the affairs of the insurer, the regulation of its business, or for defining, regulating and limiting the powers of the directors or stockholders.

c. No domestic stock insurer shall create more than one class of stock except, however, that preferred or non-voting stock, or both, may be issued if the amount of the stock so issued shall not at any time exceed the amount of common or voting stock, or both, then issued and outstanding, but preferred stock may be issued without limitation when such preferred stock is to be purchased or loaned upon by any corporation, association or agency created by or organized under any law of the United States of America.

d. A company may be formed:

(1) For the purpose of transacting one or more of the kinds of business described in sections 17B:17-3, 17B:17-4 and 17B:17-5; or

(2) For the purpose of transacting business described in section 17B:17-4 by complying with the provisions of this Code and of transacting any of those kinds of business other than those described in sections 17B:17-3, 17B:17-4 and 17A:17-5 by complying with the provisions of Title 17, not inconsistent with this Code.

§ 17B:18-5 Approval of certificate by commissioner; recording and filing

The certificate of incorporation shall be proved or acknowledged as required for deeds of real estate and be submitted to, and examined by, the commissioner, and if found by him to be in accordance with this Code and not inconsistent with the constitution and laws of this State, he shall indorse thereon or annex thereto his certificate to that effect. The certificate of incorporation shall then be recorded in a book kept for that purpose in the office of the clerk of the county wherein the principal office and place of business of the corporation is to be located, and after being so recorded, filed with the commissioner. Thereupon, such persons, their successors and assigns, shall, from the date of the filing, be a corporation by the name set forth in the certificate.

All amendments of the certificate of incorporation shall be subject to the requirements of this section.

The certificate and amendments thereof, or copies thereof, duly certified by the commissioner, shall be evidence in all courts and places.

§ 17B:18-6 Stipulations in stock subscriptions and applications

Every subscription to the capital stock of a stock insurer shall contain the stipulation that no sum shall be used for commission, promotion or organization expenses in excess of a per cent of the amount paid upon the stock subscription, to be named in the stipulation, in an amount to be named by the commissioner. Every subscription for stock and every application for insurance in the insurer made prior to the granting to the insurer by the commissioner of the certificate of authority shall contain the stipulation that the money advanced by the applicant shall be returned to him without any deduction if the insurer fails to complete its organization or procure the certificate or issue the policy applied for in the application.

§ 17B:18-7 Certificate of incorporation of mutual insurer; election of directors

a. The certificate of incorporation of any mutual insurer of this State hereafter incorporated may contain provisions for the elections of directors in the manner set forth in sections 17B:18-11 to 17B:18-17, inclusive, and any amendment of the certificate of incorporation or of the charter of any mutual insurance corporation of this State heretofore or hereafter incorporated pursuant to the provisions of any general or special law of this State, may, at the option of such corporation, contain such provisions. Such certificate of incorporation or amendment thereof or of the charter of such insurer may provide that any vacancy in its board of directors may be filled by a majority vote of the board for the unexpired term to which such vacancy relates.

b. The periods at which directors of any such corporation shall be elected, the time of the election, the number of directors to be elected at any one time, and the terms for which they shall respectively be elected may be prescribed by its certificate of incorporation or charter or amendment thereof; provided, however, that one or more directors shall be elected at least once in every 2 years and that no director shall be elected for a term longer than 5 years.

§ 17B:18-8 Loan to mutual insurer for organizational expenses

A mutual insurer organized under this Code may borrow or assume a liability for the repayment of a sum of money sufficient to defray the reasonable expenses of its organization, or to enable it to comply with any requirement of law or as a guaranty fund, upon agreement, which shall first be submitted to and approved by the commissioner, that the loan or advance, with interest, shall be repaid only out of the surplus, earnings or profits of the corporation with the approval of the commissioner whenever, in his judgment, its financial condition shall warrant. Any such loan or advance shall not form a part of the legal liabilities of the insurer, but until repaid all statements published or filed with the commissioner by the insurer shall show the amount thereof then unpaid.

§ 17B:18-10 Election of directors of mutual insurer pursuant to provision in certificate of incorporation

If the certificate of incorporation or charter of a mutual insurer, or any amendment thereto contains provisions for the election of directors in the manner set forth in sections 17B:18-11 to 17B:18-17, inclusive, as provided in section 17B:18-7, then, subject to the provisions of section 17B:18-18, the directors of any such insurer shall be elected in such manner and no other. Each director elected and qualified pursuant to such sections shall hold office until his successor shall have been duly elected and qualified.

§ 17B:18-11 Nomination of candidates for director

At least seven months before the day fixed for any election of directors, the board of directors shall by a vote of a majority of its number nominate a candidate for each office of director to be filled at such next ensuing election and shall file with the commissioner a certificate of such nominations giving the name, occupation and address of each nominee. Qualified voters of the insurer as hereinafter defined to a number of not less than 1/10 % of the number of policies of the corporation in force as set forth in the next preceding annual statement of the insurer filed with the commissioner may nominate a candidate for each office of director to be filled at such next ensuing election by filing with the commissioner at least 5 months before the day fixed for such election a certificate, which may be in any number of counterpart originals, signed and acknowledged by each of them, giving his name, address and the number of his policy and giving the name, occupation and address of each candidate so nominated, together with a statement signed by each such candidate to the effect that he will accept if elected, and by serving upon the secretary of the corporation at least 5 months before the day fixed for such election a duplicate original of such certificate and of such statement.

§ 17B:18-12 Death, withdrawal or incapacity of candidates for director

In case of the death, withdrawal or incapacity of any candidate nominated by the board of directors prior to election, the board of directors shall by a vote of a majority of its number nominate a candidate in his place by filing prior to the day fixed for the election a certificate similar to that required for an original nomination by the board of directors, and in case of the death, withdrawal or incapacity of any candidate nominated by others prior to election, such other persons or a majority of them may nominate a candidate in his place by filing and serving prior to the day fixed for the election duplicate certificates and statements similar to those required for an original nomination by such persons.

§ 17B:18-13 Qualified voters; "policyholder" defined

The qualified voters of the insurer shall consist of every policyholder who is 18 years of age or more and whose policy has been in force for at least 1 year. For the purposes of this section the term "policyholder" shall mean a. the person insured under an individual policy of life or health insurance, except where such policy declares some other person to be the owner thereof, in which case such owner shall be deemed to be the policyholder, b. the person to whom any annuity or pure endowment is presently or prospectively payable by the terms of an individual annuity or pure endowment contract except where the policy or contract declares some other person to be the owner thereof, in which case such owner shall be deemed to be the policyholder, c. the policyholder of any group life or health policy and d. the contract holder of any group annuity contract.

§ 17B:18-14 Elections of directors of mutual insurers; procedure, ballots

Each qualified voter of the insurer at such election shall be entitled to cast one vote in person or by proxy. The president, or, in his absence, a vice-president of the insurer, shall preside at the election and the secretary, or, in his absence, an assistant secretary of the insurer shall make and keep a record of the proceedings. Voting shall be by ballot and tellers to receive and count the votes and to determine the validity thereof shall be elected by a head vote of policyholders and their proxies present at the meeting. Ballots shall be prepared and furnished by the insurer to all voters at the election. No ballot shall be counted unless it shall set forth the number of the voter's policy and be signed by him or by his proxy, and no ballot shall be counted if cast for any person other than one nominated as herein provided. The polls shall remain open in no case for less than 4 hours.

§ 17B:18-15 Nominations by others than board of directors; notice of election

In case any nomination shall have been made by others than by the board of directors, the insurer shall cause notice of the time and place of the election and of the several nominations of candidates to be published at least 4 times at intervals of not less than 1 week, the first publication to be not more than 60 days and the last publication not less than 15 days prior to such election in at least 3 newspapers published in each State of the United States and in each province of Canada in which the insurer is authorized to do business, one of such publications in each State or province to be, whenever possible, in a newspaper published in the capital city of each such State or province. Such notice shall contain the names of the persons nominated by the board of directors and by others at the time of commencement of publication and the death, withdrawal or incapacity of any such nominee or the nomination of any person in his stead before or after the completion of publication shall not invalidate such notice, nor shall the omission of any publication herein prescribed invalidate such notice or the election to which it relates; provided, the insurer shall have made diligent effort to cause such publication to be made.

§ 17B:18-16 Canvass of votes; tie vote

All ballots voted shall be received by the tellers subject to verification and ascertainment of the validity thereof and of the qualification of the voters, and, in the case of ballots voted by proxy, the respective proxy instruments shall be filed with the tellers. Immediately upon the closing of the polls the tellers shall proceed to canvass the votes. The canvass shall proceed from day to day until completed. All ballots and proxy instruments received by the tellers shall immediately upon the completion of the canvass be placed in sealed packages and preserved by them for at least 1 year from the date of election. The person receiving the highest number of votes for each office of director to be filled shall be elected for a full term. In case 2 or more persons shall receive the same number of votes for the same office, the tellers shall decide the election by lot.

§ 17B:18-17 Report of result of election

At the conclusion of the canvass the tellers shall report in writing to the secretary of the corporation the result thereof and he shall thereupon make a certificate, duly sworn to, setting forth the result of the election as shown by such report and shall file the same with the commissioner.

§ 17B:18-18 Choosing of directors for mutual life insurers having in excess of ten million policies in force

The directors of any mutual insurer of this State heretofore or hereafter incorporated pursuant to the provisions of the laws of this State which now or hereafter shall have in excess of ten million life insurance policies of the insurer in force as set forth in any annual statement of such insurer filed with the commissioner shall be of the number and shall be chosen in the manner set forth in sections 17B:18-19 to 17B:18-28, inclusive, any provision of law or of the certificate of incorporation or charter of such corporation to the contrary notwithstanding.

§ 17B:18-19 Number of directors; appointment of public directors; ex officio directors

Subject to the provisions of section 17B:18-21 as to the number of elected directors, the number of the directors of any such mutual insurer to which sections 17B:18-18 to 17B:18-28, inclusive, apply, shall be twenty-three, except where the chairman of the board and not the president is the chief executive officer of the corporation in which case the number shall be twenty-four, all of whom shall be policyholders of the corporation. Six of such directors shall be appointed as hereinafter provided by the Chief Justice of the Supreme Court of New Jersey and are hereinafter called the public directors. Sixteen of such directors shall be elected in the manner hereinafter provided and are hereinafter called the elected directors. The president of the corporation shall be ex officio a director, and the chairman of the board, if he is the chief executive officer of the corporation, shall also be ex officio a director; and if the president or such chairman of the board shall be a director by appointment or election either at the time of his election as president or chairman of the board, or on the date that sections 17B:18-18 to 17B:18-28, inclusive, become applicable to such corporation, the office of director so held by the president or such chairman of the board shall become vacant.

§ 17B:18-20 Public directors; carry-overs; appointments; terms; vacancies; powers

Each director of any such mutual insurer heretofore appointed as a public director in accordance with P.L.1953, chapter 156 and holding office as such on the effective day of this Code, shall continue in office as a public director until the expiration of the term for which he shall have been appointed. Whenever the provisions of sections 17B:18-18 to 17B:18-28, inclusive, shall for the first time become applicable to any mutual insurer, other than a mutual insurer then having public directors in accordance with the first sentence of this section, the Chief Justice of the Supreme Court of New Jersey shall thereupon appoint the 6 public directors for respective terms beginning on the date of appointment, such that the term of one public director shall expire on the date of the annual election of directors in each of the first 6 calendar years following the year in which sections 17B:18-18 to 17B:18-28, inclusive, for the first time become applicable to such mutual insurer. When such mutual insurer has public directors pursuant to either the first or second sentence of this section, thereafter one public director shall be appointed annually by the Chief Justice of the Supreme Court of New Jersey for a term of 6 years and shall hold office until his successor has been appointed and has qualified. In case any vacancy shall occur in the office of public director, such vacancy shall be filled by the appointment of another public director by the Chief Justice of the Supreme Court of New Jersey for the unexpired term to which such vacancy relates. The public directors shall have the same powers, privileges and duties as the other directors, and such additional powers as provided in said sections.

§ 17B:18-21 Elected directors; carry-overs; terms; vacancies

Each director of any mutual insurer, other than its president and other than the chairman of the board if he is the chief executive officer and other than one appointed as a public director in accordance with the provisions of P.L.1953, chapter 156, holding office as such at the time sections 17B:18-18 to 17B:18-26, inclusive, for the first time become applicable to such insurer shall continue in office as an elected director until the expiration of the term for which he shall have been elected, notwithstanding the number of elected directors shall be greater or less than 16. At each annual election of directors, commencing with the annual election in the calendar year following the first year in which such insurer becomes subject to sections 17B:18-18 to 17B:18-28, inclusive, or, in the case of an insurer which on the effective date of this Code has directors who were elected in accordance with the provisions of P.L.1953, chapter 156, commencing with the first annual election of directors following the effective date of this Code, 4 elected directors shall be elected in the manner hereinafter provided, each for a term of 4 years, and each such elected director shall hold office until his successor has been elected and has qualified. Except as otherwise provided in sections 17B:18-18 to 17B:18-28, inclusive, in case any vacancies shall occur in the office of an elected director, such vacancies shall be filled by the board of directors by majority vote of its entire number for the unexpired term to which such vacancy relates.

§ 17B:18-22 Elected directors; manner of electing

The elected directors shall be elected in the manner provided in sections 17B:18-23 to 17B:18-27, inclusive, by the qualified voters of the corporation at the annual election of directors to be held on the date and at the place prescribed by the corporation's certificate of incorporation or charter, by-laws, or otherwise.

§ 17B:18-23 Qualified voters; "policyholder" for purpose of election defined

The qualified voters of the insurer shall consist of every policyholder who is 18 years of age or more and whose policy has been in force for at least 1 year. For the purposes of this section the term "policyholder" shall mean a. the person insured under an individual policy of life or health insurance, except where such policy declares some other person to be the owner thereof, in which case such owner shall be deemed to be the policyholder, b. the person to whom any annuity or pure endowment is presently or prospectively payable by the terms of an individual annuity or pure endowment contract except where the policy or contract declares some other person to be the owner thereof, in which case such owner shall be deemed to be the policyholder, c. the policyholder of any group life or health policy and d. the contract holder of any group annuity contract.

§ 17B:18-24 Nomination of candidates; demand by public directors

The board of directors shall by a vote of a majority of its entire number nominate a candidate for each office of elected director to be filled at each annual election of directors commencing with the first election at which 4 elected directors are to be elected pursuant to the provisions of section 17B:18-21 after sections 17B:18-18 to 17B:18-28, inclusive, become applicable to such insurer. Not more than 10 months, nor less than 9 months, before the date of each such annual election, the secretary of the corporation shall file a certificate of such nominations with the commissioner, giving the name, address and occupation of each candidate, together with a statement in writing from each of such candidates that he will accept if elected. If a majority of the public directors of the corporation shall determine that other candidates should be nominated in the best interests of the insurer, its policyholders and the public, they shall file with the commissioner not more than 9 months nor less than 8 months before the date of the next ensuing annual election of directors, a statement of their determination and a demand signed by a majority of them that other candidates be nominated.

§ 17B:18-25 Method of electing when no demand is made by public directors

If the public directors shall file no demand that other candidates be nominated, the election shall be according to the method prescribed in this section as follows:

a. The candidates shall be those so nominated by the board of directors and no others, subject to the nomination of substitute candidates in the case of death or withdrawal of a candidate as provided in paragraph d. of this section.

b. Tellers to receive and count the votes and to determine the validity thereof shall be appointed by the chief executive officer of the corporation and such tellers shall conduct the election. Ballots shall be prepared by the corporation and shall be furnished to voters present at the election. Any qualified voter who shall make proper application to the corporation therefor in writing not later than 60 days before the date of the election, stating his name, address, policy number and date of birth, shall be furnished a ballot not less than 30 days before the date of the election, accompanied by a gummed postpaid return envelope addressed to the corporation at the place of the election, on which the words "Ballot for Directors" shall be printed and such ballot so applied for and furnished may be cast by mail. Each qualified voter of the corporation shall be entitled to cast one vote and no ballot shall be counted unless it is cast in person by a qualified voter at the election, or, in the case of a ballot cast by mail, unless it is received by the tellers at the place of the election before the polls close on the date of the election. No ballot shall be counted unless it shall set forth the number of the voter's policy and be signed by him in person, nor if cast for any person other than one nominated as herein provided. The polls shall be open between 10 o'clock in the forenoon and 2 o'clock in the afternoon on the date of the election, and no other business shall be transacted at the election.

c. All ballots voted shall be received by the tellers subject to verification and ascertainment of the validity thereof and of the qualification of the voters. Immediately upon the closing of the polls, the tellers shall proceed to canvass the votes. All ballots received by the tellers shall at the conclusion of the election be placed in sealed packages and preserved by them for at least 1 year from the date of the election. At the conclusion of the canvass, the tellers shall report in writing the result thereof to the secretary of the corporation and he shall thereupon make a certificate setting forth the result of the election as shown by such report and shall file the same with the commissioner.

d. In case of the death or withdrawal of any candidate prior to a date 50 days before the date of the election, the board of directors shall by a vote of a majority of its entire number nominate a candidate in his place by filing not later than 40 days before the date of the election a certificate similar to that required for an original nomination by the board of directors; and in case of the death or withdrawal of any candidate within 50 days of the date of the election, no substitution of a candidate shall be made to take the place of the candidate so dying or withdrawing and the election shall nevertheless proceed. If the report of the canvass of the votes at the election shows that the candidate so dying or withdrawing, for whom no substitution shall have been made, would have been elected except for the fact of his death or withdrawal, a vacancy in the board of directors shall be deemed to have occurred as of the date of the election.

e. No election shall be held invalid by reason of any irregularity or failure in preparation or forwarding of any ballots pursuant to sections 17B:18-18 to 17B:18-28, inclusive. All voting shall be by the ballots so provided and shall be according to the provisions of said sections, any existing law of the State to the contrary notwithstanding.

§ 17B:18-26 Method of election when demand is made by public directors that other candidates be nominated

If the public directors shall file a demand pursuant to section 17B:18-24 that other candidates be nominated, the election shall be according to the method prescribed in this section as follows:

a. The commissioner within 30 days after the receipt of such demand by the public directors, shall appoint a nominating committee of 15 of such qualified voters who shall appear to the commissioner to be willing and qualified to select a candidate for each of the offices of the elected directors whose terms of office expire at the date of the next ensuing election. No officer, director, employee or agent of the corporation, nor any relative thereof by blood or connection by marriage in nearer degree than second cousin, nor any person who shall have served on such a nominating committee at any previous time, shall be eligible to be named by the commissioner to serve upon such nominating committee. The commissioner shall forthwith cause notice of the time and place of the first meeting of such committee to be sent to each member thereof. Within 30 days following the appointment or within such further period of time not exceeding 15 days as may be determined by the commissioner, the nominating committee shall by a majority vote select a candidate, suitable by training and experience to serve, for each such office of elected director, other than any candidate nominated by the board of directors, and shall within such period file with the commissioner a certificate setting forth the names, addresses and occupations of the candidates so nominated, together with a statement in writing from each of such candidates that he will accept if elected. The commissioner shall notify the secretary of the corporation of the names, addresses and occupations of the candidates so selected by the nominating committee.

b. When nominations shall have been made by such nominating committee, the commissioner shall cause notice of the election to be published at least 4 times at intervals of not less than 1 week, the first publication to be not more than 5 months and the last publication not less than 3 months prior to the date of the election in at least three newspapers published in each state of the United States and in each province of Canada in which the corporation is authorized to do business, one of such publications in each state or province to be, whenever possible, in a newspaper published in the capital city of such state or province. Not less than 4 months prior to the date of the election, copies of such notice shall be posted in such offices maintained by the corporation as the commissioner may direct, in a conspicuous place to which the general public has access, and shall remain so posted until the record date hereinafter specified. Such notice shall contain the names, addresses and occupations of the candidates nominated by the board of directors and of the candidates nominated by the nominating committee, and shall advise the policyholders as to the procedure required by sections 17B:18-18 to 17B:18-28, inclusive, to be followed in voting. The death or withdrawal of any candidate or the nomination of any candidate in his place before or after the completion of publication or posting shall not invalidate such notice. The omission of any publication or posting herein prescribed shall not invalidate such notice nor the election to which it relates.

c. The commissioner shall prepare the form of ballot which shall contain: (1) the names of the candidates for director nominated by the board of directors, and so designated, and separately the names of the candidates for director nominated by the nominating committee, and so designated; (2) the following statement: "The Commissioner of Insurance of New Jersey neither approves nor disapproves the nomination of any of the aforesaid candidates" ; (3) blank lines for the insertion of the policy number and signature of the qualified voter; and (4) such instructions for the proper completion of the ballot as the commissioner may deem necessary, including a statement of the date of the election and that the ballot must be received on or before such date. Each ballot shall be accompanied by a gummed postpaid return envelope, addressed to the commissioner, on which the words "Ballot for Directors" shall be printed. The commissioner shall cause ballots to be mailed at least 30 days prior to the date of the election to all applicants for ballots who appear to him, after checking the applications against the records of the corporation, to be qualified voters of the corporation on the record date. No election shall be held invalid by reason of any irregularity or failure in the preparation or forwarding of any ballots pursuant hereto.

d. Each qualified voter of the corporation shall be entitled to cast one vote and all ballots shall be cast by mail upon the forms provided and shall be according to the provisions of sections 17B:18-18 to 17B:18-28, inclusive, any existing law of this State to the contrary notwithstanding. Policyholders who are qualified voters may obtain ballots by applying therefor either in person or by mail to the commissioner, or to any office maintained by the corporation, on or before the record date which shall be 70 days prior to the date of the election, stating in such application for a ballot, the name, address, policy number and date of birth of the applicant. The corporation shall prepare a list or other catalog of the applicants for ballots in such form as the commissioner may direct, showing the name, address and policy number of the applicant, whether or not he is 18 years of age or more and whether his policy has been in force at least 1 year; and such list or catalog shall specify any applicants for ballots appearing not to be qualified voters of the corporation according to its records, with a statement of the reason therefor. Such list or catalog shall be transmitted at least 40 days before the date of the election to the commissioner. The commissioner shall cause notice of disqualification to be given to any applicant who shall appear to him to be not a qualified voter of the corporation, with a statement of the reason therefor; and shall grant such applicant reasonable opportunity, within such period as may be fixed by the commissioner in his sole discretion, to present facts in support of his application. The list or catalog shall remain on file with the commissioner until 30 days after the election and shall be open to inspection by any qualified voter of the corporation, as the commissioner shall determine.

e. Ballots received by the commissioner on or before the date of the election shall be canvassed by the commissioner. The commissioner may employ such persons to assist him in canvassing the ballots as he deems necessary. No ballot shall be counted unless it is received by the commissioner on or before the date of the election, nor unless it shall set forth the number of the qualified voter's policy, be signed by him in person and be completed in accordance with the instructions appearing thereon; and no ballot shall be counted if cast for any person other than for one nominated as provided in sections 17B:18-18 to 17B:18-28, inclusive, nor if cast for more than the number of elected directors whose offices are to be filled at such election. The commissioner shall be the sole judge as to the qualifications of the voters and the proper casting of the ballots. All ballots received by the commissioner shall at the conclusion of the election be placed in sealed packages and preserved by him for at least 1 year from the date of the election. The four persons receiving the highest number of votes for the offices of elected director to be filled shall be elected for full terms. In case two or more persons shall receive the same number of votes for the same office, the commissioner shall decide the election by lot. At the conclusion of the election, the commissioner shall certify in writing to the secretary of the corporation the result thereof.

f. In case of the death or withdrawal of any candidate prior to a date 50 days before the date of the election, the board of directors or the nominating committee, whichever shall have nominated such candidate, shall nominate a candidate in his place by filing not later than 40 days before the date of the election a certificate similar to that required for the original nominations; and in case of the death or withdrawal of any candidate within 50 days before the date of the election, no substitution of a candidate shall be made to take the place of the candidate so dying or withdrawing, and the election shall nevertheless proceed. If the report of the canvass of the votes at the election shows the number of votes so cast for the candidates so dying or withdrawing, for whom no substitution shall have been made, was such that he would have been elected except for the fact of his death or withdrawal, a vacancy in the board of directors shall be deemed to have occurred as of the date of the election and the same shall be filled by a majority vote of the entire number of either the board of directors or the nominating committee, whichever shall have nominated such candidate.

g. The commissioner shall conduct the election, may make such reasonable regulations for the conduct of the election not inconsistent with the provisions of sections 17B:18-18 to 17B:18-28, inclusive, as may appear to him to be necessary or desirable, and shall authorize payment of expenses incurred by the corporation for the purpose of advising policyholders, to the extent and in the manner he deems appropriate, as to the qualifications of the candidates. He may employ such persons as he may consider necessary to assist him in the performance of the duties imposed upon him under sections 17B:18-18 to 17B:18-28, inclusive, and may require the corporation to furnish assistance in such respects and in such manner as he may direct. All expenses incurred by the commissioner or by the nominating committee with the approval of the commissioner, in performing any of the duties imposed upon them by this act shall be borne by the corporation, and shall be paid by it upon the order of the commissioner. If the commissioner shall so request, the corporation shall advance to the commissioner funds reasonably sufficient to defray such expenses and the commissioner shall remit such funds to the State Treasurer as custodian thereof. The State Treasurer shall hold such funds separate from all other State moneys and shall disburse the same only upon vouchers signed by the commissioner, who shall account to the corporation therefor.

§ 17B:18-27 Mailing of ballot; effect

The mailing of a ballot to any person shall not be construed as an admission of the validity of any policy or that such person was a policyholder; and no such mailing shall be competent evidence in any action or proceeding in which the question of the validity of any policy is involved.

§ 17B:18-28 Filing certificate on number of policies; copy delivered to Chief Justice

If any annual statement of any domestic mutual insurer heretofore or hereafter filed with the commissioner sets forth a number of life insurance policies of the insurer in force in excess of ten million, such insurer shall thereafter during its corporate existence be subject to the provisions of sections 17B:18-18 to 17B:18-28, inclusive, any provisions of law or of the certificate of incorporation or charter of the corporation to the contrary notwithstanding. When any domestic mutual insurer at any time after the effective date of this Code files for the first time during its corporate existence an annual statement which shows that the number of life insurance policies of said insurer then in force is in excess of ten million, it shall immediately cause to be filed with the commissioner a certificate of the number of life insurance policies so set forth in such annual statement and the commissioner shall cause a copy thereof, duly certified by the commissioner, to be delivered to the Chief Justice of the Supreme Court of New Jersey.

§ 17B:18-29 Election of directors in mutual insurer issuing temporary stock

A bare majority of the entire board of directors of a domestic mutual insurer which issues temporary capital stock, as provided in section 17B:18-9, shall be elected by the holders of the temporary stock, and the rest of the directors shall be elected by the policyholders, in the manner and with the representation provided in its certificate of incorporation. After the retirement of the capital stock all the directors shall be so elected by the policyholders.

§ 17B:18-30 Proxy voting permitted at elections

At any election of directors, managers or other officers of a domestic insurer, except any election of directors held pursuant to N.J.S. 17B:18-18 to 17B:18-28, inclusive, every person entitled to vote at the election may vote in person or by attorney or proxy, but no proxy shall be voted, allowed or received after 3 years from its date.

§ 17B:18-31 Emergency by-laws

The board of directors of any domestic insurer may at any time adopt emergency by-laws, subject to repeal or change by action of those having power to adopt regular by-laws for the insurer, which shall be operative during a national emergency caused by an attack on the United States or by a nuclear, atomic or other disaster which makes it impossible or impracticable for an insurer to conduct its business in strict accord with applicable provisions of law, its by-laws, or its certificate of incorporation or charter. Such emergency by-laws may, notwithstanding any different provisions of the regular by-laws, or of the applicable statutes, or of the insurer's certificate of incorporation or charter, make any provision that may be reasonably necessary for the operation of the insurer during the period of such emergency.

§ 17B:18-32 Failure to adopt emergency by-laws; procedure

In the event that the board of directors of a domestic insurer has not adopted emergency by-laws, the following provisions shall become effective upon the occurrence of such a national emergency:

a. Three directors shall constitute a quorum for the transaction of business at all meetings of the board.

b. Any vacancy in the board may be filled by a majority of the remaining directors, though less than a quorum, or by a sole remaining director.

c. If there are no surviving directors, but at least 3 vice-presidents of the company survive, the 3 vice-presidents with the longest term of service in that office shall be the directors and shall possess all of the powers of the previous board of directors and such powers as are granted herein or by subsequently enacted legislation. By majority vote such emergency board of directors may elect other directors. If there are not at least 3 surviving vice-presidents, the commissioner or duly designated person exercising the powers of commissioner shall appoint 3 persons as directors who shall possess all of the powers of the previous board of directors and such powers as are granted herein or by subsequently enacted legislation, and these persons by majority vote may elect other directors.

§ 17B:18-33 National emergency; succession

At any time the board of directors of a domestic insurer may, by resolution, provide that in the event of such a national emergency and in the event of the death or incapacity of the Chairman of the Board and chief executive officer, the President, the Secretary or the Treasurer of the company, such officers, or any of them, shall be succeeded in the office by the person named or described in a succession list adopted by the board of directors. Such list may be on the basis of named persons or position titles, shall establish the order of priority and may prescribe the conditions under which the powers of the office shall be exercised.

§ 17B:18-34 National emergency; relocation of principal place of business

At any time the board of directors of a domestic insurer may, by resolution, provide that in the event of such a national emergency the home office or principal place of business of the company shall be at such location in the United States of America as is named or described in the resolution. Such resolution may provide for alternate locations and establish an order of preference.

§ 17B:18-37 Definitions; deposit prerequisite to authorization

a. As used in this section and in N.J.S.17B:18-38 and N.J.S.17B:18-39:

(1) "Bank" means a State or federally chartered bank, savings bank, or savings and loan association which has trust powers and which has its principal office in New Jersey.

(2) "Custodian" means a bank which performs fiduciary functions in the maintenance of deposits.

(3) "Deposit" means those deposits of securities required to be made by insurance companies prior to their authorization to transact business within any jurisdiction.

(4) "Federal Reserve book-entry system" means the computerized system sponsored by the United States Department of the Treasury and certain agencies and instrumentalities of the United States for holding and transferring securities of the United States government and the agencies and instrumentalities, respectively, in Federal Reserve Banks through banks which are members of the Federal Reserve System or which otherwise have access to this computerized system.

(5) "Policyholders" means those persons including subscribers, certificate holders, and others who are named in or covered by a contract of insurance.

(6) "Securities" means and shall only include:

(a) Bills, bonds and notes issued by the United States Treasury;

(b) Debt obligations of the State of New Jersey, its authorities, counties and municipalities; and

(c) Certificates of deposit of a State or federally chartered bank, savings bank, or savings and loan association with its principal office in New Jersey.

b. The commissioner shall appoint one or more custodians which shall be selected on the basis of bids submitted by banks to perform such fiduciary functions as the commissioner deems necessary in the maintenance of deposits.

c. No domestic insurer shall be issued a certificate of authority until it has deposited with the custodian on behalf of the commissioner, securities having a market value of at least $100,000.00 to be held in physical form or purchased for its account in the Federal Reserve book-entry system. The deposits are to be held for the benefit and security of all of the policyholders of the company depositing them. The records of the custodian, through which an insurance company holds securities in the Federal Reserve book-entry system or in physical form, shall at all times show that these securities are held for an insurance company and for which accounts thereof.

d. The Commissioner of Insurance may, from time to time after the company has commenced business, require it to make further deposits of securities, up to the sum of $250,000.00, as the commissioner may deem necessary to protect the policyholders of the depositing company.

§ 17B:18-38 Deposits; interest on; substitution of

The commissioner shall hold the securities deposited pursuant to N.J.S.17B:18-37 for the benefit and security of all the policyholders of the insurer depositing them, but shall, so long as it continues solvent and complies with all the requisites of the laws applicable to it, permit the insurer to collect the interest or dividends on the securities so deposited, and, from time to time to withdraw any of the securities, on depositing with him other eligible securities to the extent required to maintain the market value of the total deposit at the amount required by the commissioner.

§ 17B:18-39 Deposits to do business in other jurisdictions

The custodian, on behalf of the commissioner, may receive from any domestic insurer a deposit of securities necessary to enable it to transact business in any other state, territory, dependency or Federal District of the United States or in any foreign country under the laws thereof. Such securities shall be held by the custodian, on behalf of the commissioner, as long as the insurer desires to transact business in the state, territory, dependency or Federal District of the United States or foreign country requiring the deposit but the insurer may draw the dividends or receive the interest on the securities. When the insurer desires to discontinue its business therein and the deposit is no longer required by the laws thereof, the commissioner shall return the securities to the insurer depositing them. Before the commissioner shall return the securities deposited with him as aforesaid, the company shall institute an action and obtain a judgment therefore in the Superior Court substantially similar to that provided in R.S.17:20-3.

§ 17B:18-39.1 Fees for services of custodian required pursuant to N.J.S.17B:18-37 et seq.

The Commissioner of Insurance shall establish, by regulation, the fees to be charged insurance companies for the services of the custodian pursuant to the requirements of N.J.S.17B:18-37 through N.J.S.17B:18-39.

§ 17B:18-41 Examination before commencing business

Before issuing a certificate of authority to a domestic insurer, the commissioner shall be satisfied, by such examination and evidence as he sees fit to make and require, that the whole amount of the capital stock set forth in the certificate of incorporation and the required minimum surplus of the insurer, if a stock company, has been actually paid in cash, and is possessed by the company in money, or in stocks, bonds, or bonds and mortgages authorized for insurers by chapter 20 of this code; or, if a mutual company, that it has received and is in possession of the cash premiums, and bona fide engagements for insurance to the extent and of the value required in section 17B:18-36.

§ 17B:18-42 Certificate of authority; when issuable.

When satisfied that a domestic insurer has complied with all the requirements of this code to entitle it to engage in business and that the proposed methods of operation of the insurer are not such as would render its operation hazardous to the public or its policyholders, the commissioner shall issue to the insurer a certificate authorizing it to commence business, specifying in the certificate the particular kind or kinds of insurance it is authorized to transact. The commissioner may refuse to issue a certificate of authority if he finds that any of the insurer's directors or officers has been convicted of a crime involving fraud, dishonesty, or like moral turpitude or that said persons are not persons of good character and integrity. Any applicant for a license pursuant to this section and any officer, director, partner or owner of a controlling interest of a corporation or partnership for licensure shall submit to the commissioner the applicant's name, address, fingerprints and written consent for a criminal history record background check to be performed. The commissioner is authorized to exchange fingerprint data with and receive criminal history record information from the State Bureau of Identification in the Division of State Police and the Federal Bureau of Investigation consistent with applicable State and federal laws, rules and regulations, for the purposes of facilitating determinations concerning licensure eligibility. The applicant shall bear the cost for the criminal history record background check, including all costs of administering and processing the check. The Division of State Police shall promptly notify the commissioner in the event a current holder of a license or prospective applicant, who was the subject of a criminal history record background check pursuant to this section, is arrested for a crime or offense in this State after the date the background check was performed. No insurer shall transact the business for which it is incorporated until it has received the certificate from the commissioner. If any insurer fails to obtain the certificate of authority within one year from the date of the certificate of the commissioner to its certificate of incorporation, as provided in section 17B:18-5, and such failure is the result of its lack of due diligence in meeting the requirements therefor, the insurer shall, ipso facto, be dissolved and its certificate of incorporation be null and void.

§ 17B:18-43 Domestic insurers, powers, duties--general corporation law

a. Any domestic insurer and its stockholders, members and directors, shall have all the powers granted and be subject to all the duties and obligations imposed by New Jersey Business Corporation Act (N.J.S. 14A:1-1 et seq.), except so far as they may be inconsistent with the provisions of this Code.

b. Subject to the approval of the commissioner, a domestic insurer may, independently of any insurance or annuity contract, provide services of the kinds it performs in the normal conduct of its insurance or annuity business, including but not limited to consultative, administrative, investment, actuarial, loss prevention, data processing, accounting, claims and collection services. In granting any such approval, the commissioner may impose any limitations he may deem necessary for the protection of the interests of the policyholders of said insurer. In granting or withholding his approval, the commissioner shall take into account the effect of said insurer's providing such services on its existing insurance and annuity business and its surplus, and the risks inherent in said insurer's providing such services.

§ 17B:18-44 Stock of other insurance company

A domestic insurer which purchases stock of another insurance company in compliance with section 17B:20-4 may pay therefor in cash or its equivalent or in its own capital stock, and may issue its capital stock in payment to the persons from whom the same may be purchased or acquired, or otherwise for the purpose of the purchase or acquisition. The stock so purchased or acquired shall constitute lawful payment for the capital stock issued to purchase or acquire it and any capital stock so issued shall be deemed a part of the capital of the issuing company. The company may exhibit the amount of capital so paid up in its advertisements.

§ 17B:18-45 Authority to acquire, hold and convey real estate

Any domestic insurer, in addition to the authority contained in sections 17B:20-1 to 17B:20-5, inclusive, may acquire, hold and convey any real estate as may be convenient in its operations, provided that if the commissioner shall determine after a hearing pursuant to the Administrative Procedure Act (P.L.1968, c. 410) and any rules adopted thereunder, that the interest of such insurer's policyholders requires that any specific real estate so acquired be disposed of, then such insurer shall dispose of such real estate within such reasonable time as the commissioner shall direct.

§ 17B:18-46 Limitation on dividends to stockholders

No profits on participating policies and contracts heretofore or hereafter issued by a domestic stock insurer in excess of the larger of a. 10% of such profits before payment of policyholder dividends, or b. $0.50 per year per $1,000.00 of participating life insurance in force at the end of the year, shall inure to the benefit of the stockholders. In any annual statement made hereafter by such insurer to the commissioner, it shall exhibit the amount of participating policyholders' surplus. Both participating and nonparticipating policies or contracts may provide that, in addition to any rate of interest guaranteed by the issuing insurer to be paid on deferred payments of the proceeds thereof, additional interest may be paid thereon at such rate as the insurer may annually declare; and the inclusion of such provision in any nonparticipating policy shall not be deemed to make the policy participating.

§ 17B:18-47 Increase or decrease of capital stock

Any domestic stock insurer may increase its capital stock or decrease it to an amount not less than the minimum required by this code by proceeding in the manner and subject to the conditions of section 17B:18-56.

The whole of the increased capital stock shall be paid and may be invested, and an examination thereof shall be made in the manner provided by section 17B:18-41 for the original capital stock. Thereupon the increase shall be deemed a part of the capital of the insurer, subject to all the provisions of this code applicable thereto. When any insurer increases its capital stock by more than $50,000.00, an examination thereof shall be made whenever and as often as $50,000.00 or more of the increase is paid in, as is provided in said section 17B:18-41 for the original capital stock. Thereupon the increase of $50,000.00 or more shall be deemed a part of the capital of the insurer subject to all the provisions of this Code applicable thereto.

§ 17B:18-48 Advertisement of assets to include liabilities

When an insurer doing business in this State advertises its assets, it shall, in the same connection and equally conspicuously, advertise its liabilities, the same to be determined in the manner required in making the annual statements to the commissioner. All advertisements purporting to show the capital of the company shall exhibit only the amount of capital actually paid in cash. In the case of a company organized under the laws of a foreign country, its assets shall be considered to be only the amounts deposited with the officials of the several states of the union or held by trustees in the United States for the benefit of the policyholders and creditors of the company in the United States. All policies, renewals, signs, circulars, cards, or other means by which public announcements are made, shall be held to be advertisements within the meaning of this section.

§ 17B:18-49 Cash disbursements to be evidenced by voucher

No domestic insurer shall make any cash disbursement of $100.00 or more unless it is evidenced by a voucher, signed by or on behalf of the person receiving the money, and correctly describing the consideration for the payment. If the expenditure is for both services and disbursements, the voucher shall set forth the services rendered and an itemized statement of the disbursements made. When the voucher cannot be obtained, the expenditure shall be evidenced by an affidavit describing the character and object of the expenditure, and stating the reason for not obtaining the voucher.

§ 17B:18-50 Payment of taxes, charges and fees prior to determination of invalidity

The directors of any domestic insurer are authorized to pay, and to appropriate money to pay, such taxes, charges and fees as have been or may be imposed against the property, business, income or franchises of such insurer by the laws of this or any other State or jurisdiction in which such insurer is doing business unless, prior to the payment of any such tax, charge or other fee, the law imposing the same shall have been expressly held invalid by the State court having final appellate jurisdiction in the premises or by the Supreme Court of the United States.

§ 17B:18-51 Compensation of directors

The director of any domestic insurer when acting as its officer, counsel, agent or representative, and also for each occasion of his attendance at meetings of the board or its committees, may receive such compensation as a majority of the board deems just and reasonable.

§ 17B:18-52 Insurer payments to senior officers restricted

No domestic insurer shall:

a. Pay any salary, compensation or emolument to any of its senior officers, directors or trustees, unless the payment is first authorized by a vote of its board of directors;

b. Make any agreement with any of its officers, senior officers, directors, trustees or salaried employees whereby it agrees that for any service rendered or to be rendered he shall receive any salary, compensation or emolument that will extend beyond a period of 24 months from the date of the agreement, but nothing herein shall be construed to prevent a domestic insurer from deferring the payment of any salary, compensation or emolument for such period of time and upon such terms as it may determine or from entering into contracts with its agents or brokers for the payment of renewal commissions;

c. Grant any pension to any officer, senior officer, director, general agent, employee or trustee thereof or to any member of his family after his death, except in accordance with a written plan approved by its board of directors it may: (1) grant to its salaried officers, senior officers, directors, general agents and employees retirement and disability allowances and death benefits; (2) establish a profit sharing plan which meets the requirements of subsection (a) of section 401 of the Internal Revenue Code of 1954, 68A Stat. 134, 26 U.S.C. s. 401, or any similar legislation which might take its place and which plan, at the option of the insurer, may be in addition to any existing pension plan; and except that it may with the approval of the commissioner provide reasonable supplemental retirement allowances to any of its salaried officers, senior officers and employees and their dependents, whose retirement benefits under the insurer's plan or plans are, in the opinion of its board of directors, inadequate.

The term "senior officers" as used in this section means each officer of an insurer within the four highest salary categories of such insurer; but in instances where an insurer does not have an aggregate of at least five officers from all of the four highest salary categories, then "senior officers" for such insurer shall be the five highest salaried officers of that insurer.

§ 17B:18-53 Reporting amount of stock owned and changes therein by director, officer, and principal stockholders of domestic stock insurers

Every person who is directly or indirectly the beneficial owner of more than 10% of any class of stock of a domestic stock insurer or who is a director or officer of such insurer shall file in the office of the commissioner within 10 days after he becomes such beneficial owner, director or officer a statement, in such form as the commissioner may prescribe, of the amount of all stock of such insurer of which he is the beneficial owner, and within 10 days after the close of each calendar month thereafter, if there has been a change in such ownership during such month, shall file in the office of the commissioner a statement, in such form as the commissioner may prescribe, indicating his ownership at the close of the calendar month and such changes in his ownership as have occurred during such calendar month.

§ 17B:18-54 Suit for profits realized by director, officer, and principal stockholders

For the purpose of preventing the unfair use of information which may have been obtained by such beneficial owner, director or officer by reason of his relationship to such insurer, any profit realized by him from any purchase and sale, or any sale and purchase, of any stock of such insurer within any period of less than 6 months, unless such stock was acquired in good faith in connection with a debt previously contracted, shall inure to and be recoverable by the insurer, irrespective of any intention on the part of such beneficial owner, director or officer in entering into such transaction of holding the stock purchased or of not repurchasing the stock sold for a period exceeding 6 months. Suit to recover such profit may be instituted at law or in equity in any court of competent jurisdiction by the insurer or by the owner of any stock of the insurer in the name and in behalf of the insurer if the insurer shall fail or refuse to bring such suit within 60 days after request or shall fail diligently to prosecute the same thereafter; but no such suit shall be brought more than 2 years after the date such profit was realized. This section shall not be construed to cover any transaction where such beneficial owner was not such both at the time of the purchase and sale, or the sale and purchase, of the stock involved, or any transaction or transactions which the commissioner may by rules and regulations exempt as not comprehended within the purpose of this paragraph.

§ 17B:18-55 Limitation on sale of stock by director, officer and principal stockholders

It shall be unlawful for any such beneficial owner, director or officer, directly or indirectly, to sell any stock of such insurer if the person selling the stock or his principal a. does not own the stock sold, or b. if owning the stock, does not deliver it against such sale within 20 days thereafter, or does not within 5 days after such sale deposit it in the mails or other usual channels of transportation; but no person shall be deemed to have violated this section if he proves that notwithstanding the exercise of good faith he was unable to make such delivery or deposit within such time, or that to do so would cause undue inconvenience or expense.

§ 17B:18-56 Stock insurers; change of name, extension of corporate existence or amendment of charter or certificate of incorporation

a. Any stock insurer heretofore or hereafter incorporated under any general or special law of this State may change its name, extend its corporate existence either before or after the expiration of the period limited for its duration or amend its charter or certificate of incorporation for any lawful purpose or restate its certificate of incorporation through procedures prescribed by the statutes of this State as to business corporations in general, and by complying with the requirements of subsection b.

b. Upon adoption of such change of name, extension of corporate existence, amendment or restatement of charter, a certificate thereof shall be signed by the president or a vice-president and secretary or assistant secretary under the corporate seal and be acknowledged or proved as in the case of deeds of real estate. The certificate shall be submitted to the commissioner for his approval as provided for certificates of incorporation. When so approved, it shall be filed in the Department of Insurance whereupon the charter or certificate of incorporation shall be deemed to be amended accordingly.

§ 17B:18-57 Mutual insurers; change of name, extension of corporate existence or amendment of charter or certificate of incorporation

Mutual insurers; change of name, extension of corporate existence or amendment of charter or certificate of incorporation.

a. Any mutual insurer heretofore or hereafter incorporated under any general or special law of this State may change its name and extend its corporate existence or amend its charter or certificate of incorporation for any lawful purpose by a three-fourths vote of its directors present at any regular or special meeting, held in accordance with its charter and bylaws, held not less than 30 nor more than 90 days after notice of the proposed amendment has been given to the directors and to the commissioner.

b. Upon adoption, a certificate of such adoption setting forth such change of name, extension or amendment shall be made and filed by the president or a vice-president of the insurer and by the secretary or an assistant secretary under the corporate seal and shall be acknowledged or proved as in the case of deeds of real estate and shall be submitted to the commissioner for his approval. If the commissioner finds that such change of name, extension or amendment is in conformity with law and does not unreasonably affect the interests of the policyholders, he may endorse his approval on the certificate. When so approved, it shall be filed in the Department of Insurance whereupon the charter or certificate of incorporation shall be deemed to be amended accordingly.

c. The refusal of the commissioner to give any approval shall be subject to judicial review.

d. To the extent that an amendment of the charter or certificate of incorporation of a mutual insurer is adopted in accordance with subsection (3) of N.J.S. 14A:2-7, the commissioner shall approve such amendment unless he finds that it unreasonably affects the interest of the policyholders.

§ 17B:18-58 Mutual insurers; adoption of amended charter or certificate of incorporation

When any mutual insurer adopts an amendment to its charter or certificate of incorporation, as provided for in this chapter, the board of directors of the insurer, at the time of adopting the amendment, may adopt and ratify in its entirety an amended charter or certificate of incorporation to the end that it shall fully and completely set forth all the terms and conditions of the charter or certificate of incorporation under which the insurer shall thereafter transact business. The amended charter or certificate of incorporation shall be executed, acknowledged, approved and filed in accordance with section 17B:18-5.

§ 17B:18-59 Mutualization of stock insurers

a. A stock insurer may become a mutual insurer under such plan and procedure as may be approved by the commissioner after a hearing thereon.

b. The commissioner shall not approve any such plan, procedure or mutualization unless:

(1) It is equitable to stockholders and policyholders;

(2) It is subject to approval by the holders of not less than 2/3 of the insurer's outstanding capital stock having voting rights and by not less than 2/3 of the insurer's policyholders who are qualified voters and who vote on such plan in person, by proxy or by mail pursuant to such notice and procedure as may be approved by the commissioner;

(3) Mutualization will result in retirement of shares of the insurer's capital stock at a price not in excess of the fair market value thereof as determined by competent disinterested appraisers;

(4) The plan provides for the purchase of the shares of any nonconsenting stockholder in the same manner and subject to the same applicable conditions as provided in New Jersey Business Corporation Act (N.J.S. 14A:1-1 et seq.) as to rights of nonconsenting stockholders, with respect to consolidation or merger of private corporations;

(5) The plan provides for definite conditions to be fulfilled by a designated early date upon which such mutualization will be deemed effective; and

(6) The mutualization leaves the insurer with surplus funds reasonably adequate for the security of its policyholders and to enable it to continue successfully in business in the States in which it is then authorized to transact insurance, and for the kinds of insurance included in its certificates of authority in such States.

c. This section shall not apply to mutualization under order of court pursuant to rehabilitation or reorganization of an insurer under chapter 32 of this Title.

§ 17B:18-60 Merger and consolidation of stock insurers

a. A domestic stock insurer may merge or consolidate with one or more domestic or foreign stock insurers in the following manner and subject to the following provisions.

b. (1) Mergers or consolidations may be initially proposed at any meeting of the board of directors of a domestic stock insurer by the affirmative vote of 2/3 of the total number of directors of the insurer, or at any meeting of the stockholders of the insurer by the affirmative vote of a majority of the total number of shares of stock outstanding and entitled to vote, provided the notice of such meeting shall set forth such proposal.

(2) The plan of merger or consolidation proposed as required by paragraph (1) of this subsection, shall be submitted to a meeting of the stockholders of record of each domestic stock insurer, and may become effective only if adopted at such meeting by the affirmative vote, in person or by proxy, of 2/3 of the total number of shares of stock outstanding and entitled to vote. The said meeting shall be held upon such reasonable notice as has been approved by the commissioner and the notice shall fully set forth the terms and conditions of the proposed plan and agreement of merger or consolidation.

c. No such merger or consolidation shall be effectuated unless in advance thereof the plan and agreement therefor have been filed with the commissioner and approved in writing by him after a hearing thereon. The commissioner shall give such approval within a reasonable time after such hearing unless he finds such plan or agreement:

(1) Is contrary to law; or

(2) Inequitable to the stockholders of any insurer involved; or

(3) Would substantially reduce the security of and service to be rendered to policyholders of the domestic insurer in this State or elsewhere.

(4) Involves the merger of a domestic insurer into a nonadmitted foreign insurer.

d. No director, officer, agent or employee of any insurer party to such merger or consolidation shall receive any fee, commission, compensation or other valuable consideration whatsoever for in any manner aiding, promoting or assisting therein except as set forth in such plan or agreement.

e. If the commissioner does not approve any such plan or agreement he shall so notify the insurer in writing specifying in detail his reasons therefor.

f. Any plan or proposal through which a stock insurer proposes to acquire a controlling stock interest in another stock insurer through an exchange of stock of the first insurer issued for the purpose is deemed to be a plan or proposal of merger of the second insurer into the first insurer for the purposes of this section and is subject to the applicable provisions hereof.

g. Upon such merger or consolidation all the rights, franchises, and interest of the insurers so merging or consolidating, in and to every species of property and things in action belonging to them, or either of them, shall be deemed to be transferred to and vested in the insurer resulting from such merger or consolidation, without any other deed or transfer, and the merged or consolidated insurer shall hold and enjoy the same to the same extent as if the merging or consolidating insurers, or either of them, had continued to retain their titles and transact business.

h. The insurer so formed by or resulting from such merger or consolidation may require the return of the original certificates of stock held by each stockholder in each of the insurers involved in such merger or consolidation, and may convert said certificates into new certificates for such number of shares of the merged or consolidated insurer as each stockholder is entitled to receive. Any stockholder refusing or neglecting to so convert his stock shall be governed by the provisions of New Jersey Business Corporation Act (N.J.S. 14A:1-1 et seq.), concerning nonconsenting stockholders with respect to consolidation or merger of private corporations.

§ 17B:18-61 Merger and consolidation of mutual insurers

a. A domestic mutual insurer may merge or consolidate with one or more domestic or foreign mutual insurers in the following manner and subject to the following provisions:

b. (1) The plan for merger or consolidation may be proposed at any meeting of the board of directors of a domestic insurer by the affirmative vote of 2/3 of the total number of directors of the insurer.

(2) The plan for consolidation or merger proposed as required by paragraph (1) of this subsection, shall be submitted to a meeting of the policyholders of each domestic insurer, and may be effective only if adopted at such meeting by the affirmative vote, in person or by proxy, of a majority of the votes cast by policyholders who are qualified voters and who vote thereon. The said meeting shall be held upon such reasonable notice as has been approved by the commissioner and the notice shall fully set forth the terms and conditions of the proposed plan and agreement of merger or consolidation.

c. No such merger or consolidation shall be effectuated unless in advance thereof the plan and agreement therefor have been filed with the commissioner and approved in writing by him after a hearing thereon. The commissioner shall give such approval within a reasonable time after such hearing unless he finds such plan or agreement:

(1) Is contrary to law; or

(2) Inequitable to the policyholders of any insurer involved; or

(3) Would substantially reduce the security of and service to be rendered to policyholders of the domestic insurer in this State or elsewhere.

(4) Involves the merger of a domestic insurer into a nonadmitted foreign insurer.

d. No director, officer, agent or employee of any insurer party to such merger or consolidation shall receive any fee, commission, compensation or other valuable consideration whatsoever for in any manner aiding, promoting or assisting therein except as set forth in such plan or agreement.

e. If the commissioner does not approve any such plan or agreement he shall so notify the insurer in writing specifying in detail his reasons therefor.

f. Upon such merger or consolidation all the rights, franchises, and interest of the insurers so merging or consolidating, in and to every species of property and things in action belonging to them, or either of them, shall be deemed to be transferred to and vested in the insurer resulting from such merger or consolidation, without any other deed or transfer, and the merged or consolidated insurer shall hold and enjoy the same to the same extent as if the merging or consolidating insurers, or either of them, had continued to retain their titles and transact business.

§ 17B:18-62 "Reinsurance" defined

"Reinsurance" is a contract under which an originating insurer, called the "ceding insurer" , procures insurance for itself in another insurer, called the "assuming insurer," with respect to part or all of an insurance risk of the originating insurer.

§ 17B:18-63 Reinsurance of risks

An insurer may reinsure such risks as it is authorized to insure, subject to the provisions of this Code.

§ 17B:18-64 Prerequisites to reinsurance

a. No domestic insurer may become a ceding insurer with respect to all or any substantial part of its outstanding insurance risks or become an assuming insurer with respect to all or any substantial part of the outstanding insurance risks of another insurer until the contract of reinsurance between the ceding insurer and the assuming insurer shall have been submitted to the commissioner together with satisfactory evidence that the interests of the policyholders of each of such insurers which is authorized to do an insurance business in this State are fully protected and until such contract of reinsurance shall have been approved by him; provided however, that this section shall not be applicable to contracts of reinsurance heretofore or hereafter entered into providing for the reinsuring of single risks or policies, in whole or in part, or risks covered by any group policy or contract, in whole or in part.

b. If a domestic mutual insurer cedes all or any substantial part of its insurance risks to a stock insurer, the agreement must be approved by the commissioner. The commissioner shall not approve any such agreement unless:

(1) It is equitable to the insurer's policyholders;

(2) It is subject to approval by vote of not less than 2/3 of the insurer's current policyholders who are qualified voters and who vote thereon in person, by proxy, or by mail at a meeting of policyholders called for the purpose pursuant to such reasonable notice and procedure as may be approved by the commissioner;

(3) The equity of each policyholder in the insurer is determinable under a fair formula approved by the commissioner, which such equity shall be based upon not less than the insurer's entire surplus (after deducting contributed or borrowed surplus funds) plus a reasonable present equity in its reserves and in all nonadmitted assets;

(4) In all cases involving the ceding of all the risks of a domestic mutual insurer to a stock insurer, there shall be a proviso in such agreement that upon the consummation of such transactions, said domestic insurer shall then be automatically dissolved.

§ 17B:18-65 Extended reinsurance

In addition to the reinsurance specified in 17B:18-63, an insurer authorized to do the business specified in section 17B:17-3, 17B:17-4 and 17B:17-5 may through reinsurance assume any insurance risk and may retrocede any portion thereof; provided, however, no insurer may undertake any such extended reinsurance business without the prior approval of the commissioner.

§ 17B:18-65.1 Rules and regulations

The commissioner is authorized to adopt, promulgate and enforce such rules and regulations as he determines to be necessary to implement this act.

§ 17B:18-66 Reinsurance pooling

Any reinsurance authorized by sections 17B:18-63 or 17B:18-65 or any reinsurance of blanket accident insurance referred to in section 4 of Public Law 1939, c. 305 (17B:27-32) may be provided through pooling arrangements with other insurers for purposes of spreading the insurance risk.

§ 17B:18-67 Short title

1. Sections 2 through 6 of this act shall be known and may be cited as the "Dynamic Capital and Surplus Act of 1993."

§ 17B:18-68 Surplus, capital required

2. Except as provided by section 3 of P.L.1993, c.235 (C.17B:18-69), no domestic insurer shall commence business in this State unless the insurer has surplus and capital actually paid in cash of at least the following amounts, and no domestic insurer shall otherwise continue to transact business in this State unless it has surplus and capital of at least the following amounts:

a. For either kind or both kinds of business specified in N.J.S.17B:17-3 and N.J.S.17B:17-5, $1,000,000 in capital and $4,000,000 in surplus for a stock insurer, and $4,000,000 in surplus for a mutual insurer;

b. For the kind of business specified in N.J.S.17B:17-4, $700,000 in capital and $2,800,000 in surplus for a stock insurer, and $3,000,000 in surplus for a mutual insurer; and

c. For all three kinds of business specified in N.J.S.17B:17-3, N.J.S.17B:17-4 and N.J.S.17B:17-5, $1,530,000 in capital and $6,120,000 in surplus for a stock insurer, and $6,300,000 in surplus for a mutual insurer.

For purposes of this section, "surplus" means unencumbered assets in excess of capital and all required reserves and other liabilities.

§ 17B:18-69 Temporary waiver of capital, surplus requirements

3. An insurer authorized to transact the kind of business specified in N.J.S.17B:17-3, N.J.S.17B:17-4 or N.J.S.17B:17-5 prior to and on the effective date of this act may apply to the commissioner for a temporary waiver of the applicable capital and surplus requirements set forth in section 2 of this act. The commissioner may, in his discretion, temporarily waive the applicable capital and surplus requirements for that insurer for a period of no more than five years, except that the insurer shall remain subject to capital and surplus requirements of no less amounts than those in effect immediately prior to the effective date of this act. In considering such a temporary waiver, the commissioner shall consider: the size of the insurer's deficiency in meeting the applicable capital and surplus requirements; the adequacy of the insurer's financial plan to meet the applicable capital and surplus requirements; and any other factors deemed appropriate by the commissioner.

§ 17B:18-70 Increase in amount of required capital, surplus

4. The commissioner may increase the amount of capital or surplus required of any insurer pursuant to section 2 of this act, or subsequently revise or redetermine that increase, using appropriate methods and procedures established by rules and regulations adopted by him in order to provide adequate protection against risks affecting the insurer's financial condition that are not adequately or fully covered by its reserves or other assets, but under no circumstance shall an insurer's capital or surplus be less than the capital or surplus required pursuant to section 2 or, where applicable, section 3 of this act; provided, however, that any increase of capital or surplus pursuant to this section, including any increase required by a subsequent revision or redetermination, shall be made only after a formal departmental hearing, on a record, unless that hearing is waived by the affected insurer. All matters pertaining to a hearing or to an increase of capital or surplus pursuant to this section shall be confidential and not subject to subpoena or public inspection, except to the extent that the commissioner finds release of information necessary to protect the public. The hearing shall be initiated within 20 days after written notice to the insurer. Any decision regarding an increase of capital or surplus pursuant to this section, including an increase required by a subsequent revision or redetermination, shall contain findings specifying the factors deemed significant in regard to the particular insurer, and shall set forth the reasons supporting the increase of capital or surplus ordered by the commissioner. In determining any increase, revision or redetermination in the amount of capital or surplus, the commissioner shall consider the risks of:

a. Increases or decreases in the frequency and severity of losses under normal operating conditions, as well as increases or decreases in those values, beyond or below the levels contemplated by the rates that it charged for insurance and beyond or below those reasonably expected under normal conditions;

b. Increases or decreases in expenses under normal operating conditions, as well as increases or decreases in those values, beyond or below the levels contemplated by the rates that it charged for insurance and beyond or below those reasonably expected under normal conditions;

c. Increases or decreases in the value of, or return on, invested assets under normal operating conditions, as well as increases or decreases in those values, beyond or below those levels anticipated under normal conditions;

d. Changes in economic, social and market conditions that could adversely or favorably affect the financial condition of the insurer, including conditions that would make liquidity more or less important than contemplated and would prevent or facilitate timely investments or force or prohibit untimely sales of assets; and

e. Any other contingencies, including reinsurance and unfunded or extracontractual obligations, which may affect the insurer's financial condition.

§ 17B:18-71 Factors for determination of increase, revision, redetermination

5. In determining any increase, revision or redetermination in the capital or surplus of an insurer pursuant to the provisions of section 4 of this act, the commissioner shall take into account the following factors:

a. Methods and techniques used to measure risk exposure and variability;

b. The information available relating to the magnitude of the various risks described in section 4 of this act;

c. The extent to which the risks described in section 4 of this act are independent or interrelated, and whether any dependency is direct or inverse;

d. The insurer's financial history, projections of profits or losses and other operational characteristics;

e. The extent to which the insurer has provided protection against contingencies in ways other than the establishment of surplus, including, but not limited to: redundancy of premiums; margin in reserves and liabilities; adjustability of contracts pursuant to the terms of the contracts; voluntary or mandatory investment valuation reserves; reinsurance; the use of conservative actuarial assumptions to provide a margin of security; reserve adjustments after rate increases for policies written at earlier and less adequate rates; contingency or catastrophe reserves, and diversification of assets and underwriting risks; and

f. Any other relevant factors, including National Association of Insurance Commissioners' reports and independent judgments of the soundness of the insurer's financial condition, as evidenced by ratings and reports of reliable professional financial services.

§ 17B:18-72 Suspension, revocation of authority to do business

6. The commissioner may suspend or revoke the authority to do business in this State of any insurer that does not comply with the provisions of this act.

Chapter 19

§ 17B:19-1 Expenses of investigation, analyses, and valuation of securities

a. The purpose of this section is to provide a means of making funds not in excess of $250,000 in any one year available to the Subcommittee on Valuation of Securities of the National Association of Insurance Commissioners to defray the expenses of such committee in the investigation, analyses and valuation of securities and the determination of the amortizability of bonds, owned by insurers, for the purpose of furnishing to the several States on a uniform basis information needed in the supervision of insurers licensed to transact business in the several states. The commissioner is hereby authorized to disburse in the manner hereinafter provided, in co-operation with supervisory officials of other States, funds obtained through assessments for such purpose under this section.

b. The commissioner shall periodically obtain from such Subcommittee on Valuation of Securities a verified budget estimate of the receipts and of the expenses to be incurred by the committee for a stated period, not exceeding one year, with appropriate explanations of the estimates therein contained.

c. If the commissioner shall be satisfied as to the reasonableness of such budget estimate, he shall determine the portion of the funds required by such budget estimate, to be assessed as hereinafter provided, by deducting from such budget estimate or from the sum of $250,000, whichever is less, any amounts received or receivable by the committee from other states whose laws do not substantially conform to the method of assessment herein provided and applying to the remainder the proportion which the total investments in securities of domestic life insurers bears to the total investments in securities of life insurers domiciled in this and other States whose laws authorize and require assessments on substantially the same basis as herein provided. The commissioner shall thereafter as soon as convenient, by notice stating the method of computation thereof, assess the amount to be paid on account of such expenses, pro rata upon all domestic life insurers in the proportion which the total investments in securities of each domestic life insurer shall bear to the total investments in securities of all such insurers. The total investments in securities of any life insurer for purposes of this section shall be the total admitted value of stocks and bonds reported as such in its annual statement last filed prior to such assessment with the commissioner or other supervisory official of its state of domicile. Upon receipt of such notice each such insurer shall within thirty days pay said assessment of the commissioner who shall remit such funds to the State Treasurer as custodian thereof. The State Treasurer shall hold such funds separate from all other State moneys and shall disburse the same only upon vouchers signed by the commissioner. Such disbursements shall be made to the Subcommittee on Valuation of Securities of the National Association of Insurance Commissioners for the purposes of this section.

d. The commissioner shall require annually and at such other times as he may deem it necessary or advisable a duly certified audit of receipts and disbursements and statement of assets and liabilities, showing the details of the financial operations of the Subcommittee on Valuation of Securities.

§ 17B:19-1.1 Definitions.

58. For the purposes of chapter 19 of Title 17B of the New Jersey Statutes, N.J.S.17B:25-19, and sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14) the following definitions shall apply on or after the operative date of the valuation manual:

"Accident and health insurance" means a contract that incorporates morbidity risk and provides protection against economic loss resulting from accident, sickness, or medical conditions and as may be specified in the valuation manual.

"Appointed actuary" means a qualified actuary who is appointed in accordance with the valuation manual to prepare the actuarial opinion required in subsection e. of section 2 of P.L.1995, c.339 (C.17B:19-10).

"Company" means an entity, which:

(1) has written, issued, or reinsured life insurance contracts, accident and health insurance contracts, or deposit-type contracts in this State and has at least one such policy in force or on claim; or

(2) has written, issued, or reinsured life insurance contracts, accident and health insurance contracts, or deposit-type contracts in any state and is required to hold a certificate of authority to write life insurance, accident and health insurance, or deposit-type contracts in this State.

"Deposit-type contract" means contracts that do not incorporate mortality or morbidity risks and as may be specified in the valuation manual.

"Life insurance" means contracts that incorporate mortality risk, including annuity and pure endowment contracts, and as may be specified in the valuation manual.

"NAIC" means the National Association of Insurance Commissioners.

"Policyholder behavior" means any action a policyholder, contract holder or any other person with the right to elect options, such as a certificate holder, may take under a policy or contract subject to sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14) including, but not limited to, lapse, withdrawal, transfer, deposit, premium payment, loan, annuitization, or benefit elections prescribed by the policy or contract but excluding events of mortality or morbidity that result in benefits prescribed in their essential aspects by the terms of the policy or contract.

"Principle-based valuation" means a reserve valuation that uses one or more methods or one or more assumptions determined by the insurer and is required to comply with section 64 of P.L.2014, c.81 (C.17B:19-12) as specified in the valuation manual.

"Qualified actuary" means an individual who is qualified to sign the applicable statement of actuarial opinion in accordance with the American Academy of Actuaries qualification standards for actuaries signing such statements and who meets the requirements specified in the valuation manual.

"Tail risk" means a risk that occurs either where the frequency of low probability events is higher than expected under a normal probability distribution or where there are observed events of very significant size or magnitude.

"Valuation manual" means the manual of valuation instructions adopted by the NAIC as specified in sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14) or as subsequently amended.

§ 17B:19-2 Annual valuation of reserve liabilities for outstanding policies; foreign and alien insurers.

The commissioner shall annually value, or cause to be valued, the reserve liabilities (hereinafter called reserves) for all outstanding life insurance policies and annuity and pure endowment contracts of every life insurer doing business in this State issued prior to the operative date of the valuation manual, except that in the case of an alien insurer, such valuation shall be limited to its United States business, and may certify the amount of any such reserves, specifying the mortality table or tables, rate or rates of interest and methods (net level premium method or other) used in the calculation of such reserves. All valuations made by him or by his authority shall be upon the net premium basis or such modifications thereof as are provided by law. In calculating such reserves, he may use group methods and approximate averages for fractions of a year or otherwise and, with the concurrence of the insurer, make classifications of benefits by years of issue according to such relevant factors as the date as of which the rated age of the insured is determined, the date as of which the benefits have been provided or the premium rates have been changed, or, for policies under which premium rates are guaranteed for a limited period of time, the most recent date as of which the insurer had the right to modify those premium rates. In lieu of the valuation of the reserves herein required of any foreign or alien insurer, he may accept any valuation made, or caused to be made, by the insurance supervisory official of any state or other jurisdiction when such valuation complies with the minimum standards provided by law and if the official of such state or jurisdiction accepts as sufficient and valid for all legal purposes the certificate of valuation of the commissioner when such certificate states the valuation to have been made in a specified manner according to which the aggregate reserves would be at least as large as if they had been computed in the manner prescribed by the law of that state or jurisdiction.

Any such insurer which at any time shall have adopted any standard of valuation producing greater aggregate reserves than those calculated according to the minimum standards provided by law may, with the approval of the commissioner, adopt any lower standard of valuation, but not lower than the minimum standards so provided.

Except in the case of policies for which the reserve liabilities are valued on the basis of the provisions of the standard valuation law contained in N.J.S.17B:19-8 or policies issued on or after the operative date of the valuation manual, all valuations made by the commissioner or by his authority shall be upon the net premium basis, or such modification thereof as hereinafter expressly provided; and all policies issued prior to January 1, 1901, shall be valued according to the actuaries' table of mortality, with compound interest at the rate of 4% per annum, except in cases where a life insurer elects or has elected to have the policies or any class thereof valued according to the American Experience table of mortality, or according to the American Men Ultimate table of mortality, with compound interest at the rate of either 3% or 3 1/2 % per annum or with the approval of the commissioner at a rate of less than 3% per annum; and all policies issued on or after January 1, 1901, shall be valued according to the American Experience table of mortality, with compound interest at the rate of 3 1/2 % per annum, except in cases where a life insurer elects or has elected to have such policies or any class thereof valued according to the American Experience table of mortality with compound interest at a rate of less than 3 1/2% per annum but not less than 3% per annum or with the approval of the commissioner at a rate of less than 3% per annum; and except in cases where any life insurer with the approval of the commissioner may elect or shall have elected to have its ordinary policies or any class thereof valued according to the American Men Ultimate table of mortality, with compound interest at a rate which is not more than 3 1/2% per annum. The minimum standard for the valuation of group term insurance policies under which premium rates are not guaranteed for a period in excess of 5 years shall be the American Men Ultimate table of mortality with interest at 3 1/2 % per annum. The commissioner may vary the standards of interest and mortality in the case of annuities and industrial policies and of invalid lives and other extra hazards. When the actual premium charged for an insurance policy is less than the net premium for the insurance, computed according to the table of mortality, and the rate of interest prescribed herein, the value of the policy shall be increased by the value of an annuity, the amount of which shall equal the difference between the premiums and the term of which in years shall equal the number of future annual payments receivable on the insurance after the date of valuation.

Reserves for all policies and contracts to which the foregoing standards apply may be calculated, at the option of the insurer, according to any standards which produce greater aggregate reserves for all such policies and contracts than the minimum reserves required by this section.

§ 17B:19-2.1 Annual valuation of reserve liabilities.

60. The commissioner shall annually value, or cause to be valued, the reserve liabilities (hereinafter called reserves) for all outstanding life insurance contracts, annuity and pure endowment contracts, accident and health contracts, and deposit-type contracts of every company issued on or after the operative date of the valuation manual. In lieu of the valuation of the reserves required of a foreign or alien company, the commissioner may accept a valuation made, or caused to be made, by the insurance supervisory official of any State or other jurisdiction when the valuation complies with the minimum standard provided in sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14). The provisions set forth in sections 63 and 64 of P.L.2014, c.81 (C.17B:19-11 and C.17B:19-12) shall apply to all policies and contracts issued on or after the operative date of the valuation manual.

§ 17B:19-3 Additional reserves

Subject to the approval of the commissioner, any life insurer of this State may set up, in addition to the reserve liabilities required pursuant to section 17B:19-2, reserves to provide for any additional liability at maturity, on the basis of rates of interest and of mortality appropriate to the valuation of annuities, on policies under which by their terms or otherwise a right has been or may be exercised to elect optional modes of settlement.

The commissioner shall, at the time of the annual valuation pursuant to section 17B:19-2, make or cause to be made a valuation of the additional reserves so set up, and shall thereupon include the amount of such additional reserves in any certification of reserves made pursuant to section 17B:19-2, specifying the mortality table or tables and rate or rates of interest used in the calculation of such additional reserves.

The basis of such additional reserves set aside by any insurer at the close of any year shall not thereafter be changed to a basis producing smaller aggregate reserves except upon approval by the commissioner of the insurer's application therefor.

§ 17B:19-4 Preliminary term insurance; amount of reserve

This section applies to life insurance policies, other than policies for which the reserve liabilities are valued on the basis of the provisions of the standard valuation law contained in section 17B:19-8, which were previously issued by insurers doing business in this state and which provide for not more than one year preliminary term insurance by incorporating in the provision thereof specifying the premium consideration to be received a clause plainly showing that the first year's insurance or part thereof under the policies is term insurance, purchased by the whole or a part of the premium to be received during the first policy year.

If the premium charged for the preliminary term insurance under any such policy issued prior to January 1, 1920 did not exceed that charged at the same time for like insurance under a twenty-payment life preliminary term policy of the same insurer, issued at the same age, or if the premium charged for the preliminary term insurance under any such policy issued on or after January 1, 1920 did not exceed 150% of the net premium therefor, computed according to the table of mortality and the rate of interest adopted by the insurer, as herein provided, such policy may be valued according to its terms on the mortality and interest bases herein provided.

The reserve held on every other such policy shall be equal to that of a similar policy, issued at the same age, which does not provide for preliminary term insurance.

§ 17B:19-5 Calculations of policy and loss reserves for accident and health insurance.

The commissioner shall annually make or cause to be made or shall annually require the insurer to make calculations of policy and loss reserves for accident and health insurance written by insurers authorized to write accident and health insurance in this State as defined in N.J.S.17B:17-4. The commissioner shall promulgate regulations establishing the minimum standards applicable to the valuation of accident and health insurance reserves.

§ 17B:19-7 Abandonment of standard of valuation adopted

Except in accordance with the provisions of section 17B:19-2, a life insurer shall not abandon the standard of valuation adopted for any outstanding policies if the reserve, calculated by the proposed standard, is less than the reserve calculated by the standard which is to be abandoned.

§ 17B:19-8 Standard valuation law

This section shall be known as the standard valuation law and shall apply to all the life insurance policies, pure endowment contracts and annuity contracts issued by every life insurer on or after January 1, 1948 or such earlier date as shall have been elected by the insurer as the operative date for such insurer of the standard nonforfeiture law.

a. Except as otherwise provided in paragraph (ix) and paragraph (x) of this subsection, the minimum standard for the valuation of all such policies and contracts shall be the commissioner's reserve valuation methods defined in subsections b., e. and f. of this section, 3 1/2% interest, or in the case of life insurance policies and contracts, other than annuity and pure endowment contracts, issued on or after January 1, 1973, 4% interest for such policies issued prior to January 1, 1977 and 4 1/2% interest for such policies issued on or after January 1, 1977, and the following tables:

(i) For all ordinary policies of life insurance issued on the standard basis, excluding any disability and accidental death benefits in such policies, the Commissioners 1941 Standard Ordinary Mortality Table; provided, however, that the Commissioners 1958 Standard Ordinary Mortality Table shall be the table for the minimum standard for such policies issued on or after January 1, 1966 or, for policies in any category of ordinary insurance, such earlier date as shall have been elected by the insurer for the purpose and prior to the operative date, for such category, provided for in paragraph (xi) of subsection h. of the standard nonforfeiture law for life insurance (N.J.S.17B:25-19); provided that for any category of such policies issued on female risks on or after July 1, 1957 and prior to the operative date provided for in paragraph (xi) of subsection h. of the standard nonforfeiture law for life insurance, all modified net premiums and present values, referred to in this section may be calculated according to an age not more than six years younger than the actual age of the insured; and for such policies issued on or after the operative date provided for in paragraph (xi) of subsection h. of N.J.S.17B:25-19, the Commissioners 1980 Standard Ordinary Mortality Table, or at the election of the insurer for any one or more specified plans of life insurance, the Commissioners 1980 Standard Ordinary Mortality Table with Ten-Year Select Mortality Factors, or any ordinary mortality table, adopted after 1980 by the National Association of Insurance Commissioners, that is approved by regulation promulgated by the commissioner for use in determining the minimum standard of valuation of those policies.

(ii) For all industrial life insurance policies issued on the standard basis, excluding any disability and accidental death benefits in such policies, the 1941 Standard Industrial Mortality Table; provided, however, that the Commissioners 1961 Standard Industrial Mortality Table or any industrial mortality table, adopted after 1980 by the National Association of Insurance Commissioners, that is approved by regulation promulgated by the commissioner for use in determining the minimum standard of valuation for such policies shall be the table for the minimum standard for such policies issued on or after January 1, 1968 or such earlier date as shall have been elected by the insurer as the date on which the calculation of the adjusted premiums referred to in the standard nonforfeiture law for life insurance (N.J.S.17B:25-19) for such insurer's industrial life insurance policies became based upon said table.

(iii) For individual annuity and pure endowment contracts issued prior to the operative date of paragraph (ix) of this subsection, excluding any disability and accidental death benefits in such contracts, the 1937 Standard Annuity Mortality Table, or, at the option of the insurer, the Annuity Mortality Table for 1949, Ultimate, or any modification of either of these tables approved by the commissioner.

(iv) For group annuity and pure endowment contracts, except annuities and pure endowments purchased thereunder on or after the operative date of paragraph (ix) of this subsection, excluding any disability and accidental death benefits in such contracts, the Group Annuity Mortality Table for 1951, any modification of such table approved by the commissioner, or, at the option of the insurer, any of the tables or modifications of tables specified for individual annuity and pure endowment contracts.

(v) For total and permanent disability benefits in or supplementary to ordinary policies or contracts, for policies or contracts issued on or after January 1, 1966, the tables of Period 2 disablement rates and the 1930 to 1950 termination rates of the 1952 Disability Study of the Society of Actuaries, with due regard to the type of benefits or any tables of disablement rates and termination rates adopted after 1980 by the National Association of Insurance Commissioners, that are approved by regulation promulgated by the commissioner for use in determining the minimum standard of valuation for such policies; for policies or contracts issued on or after January 1, 1961 and prior to January 1, 1966, either such tables, or, at the option of the insurer, the Class (3) Disability Table (1926); and for policies issued prior to January 1, 1961, the Class (3) Disability Table (1926). Either table shall, for active lives, be combined with a mortality table permitted for calculating the reserves for life insurance policies.

(vi) For accidental death benefits in or supplementary to policies, for policies issued on or after January 1, 1966, the 1959 Accidental Death Benefits Table or any accidental death benefits table, adopted after 1980 by the National Association of Insurance Commissioners, that is approved by regulation promulgated by the commissioner for use in determining the minimum standard of valuation for such policies; for policies issued on or after January 1, 1961 and prior to January 1, 1966, either such table or, at the option of the insurer, the Inter-Company Double Indemnity Mortality Table; and for policies issued prior to January 1, 1961, the Inter-Company Double Indemnity Mortality Table. Either table shall be combined with a mortality table permitted for calculating the reserves for life insurance policies.

(vii) For group life insurance, life insurance issued on the substandard basis and other special benefits, such tables as may be approved by the commissioner.

(viii) For ordinary and industrial paid-up nonforfeiture term insurance, and accompanying pure endowment, the table of mortality based on the rates of mortality assumed in calculating the paid-up nonforfeiture benefits.

(ix) Except as provided in paragraph (x) of this subsection, the minimum standard for the valuation of all individual annuity and pure endowment contracts issued on or after the operative date of this paragraph (ix), as defined herein, and for all annuities and pure endowments purchased on or after such operative date under group annuity and pure endowment contracts, the commissioner's reserve valuation methods defined in subsections b. and f. and the following tables and interest rates:

(1) For individual annuity and pure endowment contracts, excluding any disability and accidental death benefits in such contracts, the 1971 Individual Annuity Mortality Table or any individual annuity mortality table, adopted after 1980 by the National Association of Insurance Commissioners, that is approved by regulation promulgated by the commissioner for use in determining the minimum standard of valuation for such contracts, or any modification of any such table approved by the commissioner, and, for such contracts issued prior to January 1, 1977, 6% interest for single premium immediate annuity contracts, and 4% interest for all other individual annuity and pure endowment contracts, and such contracts issued on or after January 1, 1977, 7 1/2% interest for single premium immediate annuity contracts and 4 1/2% interest for other individual annuity and pure endowment contracts.

(2) For all annuities and pure endowments purchased under group annuity and pure endowment contracts, excluding any disability and accidental death benefits purchased under such contracts, the 1971 Group Annuity Mortality Table or any group annuity mortality table, adopted after 1980 by the National Association of Insurance Commissioners, that is approved by regulation promulgated by the commissioner for use in determining the minimum standard of valuation for such annuities and pure endowments, or any modification of any such table approved by the commissioner, and 6% interest; except 7 1/2% interest for purchases on or after January 1, 1977.

After January 1, 1973, an insurer may file with the commissioner a written notice of its election to comply with the provisions of this paragraph (ix) beginning on a specific date that is on or after January 1, 1973 but prior to January 1, 1979. Such specific date shall be the operative date of this paragraph for such insurer, provided that if an insurer makes no such election, the operative date of this paragraph for such insurer shall be January 1, 1979.

(x) The interest rates used in determining the minimum standard for the valuation of:

all life insurance policies issued in a particular calendar year on or after the operative date provided for in subsection h. (xi) of N.J.S.17B:25-19; all individual annuity and pure endowment contracts issued in a particular calendar year on or after January 1, 1981; all annuities and pure endowments purchased in a particular calendar year on or after January 1, 1981 under group annuity and pure endowment contracts; and the net increase, if any, in a particular calendar year after January 1, 1981, in amounts held under guaranteed interest contracts shall be the calendar year statutory valuation interest rates established below.

The calendar year statutory valuation interest rates, I, shall be determined as follows and the results rounded to the nearer 1/4 of 1%:

(1) For life insurance,

I = .03 + W (R1 - .03) + W/2 (R2 - .09);

(2) For single premium immediate annuities and for annuity benefits involving life contingencies arising from other annuities with cash settlement options and from guaranteed interest contracts with cash settlement options,

I = .03 + W (R - .03)

where R1 is the lesser of R and .09,

R2 is the greater of R and .09,

R is the reference interest rate defined in subparagraph (7) of this paragraph, and W is the weighting factor defined in subparagraph (6) of this paragraph;

(3) For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on an issue year basis, except as stated in subparagraph (2) of this paragraph, the formula for life insurance stated in subparagraph (1) of this paragraph shall apply to annuities and guaranteed interest contracts with guarantee durations in excess of 10 years and the formula for single premium immediate annuities stated in subparagraph (2) of this paragraph shall apply to annuities and guaranteed interest contracts with guarantee durations of 10 years or less;

(4) For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the formula for single premium immediate annuities stated in subparagraph (2) of this paragraph shall apply; and

(5) For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a change in fund basis, the formula for single premium immediate annuities stated in subparagraph (2) of this paragraph shall apply.

However, if the calendar year statutory valuation interest rate for any life insurance policies issued in any calendar year determined without reference to this sentence differs from the corresponding actual rate for similar policies issued in the immediately preceding calendar year by less than 1/2 of 1%, the calendar year statutory valuation interest rate for such life insurance policies shall be equal to the corresponding actual rate for the immediately preceding calendar year. For purposes of applying the immediately preceding sentence, the calendar year statutory valuation interest rate for life insurance policies issued in a calendar year shall be determined for 1980 (using the reference interest rate defined for 1979) and shall be determined for each subsequent calendar year, notwithstanding when the provisions of subsection h. of N.J.S.17B:25-19, the standard nonforfeiture law for life insurance become operative;

(6) The weighting factors, W, referred to in the formulas stated above are given in the following schedules:

SCHEDULE A

Weighting Factors for Life Insurance:

Guarantee

Duration

(Years) Weighting

Factors

10 or less .50

More than 10, but not more than 20 .45

More than 20 .35

For life insurance, the guarantee duration is the maximum number of years the life insurance can remain in force on a basis guaranteed in the policy or under options to convert to plans of life insurance with premium rates or nonforfeiture values or both which are guaranteed in the original policy;

SCHEDULE B

Weighting factor for single premium immediate annuities and for annuity benefits involving life contingencies arising from other annuities with cash settlement options and guaranteed interest contracts with cash settlement options:

.80

SCHEDULE C

Weighting factors for other annuities and for guaranteed interest contracts, except as stated in Schedule B above, shall be as specified in Tables A, B and C below, according to the rules and definitions in D, E and F below:

TABLE A

For annuities and guaranteed interest contracts valued on an issue year basis:

Guarantee Weighting Factor

Duration for Plan Type

(Years) A B C

5 or less: .80 .60 .50

More than 5, but not more than 10: .75 .60 .50

More than 10, but not more than 20: .65 .50 .45

More than 20: .45 .35 .35

TABLE B

Plan Type

A B C

For annuities and guaranteed

interest contracts valued on a change

in fund basis, the factors shown in

Table A above increased by: .15 .25 .05

TABLE C

Plan Type

A B C

For annuities and guaranteed

interest contracts valued on an

issue year basis (other than those

with no cash settlement options)

which do not guarantee interest on

considerations received more than

one year after issue or purchase

and for annuities and guaranteed

interest contracts valued on a

change in fund basis which do not

guarantee interest rates on

considerations received more than

12 months beyond the valuation date,

the factors shown in Table A or

derived in Table B increased by: .05 .05 .05

Rule D. For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, the guarantee duration is the number of years for which the contract guarantees interest rates in excess of the calendar year statutory valuation interest rate for life insurance policies with guarantee durations in excess of 20 years. For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the guarantee duration is the number of years from the date of issue or date of purchase to the date annuity benefits are scheduled to commence.

Rule E. Plan type as used in the above tables is defined as follows:

Plan Type A: At any time policyholder may withdraw funds only: (1) with an adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurer, or (2) without such adjustment but in installments over five years or more, or (3) as an immediate life annuity, or (4) no withdrawal permitted.

Plan Type B: Before expiration of the interest rate guarantee, policyholder may withdraw funds only: (1) with an adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurer, or (2) without such adjustment but in installments over five years or more, or (3) no withdrawal permitted. At the end of the interest rate guarantee, funds may be withdrawn without such adjustment in a single sum or installments over less than five years.

Plan Type C: Policyholder may withdraw funds before expiration of interest rate guarantee in a single sum or installments over less than five years either: (1) without adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurer, or (2) subject only to a fixed surrender charge stipulated in the contract as a percentage of the fund.

Rule F. An insurer may elect to value guaranteed interest contracts with cash settlement options and annuities with cash settlement options on either an issue year basis or on a change in fund basis. Guaranteed interest contracts with no cash settlement options and other annuities with no cash settlement options must be valued on an issue year basis. As used in this paragraph (x) of subsection a., an issue year basis of valuation refers to a valuation basis under which the interest rate used to determine the minimum valuation standard for the entire duration of the annuity or guaranteed interest contract is the calendar year valuation interest rate for the year of issue or year of purchase of the annuity or guaranteed interest contract, and the change in fund basis of valuation refers to a valuation basis under which the interest rate used to determine the minimum valuation standard applicable to each change in the fund held under the annuity or guaranteed interest contract is the calendar year valuation interest rate for the year of the change in the fund;

(7) The reference interest rate, R, referred to in this paragraph (x) is defined as follows:

For all life insurance, the lesser of the average over a period of 36 months and the average over a period of 12 months, ending on June 30 of the calendar year next preceding the year of issue, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.

For single premium immediate annuities and for annuity benefits involving life contingencies arising from other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, the average over a period of 12 months, ending on June 30 of the calendar year of issue or year of purchase, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.

For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a year of issue basis, except as stated above, with guarantee duration in excess of 10 years, the lesser of the average over a period of 36 months and the average over a period of 12 months, ending on June 30 of the calendar year of issue or purchase, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.

For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a year of issue basis, except as stated above, with guarantee duration of 10 years or less, the average over a period of 12 months, ending on June 30 of the calendar year of issue or purchase, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.

For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the average over a period of 12 months, ending on June 30 of the calendar year of issue or purchase, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.

For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a change in fund basis, except as stated above, the average over a period of 12 months, ending on June 30 of the calendar year of the change in the fund, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.

In the event that the Monthly Average of the Composite Yield on Seasoned Corporate Bonds is no longer published by Moody's Investors Service, Inc., or in the event that the National Association of Insurance Commissioners determines that the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc., is no longer appropriate for the determination of the reference interest rate, then an alternative method for determination of the reference interest rate, which is adopted by the National Association of Insurance Commissioners and approved by regulation promulgated by the commissioner, may be substituted.

b. Except as otherwise provided in subsections e. and f. of this section, reserves according to the commissioner's reserve valuation method, for the life insurance and endowment benefits of policies providing for a uniform amount of insurance and requiring the payment of uniform premiums, shall be the excess, if any, of the present value, at the date of valuation, of such future guaranteed benefits provided for by such policies, over the then present value of any future modified net premiums therefor. The modified net premiums for any such policy shall be such uniform percentage of the respective contract premiums for such benefits that the present value, at the date of issue of the policy, of all such modified net premiums shall be equal to the sum of the then present value of such benefits provided for by the policy and the excess of (A) over (B), as follows:

(A) A net level annual premium equal to the present value, at the date of issue, of such benefits provided for after the first policy year, divided by the present value, at the date of issue, of an annuity of one per annum payable on the first and each subsequent anniversary of such policy on which a premium falls due; provided, however, that such net level annual premium shall not exceed the net level annual premium on the 19-year premium whole life plan for insurance of the same amount at an age one year higher than the age at issue of such policy.

(B) A net one-year term premium for such benefits provided for in the first policy year.

Provided that for any life insurance policy issued on or after January 1, 1985 for which the contract premium in the first policy year exceeds that of the second year and for which no comparable additional benefit is provided in the first year for such excess and which provides an endowment benefit or a cash surrender value or a combination thereof in an amount greater than such excess premium, the reserve according to the commissioner's reserve valuation method as of any policy anniversary occurring on or before the assumed ending date defined herein as the first policy anniversary on which the sum of any endowment benefit and any cash surrender value then available is greater than such excess premium shall, except as otherwise provided in subsection e., be the greater of the reserve as of such policy anniversary calculated as described in the first paragraph of this subsection and the reserve as of such policy anniversary calculated as described in that paragraph, but with (i) the value defined in subparagraph (A) of that paragraph being reduced by 15% of the amount of such excess first year premium, (ii) all present values of benefits and premiums being determined without reference to premiums or benefits provided for by the policy after the assumed ending date, (iii) the policy being assumed to mature on such date as an endowment, and (iv) the cash surrender value provided on such date being considered as an endowment benefit. In making the above comparison the mortality and interest bases stated in subsection a. of this section shall be used.

Reserves according to the commissioner's reserve valuation method for (i) life insurance policies providing for a varying amount of insurance or requiring the payment of varying premiums, (ii) group annuity and pure endowment contracts purchased under a retirement plan or plan of deferred compensation, established or maintained by an employer (including a partnership or sole proprietorship), or by an employee organization, or by both, other than a plan providing individual retirement accounts or individual retirement annuities under section 408 of the Internal Revenue Code of 1986, as now or hereafter amended, (iii) disability and accidental death benefits in all policies and contracts, and (iv) all other benefits, except life insurance and endowment benefits in life insurance policies and benefits provided by all other annuity and pure endowment contracts, shall be calculated by a method consistent with the principles of this subsection b.

c. In no event shall an insurer's aggregate reserves for all life insurance policies, excluding disability and accidental death benefits, be less than the aggregate reserves calculated in accordance with the methods set forth in subsections b., e. , f. and g. and the mortality table or tables and rate or rates of interest used in calculating nonforfeiture benefits for such policies. Reserves for any category of policies, contracts or benefits as established by the commissioner shall not be calculated according to any standards which produce smaller aggregate reserves for such category than the corresponding aggregate values of nonforfeiture benefits available as of the valuation date. In no event shall the aggregate reserves for all policies, contracts and benefits be less than the aggregate reserves determined by a qualified actuary to be necessary to render the opinion required pursuant to section 2 of P.L.1995, c.339 (C.17B:19-10).

d. Reserves for any category of policies, contracts or benefits as established by the commissioner may be calculated, at the option of the insurer, according to any standards which produce greater aggregate reserves for such category than those calculated according to the minimum standard herein provided. An insurer which adopts any standard of valuation producing greater aggregate reserves than those calculated according to the minimum standard pursuant to this section may, with the approval of the commissioner, adopt any lower standard of valuation, but not lower than the minimum standard pursuant to this section herein provided; provided, however, that, for purposes of this subsection, the holding of additional reserves previously determined by a qualified actuary to be necessary to render the opinion required pursuant to section 2 of P.L.1995, c.339 (C.17B:19-10) shall not be deemed to be the adoption of a higher standard of valuation.

e. If in any contract year the gross premium charged by any life insurer on any policy or contract is less than the valuation net premium for the policy or contract calculated by the method used in calculating the reserve thereon but using the minimum valuation standards of mortality and rate of interest, the minimum reserve required for such policy or contract shall be the greater of either the reserve calculated according to the mortality table, rate of interest, and method actually used for such policy or contract, or the reserve calculated by the method actually used for such policy or contract but using the minimum valuation standards of mortality and rate of interest and replacing the valuation net premium by the actual gross premium in each contract year for which the valuation net premium exceeds the actual gross premium.

The minimum valuation standards of mortality and rate of interest referred to in this subsection are those standards stated in subsection a. of this section.

Provided that for any life insurance policy issued on or after January 1, 1985 for which the gross premium in the first policy year exceeds that of the second year and for which no comparable additional benefit is provided in the first year for such excess and which provides an endowment benefit or a cash surrender value or a combination thereof in an amount greater than such excess premium, the foregoing provisions of this subsection e. shall be applied as if the method actually used in calculating the reserve for such policy were the method described in subsection b., notwithstanding the provisions of the second paragraph of such subsection b. The minimum reserve at each policy anniversary of such a policy shall be the greater of the minimum reserve calculated in accordance with subsection b., including the second paragraph of that subsection, and the minimum reserve calculated in accordance with this subsection e.

f. This subsection shall apply to all annuity and pure endowment contracts other than group annuity and pure endowment contracts purchased under a retirement plan or plan of deferred compensation, established or maintained by an employer (including a partnership or sole proprietorship), or by an employee organization, or by both, other than a plan providing individual retirement accounts or individual retirement annuities under section 408 of the Internal Revenue Code of 1986, as now or hereafter amended.

Reserves according to the commissioner's annuity reserve method for benefits under annuity or pure endowment contracts, excluding any disability and accidental death benefits in such contracts, shall be the greatest of the respective excesses of the present values, at the date of valuation, of the future guaranteed benefits, including guaranteed nonforfeiture benefits, provided for by such contracts at the end of each respective contract year, over the present value, at the date of valuation, of any future valuation considerations derived from future gross considerations, required by the terms of such contract, that become payable prior to the end of such respective contract year. The future guaranteed benefits shall be determined by using the mortality table, if any, and the interest rate, or rates, specified in such contracts for determining guaranteed benefits. The valuation considerations are the portions of the respective gross considerations applied under the terms of such contracts to determine nonforfeiture values.

g. In the case of any plan of life insurance which provides for future premium determination, the amounts of which are to be determined by the insurer based on then estimates of future experience, or in the case of any plan of life insurance or annuity which is of such a nature that the minimum reserves cannot be determined by the methods described in subsections b., e., and f. of this section, the reserves which are held under any such plan shall:

(i) be appropriate in relation to the benefits and the pattern of premiums for that plan, and

(ii) be computed by a method which is consistent with the principles of this standard valuation law, as determined by regulations promulgated by the commissioner.

§ 17B:19-10 Reserves, related actuarial items; annual opinion of qualified actuary.

2. a. For years ending prior to the operative date of the valuation manual, every insurer authorized to transact life, health or annuity business and every fraternal benefit society doing business in this State shall annually submit the opinion of a qualified actuary as to whether the reserves and related actuarial items held in support of the policies and contracts specified by the commissioner by regulation are: computed appropriately; based on assumptions which satisfy contractual provisions; and consistent with prior reported amounts and comply with applicable laws of this State. The commissioner shall define by regulation the specifics of this opinion and add such other items deemed to be necessary to its scope.

b. (1) Every insurer authorized to transact life, health or annuity business and every fraternal benefit society, except as exempted by the commissioner by regulation, shall also annually include in the opinion required pursuant to subsection a. of this section, an opinion of the same qualified actuary as to whether the reserves and related actuarial items held in support of the policies and contracts specified by the commissioner by regulation, when considered in light of the assets held by the insurer or society with respect to the reserves and related actuarial items, including, but not limited to, the investment earnings on the assets and the considerations anticipated to be received and retained under the policies and contracts, make adequate provision for the insurer's or society's obligations under the policies and contracts, including, but not limited to, the benefits under and expenses associated with the policies and contracts.

(2) The commissioner may provide by regulation for a transition period for establishing any higher reserves which the qualified actuary may deem necessary in order to render the opinion required by this section.

c. Each opinion required pursuant to subsection b. of this section shall be governed by the following provisions:

(1) A memorandum, in form and substance acceptable to the commissioner as specified by regulation, shall be prepared to support each actuarial opinion.

(2) If the insurer or society fails to provide a supporting memorandum at the request of the commissioner within a period specified by regulation, or the commissioner determines that the supporting memorandum provided by the insurer or society fails to meet the standards prescribed by regulation or is otherwise unacceptable to the commissioner, the commissioner may engage a qualified actuary at the expense of the insurer or society to review the opinion and the basis for the opinion and prepare such supporting memorandum as is required by the commissioner.

d. Every opinion shall be governed by the following provisions:

(1) The opinion shall be submitted with the annual statement reflecting the valuation of reserves for each year ending on or after December 31, 1995.

(2) The opinion shall apply to all policies or contracts in force, including individual and group health insurance plans, in form and substance acceptable to the commissioner as specified by regulation.

(3) The opinion shall be based on standards adopted from time to time by the Actuarial Standards Board and on such additional standards as the commissioner may by regulation prescribe.

(4) In the case of an opinion required to be submitted by a foreign or alien insurer or fraternal benefit society, the commissioner may accept the opinion filed by that insurer or society with the insurance supervisory official of another state or jurisdiction if the commissioner determines that the opinion reasonably meets the requirements applicable to an insurer or society domiciled in this State.

(5) (Deleted by amendment, P.L.2014, c.81)

(6) Except in cases of fraud or willful misconduct, the qualified actuary shall not be liable for damages to any person, other than the insurer, the fraternal benefit society and the commissioner, for any act, error, omission, decision or conduct with respect to the actuary's opinion.

(7) Disciplinary action by the commissioner against the insurer, fraternal benefit society or the qualified actuary shall be defined in regulation by the commissioner.

(8) (Deleted by amendment, P.L.2014, c.81)

e. On or after the operative date of the valuation manual, every company with outstanding life insurance contracts, accident and health insurance contracts or deposit-type contracts in this State and subject to regulation by the commissioner shall annually submit the opinion of the appointed actuary as to whether the reserves and related actuarial items held in support of the policies and contracts are computed appropriately, are based on assumptions that satisfy contractual provisions, are consistent with prior reported amounts and comply with applicable laws of this State. The valuation manual will prescribe the specifics of this opinion including any items deemed to be necessary to its scope.

f. Every company with outstanding life insurance contracts, accident and health insurance contracts or deposit-type contracts in this State and subject to regulation by the commissioner, except as exempted in the valuation manual, shall also annually include in the opinion required by subsection e. of this section, an opinion of the same appointed actuary as to whether the reserves and related actuarial items held in support of the policies and contracts specified in the valuation manual, when considered in light of the assets held by the company with respect to the reserves and related actuarial items, including but not limited to the investment earnings on the assets and the considerations anticipated to be received and retained under the policies and contracts, make adequate provision for the company's obligations under the policies and contracts, including but not limited to the benefits under and expenses associated with the policies and contracts.

g. Each opinion required by subsection e. of this section shall be governed by the following provisions:

(1) A memorandum, in form and substance as specified in the valuation manual, and acceptable to the commissioner, shall be prepared to support each actuarial opinion.

(2) If the insurer fails to provide a supporting memorandum at the request of the commissioner within a period specified in the valuation manual or the commissioner determines that the supporting memorandum provided by the insurer fails to meet the standards prescribed by the valuation manual or is otherwise unacceptable to the commissioner, the commissioner may engage a qualified actuary at the expense of the company to review the opinion and the basis for the opinion and prepare the supporting memorandum required by the commissioner.

h. Every opinion required by subsection e. of this section shall be governed by the following provisions:

(1) The opinion shall be in form and substance as specified in the valuation manual and acceptable to the commissioner.

(2) The opinion shall be submitted with the annual statement reflecting the valuation of such reserve liabilities for each year ending on or after the operative date of the valuation manual.

(3) The opinion shall apply to all policies and contracts subject to subsection f. of this section, plus other actuarial liabilities as may be specified in the valuation manual.

(4) The opinion shall be based on standards adopted from time to time by the Actuarial Standards Board or its successor, and on such additional standards as may be prescribed in the valuation manual.

(5) In the case of an opinion required to be submitted by a foreign or alien company, the commissioner may accept the opinion filed by that company with the insurance supervisory official of another state if the commissioner determines that the opinion reasonably meets the requirements applicable to a company domiciled in this State.

(6) Except in cases of fraud or willful misconduct, the appointed actuary shall not be liable for damages to any person, other than the insurance company and the commissioner, for any act, error, omission, decision or conduct with respect to the appointed actuary's opinion.

(7) Disciplinary action by the commissioner against the company or the appointed actuary shall be prescribed and defined in regulations by the commissioner.

§ 17B:19-11 Standards for policies issued on or after operative date of valuation manual.

63. a. For policies issued on or after the operative date of the valuation manual, the standard prescribed in the valuation manual is the minimum standard of valuation required under section 60 of P.L.2014, c.81 (C.17B:19-2.1) except as provided under subsection e. or g. of this section.

b. The operative date of the valuation manual is January 1 of the first calendar year following the first July 1 as of which all of the following have occurred:

(1) The valuation manual has been adopted by the NAIC by an affirmative vote of at least 42 members, or three-fourths of the members voting, whichever is greater.

(2) The NAIC Model Standard Valuation Law, as amended by the NAIC in 2009, or legislation including substantially similar terms and provisions, has been enacted by States representing greater than 75% of the direct premiums written as reported in the following annual statements submitted for 2008: life, accident and health annual statements; health annual statements; or fraternal annual statements.

(3) The NAIC Model Standard Valuation Law, as amended by the NAIC in 2009, or legislation including substantially similar terms and provisions, has been enacted by at least 42 of the following 55 jurisdictions: The 50 States of the United States, American Samoa, the American Virgin Islands, the District of Columbia, Guam, and Puerto Rico.

c. Unless a change in the valuation manual specifies a later effective date, changes to the valuation manual shall be effective on January 1 following the date when all of the following have occurred:

(1) The change to the valuation manual has been adopted by the NAIC by an affirmative vote representing:

(a) At least three-fourths (3/4) of the members of the NAIC voting, but not less than a majority of the total membership, and

(b) Members of the NAIC representing jurisdictions totaling greater than 75% of the direct premiums written as reported in the following annual statements most recently available prior to the vote in subparagraph (a) of paragraph (1) of this subsection: life, accident and health annual statements, health annual statements, or fraternal annual statements.

(2) No later than 30 days before the operative date of the valuation manual or any changes thereto adopted by the NAIC, the commissioner shall by order notify all companies as defined in section 58 of P.L.2014, c.81 (C.17B:19-1.1) of the adoption and its operative date. Failure to provide this notice shall not delay the operative date of the valuation manual or any changes thereto.

d. The valuation manual must specify all of the following:

(1) Minimum valuation standards for and definitions of the policies or contracts subject to section 60 of P.L.2014, c.81 (C.17B:19-2.1). Such minimum valuation standards shall be:

(a) The commissioner's reserve valuation method for life insurance contracts, other than annuity contracts, subject to section 60 of P.L.2014, c.81 (C.17B:19-2.1);

(b) The commissioner's annuity reserve valuation method for annuity contracts subject to section 60 of P.L.2014, c.81 (C.17B:19-2.1); and

(c) Minimum reserves for all other policies or contracts subject to section 60 of P.L.2014, c.81 (C.17B:19-2.1);

(2) Which policies or contracts or types of policies or contracts that are subject to the requirements of a principle-based valuation in subsection a. of section 64 of P.L.2014, c.81 (C.17B:19-12) and the minimum valuation standards consistent with those requirements;

(3) For policies and contracts subject to a principle-based valuation under section 64 of P.L.2014, c.81 (C.17B:19-12):

(a) Requirements for the format of reports to the commissioner under paragraph (3) of subsection b. of section 64 of P.L.2014, c.81 (C.17B:19-12) and which shall include information necessary to determine if the valuation is appropriate and in compliance with sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14);

(b) Assumptions shall be prescribed for risks over which the company does not have significant control or influence.

(c) Procedures for corporate governance and oversight of the actuarial function, and a process for appropriate waiver or modification of such procedures.

(4) For policies not subject to a principle-based valuation under section 64 of P.L.2014, c.81 (C.17B:19-12) the minimum valuation standard shall either:

(a) Be consistent with the minimum standard of valuation prior to the operative date of the valuation manual; or

(b) Develop reserves that quantify the benefits and guarantees, and the funding, associated with the contracts and their risks at a level of conservatism that reflects conditions that include unfavorable events that have a reasonable probability of occurring;

(5) Other requirements, including, but not limited to, those relating to reserve methods, models for measuring risk, generation of economic scenarios, assumptions, margins, use of company experience, risk measurement, disclosure, certifications, reports, actuarial opinions and memorandums, transition rules and internal controls; and

(6) The data and form of the data required under section 65 of P.L.2014, c.81 (C.17B:19-13) with whom the data must be submitted, and may specify other requirements, including data analyses and reporting of analyses.

e. In the absence of a specific valuation requirement or if a specific valuation requirement in the valuation manual is not, in the opinion of the commissioner, in compliance with sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14), then the company shall, with respect to such requirements, comply with minimum valuation standards prescribed by the commissioner by regulation.

f. The commissioner may engage a qualified actuary, at the expense of the company, to perform an actuarial examination of the company and opine on the appropriateness of any reserve assumption or method used by the company, or to review and opine on a company's compliance with any requirement set forth in sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14). The commissioner may rely upon the opinion, regarding provisions contained within sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14), of a qualified actuary engaged by the commissioner of another state, district or territory of the United States.

As used in this subsection f., the term "engage" includes employment and contracting.

g. The commissioner may require a company to change any assumption or method that in the opinion of the commissioner is necessary in order to comply with the requirements of the valuation manual or sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14); and the company shall adjust the reserves as required by the commissioner. The commissioner may suspend or revoke the authority to do business in this State of any company and impose a fine, after notice and a hearing, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) if it fails to comply with any provision of law obligatory upon it under sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14).

§ 17B:19-12 Establishment of reserves using principle-based valuation.

64. a. A company shall establish reserves using a principle-based valuation that meets the following conditions for policies or contracts as specified in the valuation manual:

(1) Quantify the benefits and guarantees, and the funding, associated with the contracts and their risks at a level of conservatism that reflects conditions that include unfavorable events that have a reasonable probability of occurring during the lifetime of the contracts. For policies or contracts with significant tail risk, reflects conditions appropriately adverse to quantify the tail risk.

(2) Incorporate assumptions, risk analysis methods and financial models and management techniques that are consistent with, but not necessarily identical to, those utilized within the company's overall risk assessment process, while recognizing potential differences in financial reporting structures and any prescribed assumptions or methods.

(3) Incorporate assumptions that are derived in one of the following manners:

(a) The assumption is prescribed in the valuation manual.

(b) For assumptions that are not prescribed, the assumptions shall:

(i) Be established utilizing the company's available experience, to the extent it is relevant and statistically credible; or

(ii) To the extent that company data is not available, relevant, or statistically credible, be established utilizing other relevant, statistically credible experience.

(4) Provide margins for uncertainty including adverse deviation and estimation error, such that the greater the uncertainty the larger the margin and resulting reserve.

b. A company using a principle-based valuation for one or more policies or contracts subject to this section as specified in the valuation manual shall:

(1) Establish procedures for corporate governance and oversight of the actuarial valuation function consistent with those described in the valuation manual.

(2) Provide to the commissioner and the board of directors an annual certification of the effectiveness of the internal controls with respect to the principle-based valuation. Such controls shall be designed to assure that all material risks inherent in the liabilities and associated assets subject to such valuation are included in the valuation, and that valuations are made in accordance with the valuation manual. The certification shall be based on the controls in place as of the end of the preceding calendar year.

(3) Develop, and file with the commissioner upon request, a principle-based valuation report that complies with standards prescribed in the valuation manual.

c. A principle-based valuation may include a prescribed formulaic reserve component.

§ 17B:19-13 Submission of certain data.

65. A company shall submit mortality, morbidity, policyholder behavior, or expense experience and other data as prescribed in the valuation manual.

§ 17B:19-14 "Confidential information."

66. a. For purposes of this section "confidential information" means:

(1) A memorandum in support of an opinion submitted under section 2 of P.L.1995, c.339 (C.17B:19-10) and any other documents, materials and other information, including, but not limited to, all working papers, and copies thereof, created, produced or obtained by or disclosed to the commissioner or any other person in connection with such a memorandum;

(2) All documents, materials and other information, including, but not limited to, all working papers, and copies thereof, created, produced or obtained by or disclosed to the commissioner or any other person in the course of an examination made under subsection f. of section 63 of P.L.2014, c.81 (C.17B:19-11); provided, however, that if an examination report or other material prepared in connection with an examination made under N.J.S.17B:21-1 is not held as private and confidential information under N.J.S.17B:21-1, an examination report or other material prepared in connection with an examination made under subsection f. of section 63 of P.L.2014, c.81 (C.17B:19-11) shall not be confidential information to the same extent as if such examination report or other material had been prepared under N.J.S.17B:21-1;

(3) Any reports, documents, materials and other information developed by a company in support of, or in connection with, an annual certification by the company under subsection b. of section 64 of P.L.2014, c.81 (C.17B:19-12) evaluating the effectiveness of the company's internal controls with respect to a principle-based valuation and any other documents, materials and other information, including, but not limited to, all working papers, and copies thereof, created, produced or obtained by or disclosed to the commissioner or any other person in connection with such reports, documents, materials and other information;

(4) Any principle-based valuation report developed under paragraph (3) of subsection b. of section 64 of P.L.2014, c.81 (C.17B:19-12) and any other documents, materials and other information, including, but not limited to, all working papers, and copies thereof, created, produced or obtained by or disclosed to the commissioner or any other person in connection with that report; and

(5) Any documents, materials, data and other information submitted by a company under section 65 of P.L.2014, c.81 (C.17B:19-13), collectively, "experience data," and any other documents, materials, data and other information, including, but not limited to, all working papers, and copies thereof, created or produced in connection with such experience data, in each case that include any potentially company-identifying or personally identifiable information, that is provided to or obtained by the commissioner, together with any "experience data," the "experience materials," and any other documents, materials, data and other information, including, but not limited to, all working papers, and copies thereof, created, produced or obtained by or disclosed to the commissioner or any other person in connection with such experience materials.

b. (1) Except as provided in this section, a company's confidential information is confidential by law and privileged, and shall not be subject to P.L.1963, c.73 (C.47:1A-1 et seq.), shall not be subject to subpoena and shall not be subject to discovery or admissible in evidence in any private civil action; provided, however, that the commissioner is authorized to use the confidential information in the furtherance of any regulatory or legal action brought against the company as a part of the commissioner's official duties.

(2) Neither the commissioner nor any person who received confidential information while acting under the authority of the commissioner shall be permitted or required to testify in any private civil action concerning any confidential information.

(3) In order to assist in the performance of the commissioner's duties, the commissioner may share confidential information: (a) with other state, federal and international regulatory agencies and with the National Association of Insurance Commissioners (NAIC) and its affiliates and subsidiaries; and (b) in the case of confidential information specified in paragraphs (1) and (2) of subsection a. of this section only, with the Actuarial Board for Counseling and Discipline or its successor upon request stating that the confidential information is required for the purpose of professional disciplinary proceedings; and (c) with state, federal and international law enforcement officials; in the case of (a) and (b), provided that such recipient agrees, and has the legal authority to agree, to maintain the confidentiality and privileged status of such documents, materials, data and other information in the same manner and to the same extent as required for the commissioner.

(4) The commissioner may receive documents, materials, data and other information, including otherwise confidential and privileged documents, materials, data or information, from the NAIC and its affiliates and subsidiaries, from regulatory or law enforcement officials of other foreign or domestic jurisdictions and from the Actuarial Board for Counseling and Discipline or its successor and shall maintain as confidential or privileged any document, material, data or other information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the document, material or other information.

(5) The commissioner may enter into agreements governing sharing and use of information consistent with this section.

(6) No waiver of any applicable privilege or claim of confidentiality in the confidential information shall occur as a result of disclosure to the commissioner under this section or as a result of sharing as authorized in paragraph (3) of this subsection b.

(7) A privilege established under the law of any state or jurisdiction that is substantially similar to the privilege established under this subsection shall be available and enforced in any proceeding in, and in any court of, this State.

(8) For purposes of this section "regulatory agency," "law enforcement agency" and the "NAIC" shall include, but shall not be limited to, their employees, agents, consultants and contractors.

c. Notwithstanding subsection b. of this section, any confidential information specified in paragraphs (1) and (4) of subsection a. of this section:

(1) May be subject to subpoena for the purpose of defending an action seeking damages from the appointed actuary submitting the related memorandum in support of an opinion submitted under section 2 of P.L.1995, c.339 (C.17B:19-10) or principle-based valuation report developed under subsection b. of section 64 of P.L.2014, c.81 (C.17B:19-12) by reason of an action required by sections 58, 60, 63, 64, 65 and 66 of P.L.2014, c.81 (C.17B:19-1.1, C.17B:19-2.1, C.17B:19-11, C.17B:19-12, C.17B:19-13 and C.17B:19-14) or by regulations promulgated hereunder;

(2) May otherwise be released by the commissioner with the written consent of the company; and

(3) Once any portion of a memorandum in support of an opinion submitted under section 2 of P.L.1995, c.339 (C.17B:19-10) or a principle-based valuation report developed under subsection b. of section 64 of P.L.2014, c.81 (C.17B:19-12) is cited by the company in its marketing or is publicly volunteered to or before a governmental agency other than a state insurance department or is released by the company to the news media, all portions of such memorandum or report shall no longer be confidential.

Chapter 20

§ 17B:20-1 Investments of domestic insurers.

Any domestic insurer may invest its capital, surplus and other funds, or any part thereof, in:

a. Bonds, notes, or other evidences of indebtedness or public stock issued, created, insured or guaranteed by the United States, any territory or possession thereof, this or any other state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Canada, or any of the provinces thereof, or any instrumentality, agency or political subdivision of one or more of the foregoing.

b. Real estate which may be improved or which is unimproved but acquired in accordance with a definite plan for development within not more than five years, and in the improvement, development, operation or leasing thereof; provided, that if the commissioner shall determine that the interest of such insurer's policyholders requires that any specific real estate so acquired be disposed of, then such insurer shall dispose of such real estate within such reasonable time as the commissioner shall direct; and provided further, that the sum of (1) the aggregate amount invested in such real estate (including real estate held pursuant to N.J.S.17B:18-45 of this title) and (2) the aggregate amount invested in capital stock of any subsidiary of the insurer pursuant to N.J.S.17B:20-4, engaged in a business primarily involving the owning, improving, developing, operating or leasing of real estate, shall not exceed 10% of the total admitted assets of such insurer as of December 31 next preceding. Real estate used primarily for agricultural, horticultural, ranching, mining, forestry or recreational purposes shall be deemed improved within the meaning of this subsection b. The term "real estate" as used in this chapter shall include any real property and any interest therein, including, without limitation, any interest on, above or below the surface of the land, any leasehold estate therein, and any such interest held or to be held by the insurer in cotenancy with one or more other persons and any partnership interest held by the insurer in any general or limited partnership engaged in a business primarily involving the owning, improving, developing, operating or leasing of real estate. Income produced by investment in any such leasehold shall be applied in a manner calculated to amortize the amount invested in such leasehold within a period not exceeding eight-tenths of the unexpired term of the leasehold, inclusive of enforceable options, or within 40 years, whichever is the lesser, or where the peculiar nature of the leasehold involved so dictates, within such period and subject to such other reasonable limitations as the commissioner shall by regulation impose. For the purposes of this subsection b., a mortgage loan shall not be deemed to be an investment in real estate, notwithstanding the mortgagor is an institution in which such insurer has an ownership interest as shareholder, partner, or otherwise. The commissioner may promulgate a regulation in connection with investments under this subsection b. which shall, as far as practicable, be consistent with those regulations of the department which treat with securities supported by such interests in real estate.

c. Mortgage loans on unencumbered real estate, located within the United States, any territory or possession thereof, the Commonwealth of Puerto Rico or Canada. The amount of any such loan shall not exceed 80% of the value of the real estate mortgaged unless (1) the loan is also secured by the mortgagor's interest in a lease or leases whose aggregate rentals shall be sufficient, after payment of operating expenses and fixed charges, to repay 90% of the loan with interest thereon during the initial term or terms of such lease or leases and shall be payable directly or indirectly by any governmental units, instrumentalities, agencies or political subdivisions or an institution or institutions which meet the credit standards of the insurer for an unsecured loan to such institution or institutions or (2) the loan is secured by a purchase money mortgage or like security received by the insurer upon the sale or exchange of real estate acquired pursuant to any provision of this title or (3) the excess over such 80% is insured or guaranteed or to be insured or guaranteed by the United States, any territory or possession thereof, this or any other state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Canada or any of the provinces thereof, or any instrumentality, agency or political subdivision of one or more of the foregoing. Any mortgage loan so insured or guaranteed or to be insured or guaranteed shall not be subject to the provisions of any law of this State prescribing or limiting the interest which may be charged or taken upon any such loan.

Any such insurer may hold a participation in any such mortgage loan if (1) such participation is senior and gives the holder substantially the rights of a first mortgagee or (2) the interest of such insurer in the evidence or evidences of indebtedness is of equal priority, to the extent of such interest, with other interests therein.

Any such mortgage loan which exceeds two-thirds of the value of the real estate mortgaged shall provide for such payments of principal, whatever the period of the loan, that at no time during the period of the loan shall the aggregate payments of principal theretofore required to be made under the terms of the loan be less than would have been necessary to reduce the loan to two-thirds of such value by the end of 35 years through payments of interest only for five years and equal payments applicable first to interest and then to principal at the end of each year thereafter. The commissioner may promulgate such supplemental regulations as he deems necessary with regard to particular classes of such investments, taking into consideration the type of security and the ratio of the loan to the value of the real estate mortgaged. No loan may be made on leasehold real estate unless the terms of such loan provide for payments to be made by the borrower on the principal thereof in amounts sufficient to completely repay the loan within a period not exceeding nine-tenths of the term of the leasehold, inclusive of the term or terms which may be provided by any enforceable option or options of extension or of renewal, which is unexpired at the time the loan is made.

Real estate shall not be deemed to be encumbered within the meaning of this subsection c. by reason of the existence of taxes or assessments that are not delinquent, or encumbrances that do not adversely affect the salability of the property to a material extent or as to which the insurer is insured against loss by title insurance, or any prior mortgage or mortgages held by such insurer if the aggregate of the mortgages held shall not exceed the amount hereinbefore set forth, nor when such real estate is subject to lease in whole or in part; provided, that the security created by the mortgage on such real estate is a first lien thereon. Real estate shall not be deemed to be encumbered and the security of the mortgage thereon shall be deemed a first lien within the meaning of this subsection c., notwithstanding the mortgagor is an institution in which such insurer has an ownership interest as shareholder, partner or otherwise.

No such insurer shall, pursuant to this subsection c., invest more than 2% of its total admitted assets as of December 31 next preceding in any mortgage loan secured by any one property, nor shall its total mortgage investments pursuant to this subsection c., exclusive of any mortgage loans secured by a purchase money mortgage or like security received by the insurer upon the sale or exchange of real estate acquired pursuant to any provision of this title or insured or guaranteed or to be insured or guaranteed as hereinbefore provided, exceed 60% of such admitted assets.

d. Tangible personal property, equipment trust obligations or other instruments evidencing an ownership interest or other interest in tangible personal property where there is a right to receive determined portions of rental, purchase or other fixed obligatory payments for the use or purchase of such personal property, provided, that the aggregate of such payments, together with the estimated salvage value of such property at the end of its minimum useful life and the estimated tax benefits to the insurer resulting from ownership of such property, is adequate to return the cost of the investment in such property, and provided further, that the aggregate net investments therein shall not exceed 10% of the total admitted assets of such insurer as of December 31 next preceding; or certificates of receivers of any institution where such purchase is necessary to protect an investment in the securities of such institution theretofore made under authority of this chapter; or the capital stock, beneficial shares or other instruments evidencing an ownership interest, bonds, securities or evidences of indebtedness issued, assumed or guaranteed by any institution created or existing under the laws of the United States, any territory or possession thereof, this or any other state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Canada or any of the provinces thereof; provided, that no purchase of any evidence of indebtedness which is in default as to interest shall be made by such insurer unless such purchase is necessary to protect an investment theretofore made under statutory authority.

The term "institution" as used in this chapter shall include any corporation, joint stock association, business trust, business joint venture, business partnership, savings and loan association, credit union or other mutual savings institution or limited liability company, limited liability partnership or any other similar entity. No purchase shall be made of the stock of any class of any corporation, except a subsidiary of the insurer pursuant to N.J.S.17B:20-4, unless (1) such corporation has paid cash dividends on such class of stock during each of the past five years preceding the time of purchase or (2) such corporation shall have earned during the period of such five years an aggregate sum available for dividends upon such stock which would have been sufficient, after all fixed charges and obligations, to pay dividends upon all shares of such class of stock outstanding during such period averaging 4% per annum computed upon the par value (or in the case of stock having no par value, upon the stated capital in respect thereof) of such stock. In the case of the stock of a corporation resulting from or formed by merger, consolidation, acquisition or otherwise less than five years prior to such purchase, each consecutive year next preceding the effective date of such merger, consolidation or acquisition during which dividends or other distributions of profits shall have been paid by any one or more of its constituent or predecessor institutions shall be deemed a year during which dividends have been paid on such class of stock and the earnings of such constituent or predecessor institutions available for dividends during each of such years may be included as earnings of the existing corporation whose stock is to be purchased for each of such years; provided, however, that nothing herein contained shall prohibit the purchase of stock of any class which is preferred, as to dividends, over any class the purchase of which is not prohibited by this section; and provided further, that no purchase of its own stock shall be made by any insurer except for the purpose of the retirement of such stock or except as specifically permitted by any law of this State applicable by its terms only to insurers.

e. Securities, properties and other investments in foreign countries, in addition to those specified in N.J.S.17B:20-5, which are substantially of the same character as prescribed for authorized investments for funds of the insurer under the preceding subsections of this section, to an amount valued at cost, not exceeding in the aggregate at any one time 20% of the total admitted assets of such insurer as of December 31 next preceding; provided, however, that the amount invested pursuant to this subsection e. in authorized investments, other than qualified foreign investments, shall not exceed in the aggregate, at any one time, 3% of such admitted assets; and provided further that the amount invested in authorized investments in any one foreign country pursuant to this subsection e. shall not exceed in the aggregate, at any one time, 10% of such admitted assets. For the purposes of this subsection e., Canada shall not be deemed to be a foreign country.

The term "qualified foreign investment" as used in this subsection e. shall include any investment in a foreign country where: (1) the issuer or obligor is (a) a jurisdiction which is rated in one of the two highest rating categories by an independent, nationally recognized United States rating agency, (b) any political subdivision or other governmental unit of any such jurisdiction, or any agency or instrumentality of any such jurisdiction, political subdivision or other governmental unit, or (c) an institution which is organized under the laws of any such jurisdiction, or, in the case of investments which are substantially of the same character as prescribed for investments under subsections b. and c. of this section, the real property is located in any such jurisdiction; and (2) if the investment is denominated in any currency other than United States dollars, the investment is effectively hedged, substantially in its entirety, against the United States dollar pursuant to contracts or agreements which are (a) issued by or traded on a securities exchange or board of trade regulated under the laws of the United States or Canada or a province thereof, (b) entered into with a United States banking institution which has assets in excess of $5,000,000,000 and which has obligations outstanding, or has a parent corporation which has obligations outstanding, which are rated in one of the two highest rating categories by an independent, nationally recognized United States rating agency, or with a broker-dealer registered with the Securities and Exchange Commission which has net capital in excess of $250,000,000, or (c) entered into with any other banking institution which has assets in excess of $5,000,000,000 and which has obligations outstanding, or has a parent corporation which has obligations outstanding, which are rated in one of the two highest rating categories by an independent, nationally recognized United States rating agency and which is organized under the laws of a jurisdiction which is rated in one of the two highest rating categories by an independent, nationally recognized United States rating agency.

Any investment qualified pursuant to paragraph (2) of the preceding definition of "qualified foreign investment" shall remain so qualified only at such time or times that the hedging requirements of paragraph (2) are met.

f. Bonds, notes, or other evidences of indebtedness, issued, insured or guaranteed or to be insured or guaranteed by the International Bank for Reconstruction and Development, or by the International Finance Corporation, or by the Inter-American Development Bank, or by the Asian Development Bank, or by the African Development Bank.

g. Collateral loans secured by a pledge of capital stock, beneficial shares or other instruments evidencing an ownership interest, bonds, securities or evidences of indebtedness qualified or permitted for investment under any of the preceding subsections of this section. The amount of any such loan shall not exceed 80% of the market value of the security pledged at the date of the loan.

h. Loans or investments which are not qualified or permitted under any of the preceding subsections of this section or which are not otherwise expressly authorized by law; provided, that the aggregate amount of such loans and investments, valued at cost, shall not exceed at any one time 10% of the total admitted assets of such insurer as of December 31 next preceding.

For the purposes of subsection c. and this subsection h., the portion of a mortgage loan on unencumbered real estate which does not exceed 80% of the value of the real estate mortgaged shall be deemed to be a permitted investment under subsection c. and the remainder of said loan may be deemed to be made under this subsection h. Any investment originally made under this subsection h. which would subsequently, if it were being made, qualify as a permitted investment under another subsection of this section shall thenceforth be deemed to be a permitted investment under such other subsection.

§ 17B:20-2 Limitation of investments.

The amount (excluding amounts invested in the common stock of any corporation pursuant to N.J.S.17B:20-3 and N.J.S.17B:20-4) invested by a domestic insurer (a) in the common stock of any one corporation shall not exceed 2% of the total admitted assets of such insurer as of December 31 next preceding, or (b) in the common stock of all corporations valued at cost shall not exceed 15% of such assets except that to the extent that such aggregate investment in common stock exceeds 10% of such assets, further investments shall be subject to regulation by the commissioner under a formula which shall take into consideration the actual mandatory securities valuation reserve, as defined by the Subcommittee on Valuation of Securities of the National Association of Insurance Commissioners, held by a company which is applicable to such common stock in the corresponding annual statement filed with the department. The term "common stock" shall mean any voting stock of any class of a corporation which shall not be limited to a fixed sum or percentage of par value in respect to the rights of the holders thereof to participate in dividends or in the distribution of assets upon the voluntary or involuntary liquidation, dissolution or winding up of the corporation. Neither shall the amount invested in the beneficial shares or other ownership interests (other than common stock), evidences of indebtedness (excluding amounts invested in mortgage loans pursuant to subsection c. of N.J.S.17B:20-1), preferred stock and certificates of receivers of any one institution exceed 5% of such assets of the insurer. Nothing herein contained shall prevent any such insurer from purchasing, or in any other way acquiring the voting stock of, or otherwise investing in certain corporations as hereinafter provided in N.J.S.17B:20-3 and N.J.S.17B:20-4.

The total amount of admitted assets invested in the types of investments authorized by subsections b. and c. of N.J.S.17B:20-1 shall not, in the aggregate, exceed 60% of the domestic insurer's total admitted assets.

All investments made by any such insurer shall be authorized or approved by the board of directors, or by a committee designated by the board of directors and charged with the duty of supervising such investment, or shall be made in conformity with standards or investment objectives approved by such board of directors or such committee.

No such insurer shall jointly or severally enter into any agreement to purchase the unsold amount of securities which are the subject of an offering for sale to the public or otherwise to guarantee the sale of such securities.

Nothing contained in this section shall prevent any such insurer from distributing shares of an investment company within the meaning of the Investment Company Act of 1940 for which such insurer or its subsidiary is the investment manager or investment adviser.

The term "Investment Company Act of 1940" as used in this section shall mean an Act of Congress entitled "Investment Company Act of 1940," 54 Stat. 847 (15 U.S.C. s.80a-1 et seq.) as amended from time to time, or any similar statute enacted in substitution therefor.

§ 17B:20-3 Incidental acquisition of corporate stock or securities, construction of chapter

Nothing contained in this chapter shall be construed to prohibit an insurer from accepting or acquiring corporate stock or evidences of indebtedness or other securities or property:

a. pursuant to a plan of reorganization approved or made effective by order of a court having jurisdiction over the property of a debtor,

b. pursuant to a voluntary plan or agreement of reorganization,

c. as payment on account of an existing indebtedness,

d. as realization of collateral for a loan in default,

e. received in connection with an investment by the insurer otherwise allowable as an investment by this chapter, or

f. through the exercise of rights of conversion, warrants or rights to purchase stock, or pre-emptive rights to subscribe to stock, contained in or attached to a previously existing investment of such insurer.

If any such stock, securities or property so received shall be of a kind or in an amount not otherwise allowable as an investment by this chapter, they shall be disposed of within 5 years from the time of their acquisition, unless the commissioner shall, for good cause shown, allow further time for the disposal thereof and then within the time so allowed.

§ 17B:20-4 Stock of subsidiary or alien corporations

In addition to the authority expressly contained in this chapter and notwithstanding any limitation contained in this title, any domestic insurer may invest in the voting stock of one or more subsidiaries, as provided in this section.

a. As used in this section the following terms shall have the following meanings: (1) "voting stock" as used with reference to any corporation means any shares of capital stock of such corporation having general voting power under ordinary circumstances, when voting (together with one or more other classes, if any) as a class, to elect a majority of the board of directors of such corporation irrespective of whether or not at the time stock of any other class or classes shall have, or might have, voting power by reason of the happening of any contingency, and shall also include voting trust certificates, certificates of deposit, interim receipts and other similar instruments representing such stock and (2) "subsidiary" means a corporation of which a majority of the voting stock is owned or controlled by a domestic insurer, or by one or more subsidiaries of such insurer or by such insurer and one or more subsidiaries of such insurer, except that "subsidiary" shall not include a corporation of which a majority of the voting stock is acquired by the insurer or its subsidiaries pursuant to any other section of this chapter.

b. The business of a subsidiary, whether or not it is organized under the laws of this State, shall be limited to that authorized for a corporation organized under any law of this State, except that "subsidiary" shall not include any bank organized pursuant to the laws of this State and shall not include any national bank maintaining its principal office in this State.

c. (Deleted by amendment, P.L.1989, c.267.)

d. The investments of any such subsidiary engaged exclusively in the ownership and management of assets authorized as investments for the insurer when added, on a basis proportional to the insurer's interest in such subsidiary, to the investments of such insurer (referred to herein as the "controlling insurer") shall not cause the investments of the controlling insurer to exceed any of the limitations applicable to domestic insurers contained in N.J.S.17B:20-1 or N.J.S.17B:20-2 of this chapter except as may be permitted by subsection h. of N.J.S.17B:20-1 or N.J.S.17B:20-3.

e. The investment in such subsidiary shall not tend substantially to lessen competition or tend to create a monopoly.

f. Such subsidiary shall not be used directly or indirectly to promote the private interests of any officer or director of such insurer, except that compensation may be paid by any subsidiary to officers and directors of such insurer for services rendered when such compensation is authorized by the board of directors of such subsidiary and approved by the board of directors of such insurer.

g. The aggregate amount invested by the controlling insurer in the voting stock of all subsidiaries pursuant to this section together with the aggregate amount of all other investments of the controlling insurer in such subsidiaries, valued at cost (less any amount invested by the controlling insurer and such subsidiaries in any subsidiary which is (1) engaged primarily in the life insurance business or (2) engaged exclusively in the ownership and management of assets authorized as investments for the controlling insurer) shall not exceed 8% of the total admitted assets of such insurer as of December 31 next preceding.

h. Within 30 days, or such longer period as may be permitted by the commissioner, after an investment in voting stock of any subsidiary has been made by the controlling insurer or any subsidiary thereof pursuant to this section, the controlling insurer shall file notice of such investment with the commissioner; provided, that after an investment in voting stock has been made pursuant to this section, no notice of further investments in the voting stock or other securities of the same subsidiary shall be required. The commissioner shall have the power to conduct periodic examinations and require reports in connection with the operation of subsidiaries and, if he shall determine either that the interests of policyholders or the public so require or that the investments of any subsidiary do not comply with the requirements of this section, to order that a domestic insurer or any subsidiary thereof dispose of its investment in any subsidiary or that any subsidiary dispose of any noncomplying investments, in each case within a reasonable period of time.

i. Each domestic insurer that has made investments in one or more subsidiaries shall annually, on or before May 1, file a subsidiary information report with the commissioner. The report shall set forth the name of each subsidiary in which such insurer has made an investment, the aggregate amount invested by the controlling insurer in each such subsidiary, valued at cost, and such other information with respect to each such subsidiary as the commissioner may prescribe.

j. The aggregate amount invested by the controlling insurer pursuant to this section in the voting stock of all subsidiaries engaged primarily in the life insurance business, together with the aggregate amount of all other investments of the controlling insurer in such subsidiaries, valued at cost, shall not exceed 5% of the total admitted assets of such insurer as of December 31 next preceding.

§ 17B:20-5 Securities of foreign country or property therein

Any domestic insurer lawfully doing business, directly or through any subsidiary, in any foreign country other than Canada, may also invest its funds, or permit such subsidiary to invest its funds, to an amount not exceeding 150% of the reserves and other obligations under outstanding policies of insurance issued or delivered in such foreign country by the insurer or such subsidiary, in securities properties and other investments in such foreign country substantially of the same character as that prescribed for authorized investments for the funds of the insurer under the laws of this State.

§ 17B:20-6 Reasonable and temporary additional restrictions

Notwithstanding any of the provisions of this chapter, if it shall appear to the commissioner that by reason of investment conditions generally or the financial condition or investment portfolio content of any particular insurer or insurers (giving due regard to policyholders' protection afforded by its capital, surplus and reserves), the safety of the public or policyholders so warrants, he may, upon written notice, impose reasonable and temporary additional restrictions upon the type, class or permissible extent of investments which may be made by any domestic insurer or insurers subject to this chapter. Any insurer or insurers affected shall be entitled, upon application, to a departmental hearing for the purpose of determining whether such restriction should be modified or withdrawn.

§ 17B:20-7 Securities of domestic insurers

All securities of domestic insurers shall be held for safekeeping within the geographical limits of this State, except:

a. Securities deposited with public officials of other states, the District of Columbia, the United States Government, any territory or possession thereof, the Commonwealth of Puerto Rico, and foreign countries, to the extent required by the laws of the jurisdiction as a condition for authority to transact business;

b. Securities required as collateral for loans or as security for the performance of contracts;

c. Mortgages and evidences of indebtedness secured thereby, which are held for safekeeping in one or more offices operated by and under the direct control of an officer of the company;

d. Stock and other securities representing stock or convertible into stock, and options, warrants or rights to acquire stock;

e. Debt securities with a maturity of less than one year;

f. Securities issued or guaranteed by the United States or any department or agency or instrumentality thereof; and

g. As long as there are held for safekeeping within the geographical limits of this State securities having a value of not less than $50,000,000.00, any other debt securities which are publicly traded.

This section shall not limit or prohibit: (1) the deposit of securities under transactions as provided in N.J.S.17B:20-3, or (2) the transmission of securities outside the State for the purpose of securing or recording title to the securities or to property, or for the purpose of the sale, exchange or alteration of the provisions of the securities, or for the collection of any payment due thereon, or (3) the holding of securities in the names of nominees authorized by the board of directors of such insurer, or by a committee of the board which is charged with the duty of supervising investments, or (4) the lending of securities to any institution upon adequate collateral security, or (5) the holding outside of the State, in The Depository Trust Company or any other depository institution approved by the Commissioner of Insurance, of securities which comprise all or part of a custodial account for which the fiduciary is a qualified bank pursuant to section 28 of P.L.1948, c.67 (C.17:9A-28) or is an association authorized to exercise fiduciary powers pursuant to subsection (19) of section 48 of P.L.1963, c.144 (C.17:12B-48).

§ 17B:20-8 Valuation of securities; violations; penalties

Except as otherwise required by the commissioner, securities held by insurers authorized to do business in this State shall be valued in accordance with the published valuation standards of the Securities Valuation Office of the National Association of Insurance Commissioners. Every insurer licensed to transact business in this State shall comply with the filing and valuation requirements of the Securities Valuation Office of the National Association of Insurance Commissioners or requirements established by the commissioner, as applicable, with respect to the valuation of securities. Any insurer that fails to comply with the provisions of this section shall be subject to a penalty of not less than $1,000 nor more than $5,000 for a first violation, and not less than $2,000 nor more than $10,000 for each subsequent violation.

Chapter 21

§ 17B:21-1 Annual statement; forms

a. Every insurer transacting business in this State shall annually, on or before March 1, file with the commissioner a statement subscribed and sworn to by its president or the chairman of the board if he is the chief executive officer and secretary, or, in their absence, by two of its officers and by a qualified actuary, showing the financial condition at the close of business on December 31 of the year last preceding, and its business for that year in the format adopted by the National Association of Insurance Commissioners and in use at the time the statement is due. The annual statement shall be prepared in accordance with the annual statement instructions and the Accounting Practices and Procedures Manual adopted by the National Association of Insurance Commissioners, and all applicable provisions of law. Additionally, every insurer shall file quarterly statements in the format adopted by the National Association of Insurance Commissioners covering the periods ending on March 31, June 30 and September 30, which shall be filed within 45 days after each such date. Quarterly statements shall be confidential and shall not be subject to public inspection or copying pursuant to P.L.1963, c.73 (C.47:1A-1 et seq.). All statements shall be submitted in the form and contain any additional matters the commissioner prescribes.

b. The commissioner may also address any inquiries to the insurer or its officers in relation to its condition or affairs, or any matter connected with its transactions, and the officers of the insurer shall promptly reply in writing to all such inquiries. The commissioner may, for good cause, extend the time within which the statement or any part thereof may be filed. The annual and quarterly statements of an alien insurer shall embrace only its business and condition in the United States, and shall be subscribed and sworn to by its resident manager or principal representative in charge of its United States business.

c. If an insurer domiciled in this State makes a request in writing no more than 60 days prior to December 1, the commissioner shall annually, in the month of December, furnish to such insurer one or more blanks in the form of the statement adopted by the National Association of Insurance Commissioners and in use at the time furnished.

d. Insurers issuing both participating and nonparticipating policies shall make such separate statement of profits and losses, margins and expenses, with reference to each of such kinds of business, and showing the manner in which any general outlays of the insurer have been apportioned to each of such kinds of business, as may be required by the commissioner.

e. The commissioner shall have power to make from time to time such modifications and additions in such form and the matters contained therein as he may deem desirable or necessary to ascertain the condition and affairs of the insurer.

§ 17B:21-2 Penalty for not filing annual statement; penalty for other violations

Any insurer neglecting to make and file its annual statement in the form and within the time provided by section 17B:21-1 of this Code shall forfeit $100.00 for each day's neglect, and, in addition thereto, pursuant to the provisions of the Administrative Procedure Act (P.L.1968, c. 410) and any rules adopted thereunder, the commissioner may revoke or suspend its authority to do business in this State.

The penalty for each violation of this chapter, other than the failure of a company to file an annual statement, shall be a penalty not exceeding $1,000.00 for the first offense and not exceeding $2,000.00 for each succeeding offense.

Said penalties shall be enforced and collected by the commissioner in the name of the State in a summary proceeding in accordance with the Penalty Enforcement Law (N.J.S. 2A:58-1 et seq.). A warrant may issue in lieu of a summons.

§ 17B:21-7 Fees

a. On filing any certificate, executed by an insurer of this State, in the department, there shall be paid to the commissioner, for the use of the State, fees as follows:

(1) Certificate of incorporation, for each thousand dollars ($1,000.00) of the total amount of the capital stock authorized, but in no case less than twenty-five dollars ($25.00), twenty cents ($0.20).

(2) Increase of capital stock, for each thousand dollars ($1,000.00) of the total increase authorized, but in no case less than twenty dollars ($20.00), twenty cents ($0.20).

(3) Consolidation and merger of insurers, $20.00.

(4) Extension of corporate existence, the same as required by this section for the original certificate of incorporation.

(5) Dissolution of insurer, change of name, change of nature of business, or for amended certificates of incorporation (other than those authorizing increase of capital stock), decrease of capital stock, increase or decrease of par value of shares, $20.00.

(6) In all cases where several amendments are contained in one certificate, for each amendment, $20.00.

(7) All certificates not hereby provided for, $5.00.

b. The commissioner shall also charge and collect for his services under this subtitle, in addition to any other fees and charges due and payable into the State treasury for any of his official acts or services, and pay into the State treasury the following fees:

(1) Filing the certified copy of the charter, deed of settlement or certificate of organization of an insurer of another State or foreign country, $20.00.

(2) Filing the statement of any such insurer on admission, $20.00.

(3) Filing each annual statement of each insurer, $20.00.

(4) Each certificate of authority to an agent of an insurer, $5.00.

(5) Computing the value of policies of insurers, $0.30 per $1,000.00 of value so computed for the first $1,000,000.00 of the value, $0.10 per thousand for the next $9,000,000.00, $0.05 per thousand for the next $240,000,000.00, $0.02 per thousand for the next $250,000,000.00 and $0.01 per thousand for that part of the value so computed in excess of $500,000,000.00, except that, until the time the fee so computed exceeds the fee paid for the 1930 valuation, the latter amount shall be paid instead.

(6) Each certificate of valuation of the policies, $1.00.

(7) Each certificate of the condition or qualification of an insurer, $1.00.

(8) Each service of lawful process upon the commissioner as attorney, $10.00.

(9) Each copy of any paper filed in the department, for each sheet or folio of 100 words, $0.20.

(10) Certifying the same, $1.00.

(11) For services in connection with deposits of securities by domestic insurers, the depositing insurer shall pay to the commissioner an annual fee of $15.00 on January 1 of each year and on each substitution of securities and clipping and forwarding of interest coupon an additional fee of $25.00.

Chapter 23

§ 17B:23-1 Translation of business by foreign and alien insurers

Any foreign insurer which by its charter or by the laws of the state in which it was incorporated, or any alien insurer which under the laws of the country or other jurisdiction in which it is organized, is authorized to write life insurance, annuities or health insurance or a combination thereof, may, if it meets the financial requirements of a similar domestic insurer set forth in sections 2 through 4 of P.L.1993, c.235 (C.17B:18-68 through C.17B:18-70), be admitted or continue to transact such authorized business in this State; provided that if an insurer is otherwise qualified therefor, the commissioner shall continue to so authorize any insurer which immediately prior to the effective date of this Code was lawfully authorized to write in this state a kind or kinds of insurance in addition to life insurance, annuities and health insurance.

§ 17B:23-2 Prerequisites to admission

No foreign or alien insurer shall be admitted until it:

a. Files with the commissioner a certified copy of its charter or certificate of authority, and a statement of its financial condition and business, in the form and detail the commissioner requires, signed and sworn to by its president and secretary or other proper officer;

b. Satisfies the commissioner that it is fully and legally organized under the laws of its State or country to do the business it proposes to transact; that its condition or methods of operation are not such as would render its operation hazardous to the public or its policyholders in this State; and that it meets the financial requirements specified in section 17B:23-1;

c. Constitutes, by a duly executed instrument filed in the department, the commissioner and his successor in office its true and lawful attorney, upon whom all original process in any action or legal proceeding against it may be served, and therein agrees that any original process against it which may be served upon the commissioner shall be of the same force and validity as if served on the company, and that the authority thereof shall continue in force irrevocable so long as any liability of the company remains outstanding in this State. The insurer shall file a designation of the person to whom process against it served upon the commissioner is to be forwarded. The insurer may change such designation by a new filing;

d. Obtains from the commissioner a certificate that it has complied with all the requirements of this code applicable to it and is authorized to transact business in this State. This certificate shall expire on May 1 of the following year, and shall be renewed each year before May 1; provided, that the commissioner may refuse to issue or renew any such certificate of authority if, in his judgment, such refusal will best protect the interests of the people of this State or if the company fails to comply substantially with any requirement or limitation of this code applicable to it or any rule or regulation promulgated by the commissioner thereunder which in the judgment of the commissioner is reasonably necessary to protect the interests of the people of this State, but the commissioner may not refuse to renew any such certificate except after notice and hearing pursuant to the Administrative Procedure Act (P.L.1968, c. 410) and any rules adopted thereunder and provided, that all such certificates outstanding and in force at the date of the passage of this code shall continue in full force and effect until May 1 next following the approval of this code, unless sooner revoked by the commissioner; and provided, further, that no such certificate shall be issued by the commissioner if, in the judgment of the commissioner, the name of such company shall so closely resemble the name of any existing company authorized to transact business in this State as to be likely to mislead the public.

§ 17B:23-3 Deposit by alien insurers

No alien insurer shall be admitted until, in addition to complying with the foregoing conditions, it has made a deposit or deposits with the insurance commissioner or other officer of a State or States of the United States, designated by the laws of such State or States to hold the same, of a total amount not less than $200,000.00, nor less than the capital required of a stock company of this State transacting the same kinds of business. The deposit or deposits must be in exclusive trust for the benefit and security of all the policyholders of the company in the United States, and shall be deemed for all purposes of this code the capital of the company making it.

§ 17B:23-4 Revocation of authority to do business

The authority of a foreign or alien insurer may be revoked, after notice and hearing, pursuant to the Administrative Procedure Act (P.L.1968, c. 410) and any rules adopted thereunder if it fails to comply with any provision of law obligatory upon it, or for any reason for which the commissioner may refuse to issue or renew its certificate of authority under section 17B:23-2 of this chapter, or when in the opinion of the commissioner its condition is unsound.

§ 17B:23-5 Retaliatory provision.

a. When by or pursuant to the laws of any other state or a province of Canada any taxes, licenses and other fees, in the aggregate, and any fines, penalties, deposit requirements or other obligations, prohibitions or restrictions are or would be imposed upon New Jersey insurers, or upon the agents or representatives of such insurers, which are in excess of such taxes, licenses and other fees, in the aggregate, or which are in excess of the fines, penalties, deposit requirements or other obligations, prohibitions, or restrictions directly imposed upon similar insurers, or upon the agents or representatives of such insurers of such other state or province under the statutes of this State, so long as such laws of such other state or province continue in force or are so applied, the same taxes, licenses and other fees, in the aggregate, or fines, penalties or deposit requirements or other obligations, prohibitions, or restrictions of whatever kind shall be imposed by the commissioner upon the insurers or upon the agents or representatives of such insurers, of such other state or province doing business in New Jersey. Any tax, license or other fee or other obligation imposed by any city, county, or other political subdivision or agency of such other state or province on New Jersey insurers or their agents or representatives shall be deemed to be imposed by such state or province within the meaning of this section and the commissioner may compute the burden of any such taxes on an aggregate basis as an addition to the rate of tax payable by similar New Jersey insurers in such state or province. The addition to the rate of tax payable by similar New Jersey insurers shall be determined by dividing (1) the aggregate of the tax obligations paid to such city, county or other political subdivisions of such state or province by such New Jersey insurers, by (2) the aggregate of the taxable premiums of such insurers under the premium taxing statute of such state or province. The commissioner may issue regulations to carry out the purpose of this section that may include identification of any specific obligation imposed by any other state or province, in order to ensure the ability of this State to calculate and collect all appropriate fees.

b. This section shall not apply to personal income taxes, nor as to ad valorem taxes on real or personal property nor as to special purpose obligations or assessments imposed in connection with particular kinds of insurance; except that deductions, from premium taxes otherwise payable, allowed on account of real estate or personal property taxes shall be taken into consideration by the commissioner in determining the propriety and extent of retaliatory action under this section.

c. For the purposes of this section the domicile of an alien insurer, other than insurers formed under the laws of Canada or a province thereof, shall be that state designated by the insurer in writing filed with the commissioner at time of admission to this State or within 6 months after the effective date of this code, whichever date is the later, and may be any one of the following states:

(1) That in which the insurer was first authorized to transact insurance;

(2) That in which is located the insurer's principal place of business in the United States;

(3) That in which is held the larger deposit of trusteed assets of the insurer for the protection of its policyholders and creditors in the United States;

If the insurer makes no such designation its domicile shall be deemed to be that state in which is located its principal place of business in the United States. In the case of an insurer formed under the laws of Canada or a province thereof, its domicile shall be deemed to be that province in which its head office is situated.

§ 17B:23-6 Purpose

Sections 17B:23-6 through 17B:23-11 are deemed and declared to be remedial legislation for the protection of the health and welfare of persons resident in this State by subjecting nonadmitted insurers which solicit, insure, or cause to be solicited such resident persons to the laws which govern all foreign insurers which do business in the State of New Jersey. These provisions shall be literally construed to effectuate its purpose and intent.

§ 17B:23-7 Definitions

Whenever used or referred to in sections 17B:23-6 to 17B:23-11 the term "commissioner" shall mean the Commissioner of Insurance.

§ 17B:23-8 Conditions precedent to doing business in State

No insurer organized or existing under the law of another State, or of a foreign country, or any employee, agent or other representative thereof including, without limitation, promotional media, shall by mail or otherwise, transact in any manner, directly or indirectly, the business of insurance within this State unless and until:

a. Admitted to transact the business of insurance pursuant to the provisions of this chapter; or

b. Specifically permitted by any other law of this State to transact the business of insurance within this State.

§ 17B:23-9 Actions deemed doing business in the State

Without limiting the generality of the foregoing, an insurer which performs, causes or suffers to be performed within this State any of the following acts with reference to persons located or resident in the State of New Jersey, by mail or otherwise, directly or indirectly, shall be deemed to be transacting the business of insurance within this State:

a. The solicitation of or advertising for any contract of insurance of any kind, including annuities involving life contingencies;

b. The negotiation or effectuation of any contract of insurance of any kind, including annuities involving life contingencies;

c. The signature, delivery or transmittal of any contract of insurance of any kind, including annuities involving life contingencies, or any application therefor;

d. The transmittal or receipt of any premium, commission, fee or other payment for any contract of insurance of any kind including annuities involving life contingencies;

e. The maintenance or operation of any office for the transaction of the business of insurance;

f. The offering for sale, sale, promotion of, or issuance of any contract of insurance of any kind, including annuities involving life contingencies; or

g. Any other acts normally incident to the transaction of the business of insurance.

§ 17B:23-10 Enforcement

Whenever it shall appear to the commissioner that any insurer, or any employee, agent, promotional medium, or other representative thereof, has violated, is violating, or is about to violate the provisions of this act, the Attorney General, upon the request of the commissioner, shall institute a civil action in the Superior Court for injunctive relief and for such other relief as may be appropriate under the circumstances. Process in such action may be served in accordance with the provisions of chapter 33 of this Title or as provided in the laws of this State and the rules of the Superior Court. Such action may proceed in a summary manner or otherwise. Nothing contained in this section shall limit or abridge the right to serve any process, notice or demand upon any person or insurer in any other manner now or hereafter deemed lawful.

§ 17B:23-11 Excluded actions

The provisions of this act shall not be construed to apply to:

a. The investigation, settlement or litigation of claims under any policy of insurance of any kind lawful when written in this State, or the liquidation of the assets and liabilities of an insurer (other than the collection of new premiums) resulting from the operations of an insurer within this State which were lawful when conducted;

b. Transactions involving any policy of insurance of any kind, which occur subsequent to the issuance thereof, provided, however, such policy of insurance does not cover a subject of insurance resident in this State, or located in this State, or expressly requiring the performance in this State at the time of issuance; and provided further, that such policy was lawfully solicited, written and delivered outside this State, at the time of issue;

c. The continuation and servicing of life insurance or accident or health insurance policies or annuity contracts remaining in force as to residents of this State when the insurer has withdrawn from this State and is not collecting new premiums within or from this State;

d. The lawful transaction of contracts of reinsurance by insurers;

e. Transactions involving group life insurance, group or blanket accident and health insurance, and group annuities where the master policy for such groups was lawfully issued and delivered in a State in which the insurer is duly admitted, and such policy conforms to the laws of the State in which it is delivered.

f. Any life insurance company organized and operated without profit to any private shareholder or individual and exclusively for the purpose of aiding educational or scientific institutions organized and operated without profit to any private shareholder or individual, which issues to residents of this State directly from its home office without agents, representatives or other field operations in this State, contracts of insurance and annuity contracts only to or for the benefit of such institutions and to individuals engaged in the service of such institutions; nor shall this subsection apply to any life, accident and health or annuity contracts issued by such life insurance company, provided that any such life insurance company shall: (1) furnish to the commissioner a copy of any policy or contract form issued to residents of this State; (2) furnish to the commissioner a copy of its annual statement prepared pursuant to the laws of the State of domicile of such life insurance company, as well as such other reports, documents and financial material as may be requested by the commissioner; and (3) designate the commissioner as its true and lawful attorney upon whom may be served all lawful process in any action or proceeding against such life insurance company arising under any contract of insurance or annuity contract it has issued to, or which is held by, a resident of this State, and process so served against such life insurance company shall have the same force and validity as if served upon said life insurance company; and provided further that the commissioner may, if in his judgment the interest of the public so requires, promulgate regulations affecting the contracts, investments, or other aspects of the operations of companies covered by this subparagraph f., which shall be not more restrictive than the laws and regulations applicable to admitted life insurance companies.

Chapter 24

§ 17B:24-1.1 Insurable interests

1. a. For the purpose of life insurance, health insurance or annuities:

(1) An individual has an insurable interest in his own life, health and bodily safety.

(2) An individual has an insurable interest in the life, health and bodily safety of another individual if he has an expectation of pecuniary advantage through the continued life, health and bodily safety of that individual and consequent loss by reason of his death or disability.

(3) An individual has an insurable interest in the life, health and bodily safety of another individual to whom he is closely related by blood or by law and in whom he has a substantial interest engendered by love and affection. An individual liable for the support of a child or former wife or husband may procure a policy of insurance on that child or former wife or husband.

(4) A corporation has an insurable interest: (a) in the life or physical or mental ability of any of its directors, officers, or employees, or the directors, officers, or employees of any of its subsidiaries or any other person whose death or physical or mental disability might cause financial loss to the corporation; (b) pursuant to any contractual arrangement with any shareholder concerning the reacquisition of shares owned by him at the time of his death or disability, in the life or physical or mental ability of that shareholder for the purpose of carrying out that contractual arrangement; (c) pursuant to any contract obligating the corporation as part of compensation arrangements, in the life of the individual for whom compensation is to be provided; or (d) pursuant to a contract obligating the corporation as guarantor or surety, in the life of the principal obligor. The trustee of a trust established and fully funded by a corporation providing solely life, health, disability, retirement, or similar benefits to employees of the corporation or its affiliates and acting in a fiduciary capacity with respect to those employees, retired employees, or their dependents or beneficiaries, has an insurable interest in the lives of employees for whom such benefits are to be provided.

(5) A nonprofit or charitable entity qualified pursuant to section 501 (c) (3) of the Internal Revenue Code of 1986 (26 U.S.C. s.501(c)(3)), or a government entity has an insurable interest in the life or physical or mental ability of its directors, officers, employees, supporters or their designees or others to whom it may look for counsel, guidance, fundraising or assistance in the execution of its legally established purpose, who either: (a) join with the entity in signing the application for insurance, which application names the entity as the owner and irrevocable beneficiary of the policy; or (b) after having been listed as owner, subsequently transfer ownership of the insurance to the entity and name the entity as the irrevocable beneficiary of the policy. The trustee of a trust established and fully funded by a nonprofit or charitable entity qualified pursuant to section 501 (c) (3) of the Internal Revenue Code of 1986 (26 U.S.C. s.501(c)(3)), or a government entity providing solely life, health, disability, retirement, or similar benefits to employees of the entity or its affiliates and acting in a fiduciary capacity with respect to those employees, retired employees, or their dependents or beneficiaries, has an insurable interest in the lives of employees for whom such benefits are to be provided.

b. No person shall procure or cause to be procured any insurance contract upon the life, health or bodily safety of another individual unless the benefits under that contract are payable to the individual insured or his personal representative, or to a person having, at the time when that contract was made, an insurable interest in the individual insured.

c. If the beneficiary, assignee, or other payee under any contract made in violation of this section receives from the insurer any benefits thereunder accruing upon the death, disablement, or injury of the individual insured, the individual insured, or his executor or administrator, as the case may be, may maintain an action to recover those benefits from the person so receiving them.

d. An insurer shall be entitled to rely upon all statements, declarations and representations made by an applicant for insurance relating to the insurable interest of the applicant in the insured and no insurer shall incur legal liability, except as set forth in the policy, by virtue of any untrue statements, declarations or representations so relied upon in good faith by the insurer.

e. This section shall not apply to group life insurance, group health insurance, blanket insurance or group annuities.

§ 17B:24-2 Minors

a. Any minor not less than 15 years of age may, notwithstanding such minority, contract for annuities or for insurance, or affirm by novation or otherwise pre-existing contracts for annuities or insurance, upon his own life, body or health, or upon the life, body or health of another person in whom the minor has an insurable interest.

b. Any minor not less than 15 years of age may, notwithstanding such minority, acquire ownership of and exercise every right, privilege and power with respect to or under any contract of annuity or insurance upon the life, body or health of such minor or of another person, whether or not such contract was applied for by such minor.

A minor shall be deemed competent to receive and give full acquittance for any payment made by any insurer under the provisions and options of, or under a settlement agreement arising from, any contract of annuity or insurance in which a minor has acquired any interest, or is a beneficiary as follows:

(1) As to a minor not less than 15 years of age--a payment or payments in aggregate not exceeding $2,000.00 in any 1 calendar year, or,

(2) As to a minor not less than 18 years of age--a payment or payments in aggregate not exceeding $5,000.00 in any 1 calendar year;

provided that prior to any such payment to a minor the insurer has not received at its home office written notice of the appointment of a duly qualified guardian of the property of the minor. A minor shall not be deemed competent to alienate the right to or to anticipate or commute such payment. A minor shall not by reason of his minority, be entitled to rescind, avoid or repudiate such a contract or any exercise of a right, privilege or power, or acquittance given, thereunder; except that a minor not otherwise emancipated shall not be bound by any unperformed agreement to pay, by promissory note or otherwise, any premium on any such annuity or insurance contract.

c. The provisions of this section shall not be deemed as requiring any insurance company making such payment to determine whether any other insurance company may be effecting a similar payment to the same minor.

§ 17B:24-3 Application as evidence

a. No application for any life or health insurance policy or annuity contract shall be admissible in evidence in any action relative to such policy or contract, unless a copy of the application was attached to or endorsed upon the policy or contract when issued.

b. If any life or health insurance policy or annuity contract delivered in this State is reinstated or renewed, and the insured or the beneficiary or assignee of the policy or contract makes written request to the insurer for a copy of the application, if any, for such reinstatement or renewal, the insurer shall, within 30 days after receipt of such request at its home office, deliver or mail to the person making such request a copy of such application reproduced by any legible means. In the case of such a request from a beneficiary or assignee, the time within which the insurer is required to furnish a copy of such application shall not begin to run until after receipt of evidence satisfactory to the insurer of the beneficiary's or assignee's interest in the policy or contract.

c. No alteration on any written application for any such policy or contract shall be made by any person other than the applicant without his written consent, except that insertions may be made by the insurer, for administrative purposes only, in such manner as to indicate clearly that such insertions are not to be ascribed to the applicant.

d. The falsity of any statement in the application for any policy or contract covered by this section may not bar the right to recovery thereunder unless such false statement materially affected either the acceptance of the risk or the hazard assumed by the insurer.

e. This section shall not apply to group life insurance, group health insurance, or blanket insurance policies or to group annuity contracts.

§ 17B:24-4 Assignments

a. Nothing in this Title shall prohibit any person insured under an insurance policy or annuity contract, other than group, from assigning or not assigning, as provided by its terms. Subject to its terms relating to assignability, any life or health insurance policy or annuity contract, other than group, whether heretofore or hereafter issued, under the terms of which the beneficiary may be changed upon the sole request of the insured or owner, if other than the insured, may be assigned either by pledge or transfer of title, by an assignment executed by the insured or such owner alone and delivered to the insurer, whether or not the pledgee or assignee is the insurer. Any such assignment shall entitle the insurer to deal with the assignee as the owner or pledgee of the insurance policy or annuity contract, other than group, in accordance with the terms of the assignment, until the insurer has received at its home office written notice of termination of the assignment or pledge.

b. Nothing in this title shall prohibit any person insured under a group insurance contract, pursuant to an arrangement among the insured, the group policyholder and the insurer, from making to any person an assignment of the rights and benefits conferred on him by any provision of such contract or by law including specifically but not by way of limitation the right to have issued to him an individual policy as set forth in section 17B:27-19 and section 17B:27-20, the right to name a beneficiary and the right to receive any proceeds of the policy payable during the lifetime of the insured. Any such assignment, whether made before or after the effective date of this law, shall entitle the insurer to deal with the assignee as the owner of all rights and benefits conferred on the insured under the policy in accordance with the terms of the assignment.

§ 17B:24-5 Payment discharges insurer

Whenever the proceeds of or payments under a life or health insurance policy or annuity contract heretofore or hereafter issued become payable in accordance with the terms of such policy or contract, or the exercise of any right or privilege thereunder, payment thereof by the insurer in accordance therewith or in accordance with any written assignment thereof shall fully discharge the insurer from all claims under the policy or contract.

§ 17B:24-6 Exemption of proceeds--life insurance

a. If a policy of insurance, whether heretofore or hereafter issued, is affected by any person on his own life, or on another life, in favor of a person other than himself, or, except in cases of transfer with intent to defraud creditors, if a policy of life insurance is assigned or in any way made payable to any such person, then the lawful beneficiary, assignee or payee of such policy, shall be entitled to its proceeds and avails against the creditors and representatives of the insured and of the person effecting the same, whether or not the right to change the beneficiary is reserved or permitted, or the policy is made payable to the person whose life is insured or to the executors or administrators of such person if the beneficiary shall predecease such person.

Except however the foregoing shall not be applicable if the lawful beneficiary, assignee or payee of such policy is any of the following:

(1) The insured,

(2) The person so effecting such insurance, or

(3) The executors or administrators of such insured or the person so effecting such insurance.

b. Such proceeds and avails shall be exempt from any liability for any debt of the beneficiary existing at the time the proceeds and avails become available for his use; provided that, subject to the statute of limitations, the amount of any premiums for such insurance paid with intent to defraud creditors, with interest thereon, shall inure to their benefit from the proceeds of the policy; but the insurer issuing the policy shall be discharged of all liability thereon by payment of its proceeds in accordance with its terms, unless, before such payment, the insurer shall have received written notice at its home office, by or in behalf of a creditor, of a claim to recover for transfer made or premiums paid with intent to defraud creditors setting forth such facts as will enable the insurer to ascertain the particular policy.

c. For the purposes of subsections a. and b. above, a policy shall also be deemed to be payable to a person other than the insured if and to the extent that a facility-of-payment clause or similar clause in the policy permits the insurer to discharge its obligation after the death of the individual insured by paying the death benefits to a person as permitted by such clause.

§ 17B:24-7 Exemption of proceeds--annuity contracts

a. The benefits, rights, privileges, powers and options which under any annuity contract heretofore or hereafter issued are due or prospectively due the annuitant, shall not be subject to execution, garnishment, attachment, sequestration or other legal process nor shall the annuitant be compelled to exercise any such rights, privileges, powers, or options, nor shall creditors be allowed to interfere with or terminate the contract, except:

(1) As to amounts paid, with intent to defraud creditors, for or as consideration for any such annuity, with interest thereon, and of which the creditor has given the insurer written notice at its home office prior to the making of the payments to the annuitant out of which the creditor seeks to recover. Any such notice shall set forth such facts as will enable the insurer to ascertain the particular annuity contract.

(2) The total exemption of benefits presently due and payable to any annuitant periodically or at stated times under all annuity contracts under which he is an annuitant, shall not at any time exceed $500.00 per month for the length of time represented by such installments, and such periodic payments in excess of $500.00 per month shall be subject to garnishee execution to the same extent as are wages and salaries.

(3) If the total benefits presently due and payable to any annuitant under all annuity contracts under which he is an annuitant, shall at any time exceed payment at the rate of $500.00 per month, then the court may order such annuitant to pay to a judgment creditor or apply on the judgment, in installments, such portion of such excess benefits as to the court may appear just and proper, after due regard for the reasonable requirements of the judgment debtor and his family, if dependent upon him as well as any prior court orders.

b. If the contract so provides, the benefits, rights, privileges, powers or options accruing under such contract to a beneficiary or assignee shall not be transferable nor subject to commutation, and if the benefits are payable periodically or at stated times, the same exemptions and exceptions contained herein for the annuitant, shall apply with respect to such beneficiary or assignee.

§ 17B:24-8 Exemption of proceeds--health insurance and disability provisions

Except as may otherwise be expressly provided by the policy or contract, the proceeds or avails of all policies of health insurance and of provisions providing benefits on account of the insured's dismemberment, loss of sight or disability which are supplemental to life insurance policies or annuity contracts, heretofore or hereafter effected, shall be exempt from all liability for any debt of the insured, and from any debt of the beneficiary existing at the time the proceeds are made available for his use. Nothing herein contained shall apply to any income disability benefit in any action to recover for necessaries contracted for after the commencement of the disability covered by the disability clause or contract allowing such income benefit.

§ 17B:24-9 Exemption of proceeds--group insurance

a. A policy of group life insurance or group health insurance or the proceeds thereof payable to the individual insured or to the beneficiary thereunder, shall not be liable, either before or after payment, to be applied by any legal or equitable process to pay any debt or liability of such insured individual or his beneficiary or of any other person having a right under the policy. The proceeds thereof, when not made payable to a named beneficiary or to a third person pursuant to a facility-of-payment clause, shall not constitute a part of the estate of the individual insured for the payment of his debts. Nothing herein contained shall apply to any income disability benefit in any action to recover for necessaries contracted for after the commencement of the disability covered by the disability clause or contract allowing such income benefit.

b. This section shall not apply to group insurance covering the debtors of a creditor, to the extent that such proceeds are applied to payment of the obligation for the purpose of which the insurance was so issued.

§ 17B:24-10 Policy settlements

Any life insurer shall have the power to hold under agreement the proceeds of any policy issued by it, upon such terms and restrictions as to revocation by the policyholder and control by beneficiaries, and with such exemptions from the claims of creditors of beneficiaries other than the policyholder as set forth in the policy or as agreed to in writing by the insurer and the policyholder. Upon maturity of a policy, in the event the policyholder has made no such agreement, the insurer shall have the power to hold the proceeds of the policy under an agreement with the beneficiaries. The insurer shall not be required to segregate the funds so held but may hold them as part of its general assets.

§ 17B:24-11 Participating and nonparticipating policies--right to issue; payment of commissions thereon

A stock or mutual life insurer may issue policies on both the participating and nonparticipating basis, provided that the right or absence of right of participation is reasonably related to the premium charged and that the policy indicates clearly whether it is participating or nonparticipating.

No life insurance company doing business in this State, and issuing policies both on participating and nonparticipating bases, shall pay commissions at a higher rate with respect to participating policies than it pays with respect to comparable nonparticipating policies.

§ 17B:24-12 Separate risks and premiums

When a policy shall insure against more than one hazard or peril, the insurance against any specific hazard or peril shall not be separately cancelable unless the policy shall specify a separate premium for any such insurance so cancelable. No policy of life insurance or annuity contract as the same are defined in 17B:17-3 and 17B:17-5 shall cover any other hazard or peril than insurance against bodily injury or death by accident, and upon the health of persons as the same is defined in section 17B:17-4.

Chapter 25

§ 17B:25-1 "Industrial life insurance" ; definition

For the purpose of this code, "Industrial life insurance" is that form of life insurance, issued by an insurer which, as to such insurance, is operating under a debit plan of premium collection by agents, and under which the premiums are payable monthly or oftener and the words "industrial policy" or words of similar import are printed upon the policy as part of the descriptive matter.

§ 17B:25-2 Standard provisions required

a. No policy of life insurance, other than group insurance and pure endowments with or without return of premiums or of premiums and interest, shall be delivered or issued for delivery in this State unless it contains in substance all of the applicable provisions specified in sections 17B:25-3 to 17B:25-14, inclusive, of this chapter or provisions which in the opinion of the commissioner are not less favorable to the insured or the owner if other than the insured. This section shall not apply to any provision of a life insurance policy, or contract supplemental thereto, relating to disability benefits or to additional benefits in event of death by accident or accidental means or in event of dismemberment or loss of sight.

b. If any such provision is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy (such as a single premium policy, a term policy, or a policy insuring more than one person) the insurer, with the approval of the commissioner, shall omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of a provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

c. In lieu of the provisions required by this section, substantially similar provisions required by the law of the domicile of a foreign or alien insurer may be used with the approval of the commissioner.

d. Where a policy of life insurance provides for both insurance and an annuity, this section shall apply only to that part of the policy which provides for insurance.

§ 17B:25-2.1 Cancellation of policy within 10 days after receipt

No policy of life insurance, other than group insurance, shall be delivered or issued for delivery in this State unless such policy contains in substance a provision or has attached to it a notice stating that during a period of no less than 10 days after the date the policyholder receives the policy, the policyholder may cancel the policy and receive from the insurer a prompt refund of any premium paid therefor, including any policy fees or other charges, by mailing or otherwise surrendering the policy to the insurer together with a written request for cancellation.

§ 17B:25-3 Grace period

There shall be a provision that a grace period of 30 days, or, at the option of the insurer, of 1 month of not less than 30 days, or of 4 weeks in the case of industrial life insurance policies the premiums for which are payable more frequently than monthly, shall be allowed within which the payment of any premium after the first may be made, subject, at the option of the insurer, to an interest charge not in excess of 6% per annum for the number of days of grace elapsing before the payment of the premium, during which period of grace the policy shall continue in full force; but if a claim arises under the policy during such period of grace, the amount of any premium due or overdue, together with such interest, if any, and any deferred premiums of the current policy year may be deducted from any amount payable under the policy in settlement.

§ 17B:25-4 Incontestability

There shall be a provision that the policy (exclusive of provisions of the policy or any contract supplemental thereto relating to disability benefits or to additional benefits in event of death by accident or accidental means or in event of dismemberment or loss of sight) shall be incontestable, except for nonpayment of premiums, after it has been in force during the lifetime of the insured for a period of 2 years from its date of issue.

§ 17B:25-5 Entire contract

There shall be a provision that the policy, or the policy and the application therefor if a copy of such application is attached to or endorsed upon the policy when issued, shall constitute the entire contract between the parties, and that all statements contained in such an application shall, in the absence of fraud, be deemed representations and not warranties.

§ 17B:25-6 Misstatement of age

There shall be a provision that if the age of the insured or of any other person whose age is considered in determining the premium or benefit has been misstated, any amount payable or benefit accruing under the policy shall be such as the premium would have purchased at the correct age or ages.

§ 17B:25-7 Dividends

a. There shall be a provision in participating policies other than industrial life insurance policies that, beginning not later than the end of the third policy year, the insurer shall annually ascertain and apportion the divisible surplus, if any, that will accrue on the policy anniversary or other dividend date specified in the policy provided the policy is in force and all premiums to that date are paid. Except as hereinafter provided, any dividend credited to the policy shall at the option of the party entitled to elect such option be either:

(1) payable in cash, or

(2) applied to any one of such other dividend options as may be provided by the policy.

If any such other dividend options are provided, the policy shall further state which option shall be automatically effective if such party shall not have elected some other option. If the policy specifies a period within which such other dividend option may be elected, such period shall be not less than 30 days following the date on which such dividend is due and payable. The annually apportioned dividend shall be deemed to be payable in cash within the meaning of (1) above even though the policy provides that payment of such dividend is to be deferred for a specified period, provided that such period does not exceed 6 years from the date of apportionment and provided that interest will be added to such dividend at a specified rate. If a participating policy provides that the benefit under any paid-up nonforfeiture provision is to be participating, it may provide that any divisible surplus credited to the policy while the insurance is in force under such nonforfeiture provision shall be applied in the manner set forth in the policy.

b. In participating industrial life insurance policies there shall be a provision that, beginning not later than the end of the fifth policy year, the policy shall participate annually in the divisible surplus, if any, in the manner set forth in the policy.

§ 17B:25-8 Policy loan

There shall be a provision that after 3 full years' premiums have been paid and after the policy has a cash surrender value and while no premium is in default beyond the grace period for payment, the insurer will advance, on proper assignment or pledge of the policy and on the sole security thereof, at a specified rate of interest, an amount equal to or, at the option of the party entitled thereto, less than the loan value of the policy. The loan value of the policy shall be at least equal to the cash surrender value at the end of the then current policy year, provided that the insurer may deduct, either from such loan value or from the proceeds of the loan, any existing indebtedness not already deducted in determining such cash surrender value including any interest then accrued but not due, any unpaid balance of the premium for the current policy year, and interest on the loan to the end of the current policy year. The policy may also provide that if interest on any indebtedness is not paid when due it shall then be added to the existing indebtedness and shall bear interest at the same rate, and that if and when the total indebtedness on the policy, including interest due or accrued, equals or exceeds the amount of the loan value thereof, then the policy shall terminate and become void but not until at least 30 days' notice shall have been mailed by the insurer to the last known address of the insured or other policy owner and of any assignee of record at the home office of the insurer. The policy shall reserve to the insurer the right to defer the granting of a loan, other than for the payment of any premium to the insurer, for 6 months after application therefor. The policy may, at the insurer's option, contain automatic premium loan provisions and may provide that such provisions do not become operative unless so elected by the person entitled to do so. This section shall not apply to term insurance, or to industrial life insurance policies.

§ 17B:25-9 Reinstatement

There shall be a provision that unless:

a. the policy has been surrendered for its cash surrender value, or

b. its cash surrender value has been exhausted, or

c. the paid-up term insurance, if any, has expired,

the policy will be reinstated at any time within 3 years (or 2 years in the case of industrial life insurance policies) from the due date of the first premium in default upon written application therefor, the production of evidence of insurability satisfactory to the insurer, the payment of all premiums in arrears and the payment or reinstatement of any indebtedness to the insurer upon the policy, all with interest at a specified rate and which may be compounded as specified.

§ 17B:25-10 Payment of premiums

There shall be a provision relative to the payment of premiums.

§ 17B:25-10.1 Notice mailed to holders of life insurance policy

An insurer shall give written notice by regular mail to the holder of a life insurance policy when, to prevent lapse of the policy, a premium is paid automatically by charging it against the policy's loan value which is derived from the cash value of the policy. The notice shall show the amount of the loan and the loan interest rate. The notice shall be mailed no later than 30 days after the end of the grace period of the premium paid by loan.

§ 17B:25-11 Payment of claims

a. There shall be a provision that when benefits under the policy shall become payable by reason of the death of the insured, settlement shall be made within 60 days after receipt of due proof of death and, at the insurer's option, surrender of the policy or proof of the interest of the claimant or both.

b. If a claim or a portion of a claim for benefits under a policy requires additional investigation or is denied by the insurer, the claimant shall be notified in writing no later than the 45th calendar day following receipt by the insurer of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer under the terms of the policy, that the claim, or a portion thereof, is subject to additional investigation or denied, and the reason the claim is being investigated or denied. Notwithstanding the provisions of this subsection b. to the contrary, the notice to the claimant for any claim which the insurer concludes, based upon its investigation and which conclusion is reasonably based upon the contents of the insurer's claim file, constitutes probable cause for fraud shall not be required to contain the specific reasons for the investigation. A conclusion of fraud that is not reasonably based upon the contents of the insurer's claim file, notwithstanding that the violation did not occur with such frequency as to indicate a general business practice, shall be a violation of section 1 of P.L. 1975, c. 101 (C. 17B:30-13.1). Any uncontested portion of a claim shall be paid no later than the 60th calendar day following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer under the terms of the policy.

c. The insurer, upon receipt of any document or information requested relating to a claim or portion of a claim under investigation, shall pay the benefits for which the claim is made or deny the claim no later than the 90th calendar day following the receipt of the document or information.

d. Payment of a claim or a portion thereof that is not under investigation by the insurer shall be overdue if not remitted to the claimant by the insurer on or before the 60th calendar day following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer pursuant to the policy. Payment of a claim or a portion of a claim under investigation or denied that becomes eligible for payment shall be overdue if not remitted to the claimant by the insurer on or before the 90th calendar day following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer. Overdue payments shall bear an annual rate of interest equal to the average rate of return of the State of New Jersey Cash Management Fund, established pursuant to section 1 of P.L.1977, c.281 (C.52:18A-90.4), for the preceding fiscal year, rounded to the nearest one-half percent.

§ 17B:25-12 Beneficiary; industrial policies

An industrial life insurance policy shall have the name of the beneficiary designated thereon, or in the application or other form if attached to the policy, with a reservation of the right to designate or change the beneficiary after the issuance of the policy, unless such beneficiary be irrevocably designated. The policy may also provide that no designation or change of beneficiary shall be binding on the insurer until endorsed on the policy by the insurer, and that the insurer may refuse to endorse the name of any proposed beneficiary who does not appear to the insurer to have an insurable interest in the life of the insured. The policy may also provide that if the beneficiary designated in the policy does not make a claim under the policy or does not surrender the policy with due proof of death within the period stated in the policy, which shall not be less than 30 days after the death of the insured, or if the beneficiary is the estate of the insured, or is a minor, or dies before the insured, or is not legally competent to give a valid release, then the insurer may make any payment thereunder to the executor or administrator of the insured, or to any relative of the insured by blood or legal adoption or connection by marriage, or to any person appearing to the insurer to be equitably entitled thereto by reason of having been named beneficiary, or by reason of having incurred expense for the maintenance, medical attention or burial of the insured. The policy may also include a similar provision applicable to any other payment under the policy.

§ 17B:25-13 Nonforfeiture benefits and cash surrender values

There shall be a provision for nonforfeiture benefits and cash surrender values in accordance with the requirements of section 17B:25-19.

§ 17B:25-14 Title

There shall be a title on the policy, briefly describing it.

§ 17B:25-15 Provision prohibited

No policy of life insurance shall be delivered or issued for delivery in this State which limits the time within which any action may be commenced to less than 5 years after the cause of action accrues.

§ 17B:25-16 Excluded or restricted coverage

A clause in any policy of life insurance providing that such policy shall be incontestable after a specified period shall preclude only a contest of the validity of the policy, and shall not preclude the assertion at any time of defenses based upon provisions in the policy which exclude or restrict coverage, whether or not such restrictions or exclusions are excepted in such clause.

§ 17B:25-17 Incontestability; limitation of liability after reinstatement

a. A reinstated policy of life insurance may be contested on account of fraud or misrepresentation of facts material to the reinstatement only for the same period following reinstatement and with the same conditions and exceptions as the policy provides with respect to contestability after original issuance.

b. When any life insurance policy is reinstated, such reinstated policy may exclude or restrict liability to the same extent that such liability could have been excluded or restricted when the policy was originally issued, and such exclusion or restriction shall be effective from the date of reinstatement.

§ 17B:25-18 Filing of forms

a. No life insurance policy, or application, if a written application is required and is to be made a part of the policy, or printed rider or endorsement for use with the policy, shall be delivered or issued for delivery in this State unless the form has been filed with the commissioner for approval in accordance with the provisions of section 16 of P.L.1995, c.73 (C.17B:25-18.2). This section shall not apply to policies of group life insurance and applications, printed riders or endorsements for use with such policies.

b. (Deleted by amendment, P.L.1995, c.73.)

c. If a form is disapproved by the commissioner during that 60-day period, it may not be delivered or issued for delivery unless it is resubmitted and approved in accordance with the provisions of subsections b., c., and d. of section 16 of P.L.1995, c.73 (C.17B:25-18.2. Such disapproval shall be subject to review in accordance with the procedure described in the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder. Any such form which is filed by the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith.

d. (Deleted by amendment, P.L.1995, c.73.)

e. (Deleted by amendment, P.L.1995, c.73.)

f. This section shall not apply to documents which relate only to the manner of distribution of benefits or to the reservation of rights and benefits under life insurance policies and which are used at the request of the individual policyholder.

g. The commissioner may exempt from the requirements of this section for so long as he deems proper any insurance document or form or type thereof to which, in his opinion, this section may not practicably be applied, or the filing of which is, in his opinion, not desirable or necessary for the protection of the public.

h. The disapproval by the commissioner of any such form may be on the ground that the form contains provisions which are unjust, unfair, inequitable, misleading, contrary to law or to the public policy of this State.

§ 17B:25-18.1 Life, health insurance policy, contract; compliance

15. No life insurance policy, health insurance policy, annuity, or variable contract subject to the provisions of Title 17B of the New Jersey Statutes, or application for that insurance if a written application is required and is to be made a part of that policy or contract, or a printed rider or an endorsement for use with that policy or contract, shall be delivered or issued for delivery in this State unless its provisions comply with all of the applicable requirements of Title 17B of the New Jersey Statutes and any regulations adopted or guidelines published by the Commissioner of Insurance consistent with the requirements thereof. Any policy, contract, application, rider, or endorsement issued or delivered in this State that is not in compliance with that law or regulations or guidelines shall be deemed to be in compliance with the requirements and shall be interpreted by the courts and among the persons affected by the policy or contract as if that policy or contract form were in compliance with the requirements; except that this provision shall not relieve the insurer from any penalty that may be imposed for violation of this act or any other applicable provision of Title 17B of the New Jersey Statutes.

§ 17B:25-18.2 Filing of policy, contract or related form

16. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), any life insurance policy or contract, health insurance policy or contract, annuity, or variable contract subject to the provisions of Title 17B of the New Jersey Statutes, including any application, rider, or endorsement which is made a part of that policy or contract shall be filed with the commissioner for approval as provided in this section. Any such policy or contract and any related form, except those certified pursuant to section 17 of this act, shall be filed with the commissioner for approval pursuant to this section.

b. Any policy, contract or related form filed with the commissioner for approval pursuant to this section shall be deemed approved upon the expiration of 60 days after the submission of the form unless disapproved in writing by the commissioner within that time. Any such disapproval shall be based only on the specific provisions of applicable statutes or regulations adopted by the commissioner, or guidelines published by the commissioner as of the effective date of this act, with regard to forms of that type. A disapproved policy, contract or related form may be resubmitted.

c. Any life insurance policy, health insurance policy, annuity, or variable contract or related form submitted for approval pursuant to this section and disapproved by the commissioner before the expiration of 60 days after its submission shall be deemed withdrawn at the expiration of 60 days after the transmittal of the commissioner's specific objections unless the filer submits a complete written response to all of the commissioner's objections regarding the submission within the 60 day period.

d. A life insurance policy, health insurance policy, annuity, or variable contract or related form, resubmitted in response to the commissioner's objections pursuant to subsection b. of this section, shall be deemed approved upon the expiration of 30 days after its resubmission unless disapproved in writing by the commissioner within that time. No disapproval by the commissioner of a resubmission shall be based on any objection not specified by the commissioner in his initial disapproval of the filing, except that the commissioner may disapprove such form based on any new provisions introduced in the resubmission or if in addressing the specified objections cited in the commissioner's disapproval transmission, the insurer changes or modifies any substantive provisions of the form. Any policy, contract or related form resubmitted for approval pursuant to this section and disapproved by the commissioner before the expiration of 30 days after its submission shall be deemed withdrawn at the expiration of 30 days after the transmittal of the commissioner's specific objections, unless the filer submits a complete written response to all of the commissioner's objections regarding the submission within the 30 day period.

e. With respect to all types of policies, contracts or related forms required to be filed pursuant to this section and currently on file with and approved by the commissioner upon enactment of this act, the commissioner shall propose regulations, which may be amended or modified by the commissioner from time to time after adoption, concerning any actuarial or form requirements consistent with applicable statutory provisions but not specified therein, not later than 180 days after enactment of this act. Any such regulation shall be adopted not later than 180 days after it is proposed. With respect to any type of form not then on file with the commissioner but filed subsequent to the enactment of this act, the commissioner shall propose regulations, which may be amended or modified by the commissioner from time to time after adoption, concerning any actuarial or form requirements consistent with applicable statutory provisions but not specified therein, within 120 days after the form is approved or deemed approved by the commissioner pursuant to this section. Any such regulation shall be adopted not later than 180 days after it is proposed. The commissioner may issue bulletins which are interpretive of existing regulations consistent with statutory provisions, with respect to any type of policy or contract form that may be certified pursuant to section 17 of this act. Nothing in this section shall preclude an insurer from filing a certifiable policy, contract or related form for approval by the commissioner.

f. Any such form which is filed with the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith.

g. For purposes of this section, "days" means calendar days, except that when the last day of any specified time period is a Saturday, Sunday, or State holiday, then the time period shall end on the next following business day. With respect to any specified time period pertaining to correspondence between an insurer and the commissioner, the time period shall commence on the date that such correspondence is postmarked or submitted to a private delivery service.

§ 17B:25-18.3 Policies, contract forms; certification memorandums; exceptions

17. a. Pursuant to the provisions of this section, an insurer authorized to do business in this State may file with the commissioner and use, in accordance with subsection d. of this section, any form of life insurance policy, health insurance policy, annuity, variable contract, endorsement or related form that is stipulated by the commissioner to be of a kind or type eligible for file and use pursuant to subsection b. of this section. The form shall be accompanied by a certification memorandum which includes a statement that it is filed in accordance with the provisions of this section, and which is executed by a responsible officer of the insurer who certifies that the form being filed is in conformance with the law and regulation applicable to that type or kind of form as specified in a certification form to be determined by the commissioner, except that any life insurance policy or contract form that is the same as or substantially similar to a life insurance policy or contract form that has been approved for use in at least 42 other states in which the combined population equals or exceeds two-thirds of the total United States population, except that the population of the State of New Jersey shall not be included in the total United States population, as determined by the most current decennial census shall be deemed to comply with the law and regulation applicable to that type or kind of form, except for the conditions provided therefor in subsection b. of this section. If the commissioner determines that the form being filed does not conform with the law or regulation applicable to that type or kind of form, the commissioner shall notify the insurer of his objections in writing and may disapprove that form for further use in New Jersey.

b. Policy and contract forms, including related endorsements, riders and application forms, eligible for certification pursuant to this section shall include, but not be limited to certain categories of individual life, individual annuity, group annuity, group life, group health, individual health and variable contracts which the commissioner shall define by regulation and, notwithstanding any other provision of law or regulation to the contrary, any life insurance policy or contract form that is the same as or substantially similar to a life insurance policy or contract form that has been approved for use in at least 42 other states in which the combined population equals or exceeds two-thirds of the total United States population, except that the population of the State of New Jersey shall not be included in the total United States population, as determined by the most current decennial census unless disapproved by the commissioner within 60 days of filing with the commissioner. Such disapproval shall be in writing and shall set forth the substantive, not arbitrary, reasons for the disapproval.

c. The certification memorandum shall be signed and acknowledged by a responsible officer of the insurer. The acknowledgment by that officer shall be done in the same manner in which documents for recording instruments conveying or affecting interests in real estate in this State must be acknowledged to be eligible for recording, or in such other manner as specified by the commissioner by regulation from time to time.

d. Upon receipt of an acknowledgment from the commissioner that the form and a certification memorandum which conforms to the requirements of this section have been received, the form so submitted may be used by the insurer. The acknowledgment shall be sent by first class mail by the commissioner to the insurer within 60 days of receipt by the commissioner of the form and the certification memorandum which conforms to the requirements of this section.

e. (1) Improper certification shall subject an insurer submitting such improper certification to a fine not to exceed $50,000 and, in addition, a maximum penalty of $1,000 per policy issued on a form determined to be improperly certified pursuant to the provisions of this section. The commissioner shall promulgate a schedule of penalties to be applied pursuant to this section. In determining the amount of any penalty to be imposed, the commissioner shall consider the severity of the violation based upon the potential adverse impact to the public and whether it is the filer's first violation of this section.

(2) If after notice and a hearing pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), an insurer is found by the commissioner to be in violation of this section, the form may be disapproved, and in addition to any other penalties that may be imposed under Title 17B of the New Jersey Statutes, the commissioner may bar that insurer from participating in the certification process pursuant to this section for a period not to exceed one year.

f. The commissioner shall hold a hearing annually, or more often, for the purpose of adopting regulations to define the specific forms eligible for certification pursuant to this section. Initial regulations shall be adopted pursuant to this section no later than 180 days after enactment of this act.

g. For purposes of this section:

(1) "a responsible officer of the insurer" means a corporate officer of the level of vice president or higher, or of equivalent title within the insurer's structure, who is either the actuary of the insurer with responsibility for the type of form filed, or the individual with responsibility for managing the form filing process for the insurer with regard to the type of form filed; and

(2) "improper certification" means providing any misrepresentation or false statement material to a certification form required pursuant to subsection a. of this section.

§ 17B:25-18.4 Filing of certain forms of life insurance approved in other states.

1. a. Notwithstanding the provisions of any other law to the contrary and pursuant to the provisions of this section, an insurer authorized to do business in this State may file with the Commissioner of Banking and Insurance and make available for sale or use, in accordance with subsection d. of this section, any form of life insurance policy, annuity, variable contract, endorsement, riders and application forms. The form shall be accompanied by a certification memorandum that includes a statement that it is filed in accordance with the provisions of this section, and which is executed by a responsible officer of the insurer. The certification shall state that the form has been made available for sale or use in accordance with current state regulations governing the type of product submitted, subject to state variations that do not alter the unique product features or design of the product, in 40 states. If that certification is made, the form shall be available for sale or use in the State of New Jersey. Filing pursuant to this section shall not preclude an insurer from filing under other laws or rules and regulations of this State.

b. Policy and contract forms, including related endorsements, riders and application forms, eligible for certification pursuant to this section shall include, but not be limited to, individual life, individual annuity, group annuity, group life, variable life and variable annuity contracts, excluding specified disease and critical illness policies or contracts.

c. The certification memorandum shall be signed and acknowledged by a responsible officer of the insurer. The acknowledgment by that officer shall be done in the same manner in which documents for recording instruments conveying or affecting interests in real estate in this State must be acknowledged to be eligible for recording, or in such other manner as specified by the commissioner by regulation from time to time.

d. Upon receipt of an acknowledgment from the commissioner that the form and the certification memorandum which conforms to the requirements of this section have been received, the form so submitted may be used in this State by the insurer. The acknowledgment shall be sent by first class mail by the commissioner to the insurer within 30 days of receipt by the commissioner of the form and the certification memorandum that conforms to the requirements of this section.

e. (1) An insurer submitting an improper certification shall be subject to a fine not to exceed $50,000 and, in addition, a maximum penalty of $1,000 per policy issued on a form determined to be improperly certified pursuant to the provisions of this section. The commissioner shall promulgate a schedule of penalties to be applied pursuant to this section. In determining the amount of any penalty to be imposed, the commissioner shall consider the severity of the violation based upon the potential adverse impact to the public and whether it is the filer's first violation of this section.

(2) If, after notice and a hearing pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), an insurer is found by the commissioner to be in violation of this section, the form may be disapproved, and in addition to any other penalties that may be imposed under Title 17B of the New Jersey Statutes, the commissioner may bar that insurer from participating in the certification process pursuant to this section for a period not to exceed one year.

f. (1) Initial regulations shall be adopted pursuant to this section no later than 120 days after enactment of this act. These regulations shall stand on their own and deal solely and specifically with the provisions of this section and only address the certification and the process of certification required by this section.

(2) Until the commissioner adopts rules and regulations pursuant to this act, an insurer may submit certifications in any format that satisfies the requirements of this section.

(3) The commissioner shall submit an annual report, on or before December 1, to the Governor and the Legislature, on the administration of this act including, but not limited to, the number and type of forms approved and rejected pursuant to the provisions of this section.

g. (1) The certification memorandum shall list the 40 States, the form number submitted and the date that form was made available for sale or use in each state.

(2) An insurer who files in accordance with this section shall be exempt from the certification requirements of section 17 of P.L.1995, c.73 (C.17B:25-18.3).

h. For purposes of this section:

(1) "A responsible officer of the insurer" means a corporate officer of the level of vice president or higher, or of equivalent title within the insurer's structure, who is either the actuary of the insurer with responsibility for the type of form filed, or the individual with responsibility for managing the form filing process for the insurer with regard to the type of form filed;

(2) "Available for sale or use" means that the insurer has complied with the state's laws, regulations, and procedures to allow the insurer to sell or use the form in that state;

(3) "Improper certification" means providing any misrepresentation or false statement material to a certification form required.

§ 17B:25-18.5 Certain actions taken by department employees to result in termination.

2. a. An officer or employee of the Department of Banking and Insurance shall not take or threaten any action or omission in retaliation against a person for efforts of that person, or a person acting on his behalf, to secure or enforce any rights under contract, the laws of this State or the laws of the United States, or the good faith complaint of that person, or a person acting on his behalf, to any other government official, officer or employee or other person concerning any actions or omissions of the officer or employee of the department in regard to that person.

b. Any officer or employee who violates the provisions of subsection a. of this section shall, after notice and a hearing, be terminated from employment with the State.

§ 17B:25-19 Standard nonforfeiture law for life insurance.

This section shall be known as the standard nonforfeiture law for life insurance.

a. No policy of life insurance, except as stated in subsection l., shall be delivered or issued for delivery in this State unless it shall contain in substance the following provisions, or corresponding provisions which in the opinion of the commissioner are at least as favorable to the defaulting or surrendering policyholder as are the minimum requirements hereinafter specified and are essentially in compliance with subsection k. of this section:

(1) That, in the event of default in any premium payment, the insurer will grant, upon proper request not later than 60 days after the due date of the premium in default, a paid-up nonforfeiture benefit on a plan stipulated in the policy, effective as of such due date, of such amount as may be hereinafter specified. In lieu of such stipulated paid-up nonforfeiture benefit, the insurer may substitute, upon proper request not later than 60 days after the due date of the premium in default, an actuarially equivalent alternative paid-up nonforfeiture benefit which provides a greater amount or longer period of death benefits or, if applicable, a greater amount or earlier payment of endowment benefits.

(2) That, upon surrender of the policy within 60 days after the due date of any premium payment in default after premiums have been paid for at least 3 full years in the case of ordinary insurance or 5 full years in the case of industrial insurance, the insurer will pay, in lieu of any paid-up nonforfeiture benefit, a cash surrender value of such amount as may be hereinafter specified.

(3) That a specified paid-up nonforfeiture benefit shall become effective as specified in the policy unless the person entitled to make such election elects another available option not later than 60 days after the due date of the premium in default.

(4) That, if the policy shall have become paid up by completion of all premium payments or if it is continued under any paid-up nonforfeiture benefit which became effective on or after the third policy anniversary in the case of ordinary insurance or the fifth policy anniversary in the case of industrial insurance, the insurer will pay, upon surrender of the policy within 30 days after any policy anniversary, a cash surrender value of such amount as may be hereinafter specified.

(5) In the case of policies which cause on a basis guaranteed in the policy unscheduled changes in benefits or premiums, or which provide an option for changes in benefits or premiums other than a change to a new policy, a statement of the mortality table, interest rate, and method used in calculating cash surrender values and the paid-up nonforfeiture benefits available under the policy. In the case of all other policies, a statement of the mortality tables and interest rates used in calculating the cash surrender values and the mortality tables and interest rates used in calculating the paid-up nonforfeiture benefits available under the policy, together with a table showing the cash surrender value, if any, and paid-up nonforfeiture benefit, if any, available under the policy on each policy anniversary either during the first 20 policy years or during the term of the policy, whichever is shorter, such values and benefits to be calculated upon the assumption that there are no dividends or paid-up additions credited to the policy and that there is no indebtedness to the insurer on the policy.

(6) A statement that the cash surrender values and the paid-up nonforfeiture benefits available under the policy are not less than the minimum values and benefits required by or pursuant to the insurance law of the state in which the policy is delivered; an explanation of the manner in which the cash surrender values and the paid-up nonforfeiture benefits are altered by the existence of any paid-up additions credited to the policy or any indebtedness to the insurer on the policy; if a detailed statement of the method of computation of the cash surrender values and paid-up nonforfeiture benefits shown in the policy is not stated therein, a statement that such method of computation has been filed with the insurance supervisory official of the state in which the policy is delivered; and a statement of the method to be used in calculating the cash surrender value and paid-up nonforfeiture benefit available under the policy on any policy anniversary beyond the last anniversary for which such values and benefits are consecutively shown in the policy.

Any of the foregoing provisions or portions thereof not applicable by reason of the plan of insurance may, to the extent inapplicable, be omitted from the policy.

The insurer shall reserve the right to defer the payment of any cash surrender value for a period of 6 months after demand therefor with surrender of the policy.

b. (Deleted by amendment; P.L.1981, c.285.)

c. Any cash surrender value available under any policy referred to in subsection a. in the event of default in a premium payment due on any policy anniversary, whether or not required by subsection a., shall be an amount not less than the excess, if any, of the present value, on such anniversary, of the future guaranteed benefits which would have been provided for by the policy, including any existing paid-up additions, if there had been no default, over the sum of (1) the then present value of the adjusted premiums as defined in subsection g., corresponding to premiums which would have fallen due on and after such anniversary, and (2) the amount of any indebtedness to the insurer on the policy.

Provided, however, that for any policy issued on or after the operative date provided for in paragraph (xi) of subsection h. of N.J.S.17B:25-19, which provides supplemental life insurance or annuity benefits at the option of the insured and for an identifiable additional premium by rider or supplemental policy provision, the cash surrender value referred to in the first paragraph of this subsection shall be an amount not less than the sum of the cash surrender value as defined in that paragraph for an otherwise similar policy issued at the same age without such rider or supplemental policy provision and the cash surrender value as defined in that paragraph for a policy which provides only the benefits otherwise provided by such rider or supplemental policy provision.

Provided, further, that for any family policy issued on or after the operative date provided for in paragraph (xi) of subsection h., which defines a primary insured and provides term insurance on the life of the spouse of the primary insured expiring before the spouse's age 71, the cash surrender value referred to in the first paragraph of this subsection shall be an amount not less than the sum of the cash surrender value as defined in that paragraph for an otherwise similar policy issued at the same age without such term insurance on the life of the spouse and the cash surrender value as defined in that paragraph for a policy which provides only the benefits otherwise provided by such term insurance on the life of the spouse.

Any cash surrender value available within 30 days after any policy anniversary under any policy paid up by completion of all premium payments or any policy continued under any paid-up nonforfeiture benefit, whether or nor required by subsection a., shall be an amount not less than the present value, on such anniversary, of the future guaranteed benefits provided for by the policy, including any existing paid-up additions, decreased by any indebtedness to the insurer on the policy.

d. Any paid-up nonforfeiture benefit available under any policy referred to in subsection a. in the event of default in a premium payment due on any policy anniversary shall be such that its present value as of such anniversary shall be at least equal to the cash surrender value then provided for by the policy or, if none is provided for, that cash surrender value which would have been required by this section in the absence of the condition that premiums shall have been paid for at least a specified period.

e. (Deleted by amendment; P.L.1981, c.285.)

f. (Deleted by amendment; P.L.1981, c.285.)

g. This subsection shall not apply to policies issued on or after the operative date of subsection h. as defined therein. Except as provided in the third paragraph of this subsection, the adjusted premiums for any policy referred to in subsection a. shall be calculated on an annual basis and shall be such uniform percentage of the respective premiums specified in the policy for each policy year, excluding any extra premiums charged because of impairments or special hazards, that the present value, at the date of issue of the policy, of all such adjusted premiums shall be equal to the sum of (1) the then present value of the future guaranteed benefits provided for by the policy; (2) 2% of the amount of insurance, if the insurance be uniform in amount or of the equivalent uniform amount, as hereinafter defined, if the amount of insurance varies with duration of the policy; (3) 40% of the adjusted premium for the first policy year; (4) 25% of either the adjusted premium for the first policy year or the adjusted premium for a whole life policy of the same uniform or equivalent uniform amount with uniform premiums for the whole of life issued at the same age for the same amount of insurance, whichever is less; provided, however, that in applying the percentages specified in (3) and (4) above, no adjusted premium shall be deemed to exceed 4% of the amount of insurance or uniform amount equivalent thereto. The date of issue of a policy for the purpose of this subsection shall be the date as of which the rated age of the insured is determined.

In the case of a policy providing an amount of insurance varying with duration of the policy, the equivalent uniform amount thereof for the purpose of this subsection shall be deemed to be the uniform amount of insurance provided by an otherwise similar policy, containing the same endowment benefit or benefits, if any, issued at the same age and for the same term, the amount of which does not vary with duration, and the benefits under which have the same present value at the date of issue as the benefits under the policy; provided, however, that in the case of a policy providing a varying amount of insurance issued on the life of a child under age 10, the equivalent uniform amount may be computed as though the amount of insurance provided by the policy prior to the attainment of age 10 were the amount provided by such policy at age 10.

The adjusted premiums for any policy providing term insurance benefits by rider or supplemental policy provision shall be equal to (a) the adjusted premiums for an otherwise similar policy issued at the same age without such term insurance benefits, increased, during the period for which premiums for such term insurance benefits are payable, by (b) the adjusted premiums for such term insurance, the foregoing items (a) and (b) being calculated separately and as specified in the first two paragraphs of this subsection except that, for the purpose of (2), (3) and (4) of the first such paragraph, the amount of insurance or equivalent uniform amount of insurance used in the calculation of the adjusted premiums referred to in (b) shall be equal to the excess of the corresponding amount determined for the entire policy over the amount used in the calculation of the adjusted premiums in (a).

All adjusted premiums and present values referred to in this subsection shall for all policies of ordinary insurance be calculated on the basis of the Commissioners 1958 Standard Ordinary Mortality Table. Notwithstanding this provision, for any category of ordinary insurance such calculations may be made, at the option of the insurer, on the basis of the Approved Standard Ordinary Mortality Table; provided, further, that for any category of ordinary insurance issued on female risks adjusted premiums and present values may be calculated, at the option of the insurer with approval of the commissioner, according to an age not more than 6 years younger than the actual age of the insured. Such calculations for all policies of industrial insurance shall be made on the basis of the Commissioners 1961 Standard Industrial Mortality Table.

All calculations shall be made on the basis of the applicable rates of interest specified in the policy for calculating cash surrender values and paid-up nonforfeiture benefits not exceeding 5 1/2 % per annum. Provided, however, that in calculating the present value of any paid-up term insurance with accompanying pure endowment, if any, offered as a nonforfeiture benefit, the rates of mortality assumed may be not more than the rates shown in the Commissioners 1958 Extended Term Insurance Table if the adjusted premiums for the policy are calculated on the basis of the Commissioners 1958 Standard Ordinary Mortality Table, may be not more than 130% of the rates shown in the Approved Standard Ordinary Mortality Table if the adjusted premiums for the policy are calculated on the basis of said table, and may be not more than the rates shown in the Commissioners 1961 Industrial Extended Term Insurance Table if the adjusted premiums for the policy are calculated on the basis of the Commissioners 1961 Standard Industrial Mortality Table. Provided, further, that for insurance issued on a substandard basis, the calculation of any such adjusted premiums and present values may be based on such other table of mortality as may be specified by the insurer and approved by the commissioner.

h. (i) This subsection h. shall apply to all policies issued on or after the operative date established by paragraph (xi) of this subsection h. Except as provided in paragraph (vii) of this subsection, the adjusted premiums for any policy shall be calculated on an annual basis and shall be such uniform percentage of the respective premiums specified in the policy for each policy year, excluding amounts payable as extra premiums to cover impairments or special hazards and also excluding any uniform annual contract charge or policy fee specified in the policy in a statement of the method to be used in calculating the cash surrender values and paid-up nonforfeiture benefits, that the present value, at the date of the policy, of all adjusted premiums shall be equal to the sum of (A) the then present value of the future guaranteed benefits provided for by the policy; (B) 1% of either the amount of insurance, if the insurance be uniform in amount, or the average amount of insurance at the beginning of each of the first 10 policy years; and (C) 125% of the nonforfeiture net level premium as defined in paragraph (ii). Provided, however, that in applying the percentage specified in (C) above no nonforfeiture net level premium shall be deemed to exceed 4% of either the amount of insurance, if the insurance be uniform in amount, or the average amount of insurance at the beginning of each of the first 10 policy years. The date of issue of a policy for the purpose of this section shall be the date as of which the rated age of the insured is determined.

(ii) The nonforfeiture net level premium shall be equal to the present value, at the date of issue of the policy, of the guaranteed benefits provided for by the policy divided by the present value, at the date of issue of the policy, of an annuity of one per annum payable on the date of issue of the policy and on each anniversary of such policy on which a premium falls due.

(iii) In the case of policies which cause on a basis guaranteed in the policy unscheduled changes in benefits or premiums, or which provide an option for changes in benefits or premiums other than a change to a new policy, the adjusted premiums and present values shall initially be calculated on the assumption that future benefits and premiums do not change from those stipulated at the date of issue of the policy. At the time of any such change in the benefits or premiums the future adjusted premiums, nonforfeiture net level premiums and present values shall be recalculated on the assumption that future benefits and premiums do not change from those stipulated by the policy immediately after the change.

(iv) Except as otherwise provided in paragraph (vii) of this subsection, the recalculated future adjusted premiums for any such policy shall be such uniform percentage of the respective future premiums specified in the policy for each policy year, excluding amounts payable as extra premiums to cover impairments and special hazards, and also excluding any uniform annual contract charge or policy fee specified in the policy in a statement of the method to be used in calculating the cash surrender values and paid-up nonforfeiture benefits, that the present value, at the time of change to the newly defined benefits or premiums, of all such future adjusted premiums shall be equal to the excess of the sum of the then present value of the then future guaranteed benefits provided for by the policy and the additional expense allowance, if any, over the then cash surrender value, if any, or present value of any paid-up nonforfeiture benefit under the policy.

(v) The additional expense allowance, at the time of the change to the newly defined benefits or premiums, shall be the sum of 1% of the excess of the average amount of insurance at the beginning of each of the first 10 policy years subsequent to the change over the average amount of insurance prior to the change at the beginning of each of the first 10 policy years subsequent to the time of the most recent previous change, or, if there has been no previous change, the date of issue of the policy; and 125% of the increase, if positive, in the nonforfeiture net level premium.

(vi) The recalculated nonforfeiture net level premium shall be equal to the result obtained by dividing (A) by (B) where

(A) equals the sum of the nonforfeiture net level premium applicable prior to the change times the present value of an annuity of one per annum payable on each anniversary of the policy on or subsequent to the date of the change on which a premium would have fallen due had the change not occurred, and the present value of the increase in future guaranteed benefits provided for by the policy, and

(B) equals the present value of an annuity of one per annum payable on each anniversary of the policy on or subsequent to the date or change on which a premium falls due.

(vii) Notwithstanding any other provisions of this subsection to the contrary, in the case of a policy issued on a substandard basis which provides reduced graded amounts of insurance so that, in each policy year, such policy has the same tabular mortality cost as an otherwise similar policy issued on the standard basis which provides higher uniform amounts of insurance, adjusted premiums and present values for such substandard policy may be calculated as if it were issued to provide such higher uniform amounts of insurance on the standard basis.

(viii) For purposes of this subsection, the term "operative date of the valuation manual" means the January 1 of the first calendar year that the valuation manual as defined in section 58 of P.L.2014, c.81 (C.17B:19-1.1) is effective. All adjusted premiums and present values referred to in this subsection shall for all policies of ordinary insurance be calculated on the basis of the Commissioners 1980 Standard Ordinary Mortality Table or at the election of the insurer for any one or more specified plans of life insurance, the Commissioners 1980 Standard Ordinary Mortality Table with 10-Year Select Mortality Factors; shall for all policies of industrial insurance be calculated on the basis of the Commissioners 1961 Standard Industrial Mortality Table; and shall for all policies issued in a particular calendar year be calculated on the basis of a rate of interest not exceeding the nonforfeiture interest rate as defined in paragraph (ix) of this subsection for policies issued in that calendar year. Provided, however, that:

At the option of the insurer, calculations for all policies issued in a particular calendar year may be made on the basis of a rate of interest not exceeding the nonforfeiture interest rate, as defined in this section, for policies issued in the immediately preceding calendar year.

Under any paid-up nonforfeiture benefit, including any paid-up dividend additions, any cash surrender value available, whether or not required by subsection a., shall be calculated on the basis of the mortality table and rate of interest used in determining the amount of such paid-up nonforfeiture benefit and paid-up dividend additions, if any.

An insurer may calculate the amount of any guaranteed paid-up nonforfeiture benefit including any paid-up additions under the policy on the basis of an interest rate not lower than that specified in the policy for calculating cash surrender values.

In calculating the present value of any paid-up term insurance with accompanying pure endowment, if any, offered as a nonforfeiture benefit, the rates of mortality assumed may be not more than those shown in the Commissioners 1980 Extended Term Insurance for policies of ordinary insurance and not more than the Commissioners 1961 Industrial Extended Term Insurance Table for policies of industrial insurance.

For insurance issued on a substandard basis, the calculation of such adjusted premiums and present values may be based on appropriate modifications of the aforementioned tables.

For policies issued prior to the operative date of the valuation manual, any Commissioners Standard ordinary mortality tables, adopted after 1980 by the National Association of Insurance Commissioners, that are approved by regulation promulgated by the commissioner for use in determining the minimum nonforfeiture standard may be substituted for the Commissioners 1980 Standard Ordinary Mortality Table with or without 10-Year Select Mortality Factors or for the Commissioners 1980 Extended Term Insurance Table.

For policies issued on or after the operative date of the valuation manual, the valuation manual shall provide the Commissioners Standard mortality table for use in determining the minimum nonforfeiture standard that may be substituted for the Commissioners 1980 Standard Ordinary Mortality Table with or without Ten-Year Select Mortality Factors or for the Commissioners 1980 Extended Term Insurance Table. If the commissioner approves by regulation any Commissioners Standard ordinary mortality table adopted by the National Association of Insurance Commissioners for use in determining the minimum nonforfeiture standard for policies issued on or after the operative date of the valuation manual, then that minimum nonforfeiture standard supersedes the minimum nonforfeiture standard provided by the valuation manual.

For policies issued prior to the operative date of the valuation manual, any Commissioners Standard industrial mortality tables, adopted after 1980 by the National Association of Insurance Commissioners, that are approved by regulation promulgated by the commissioner for use in determining the minimum nonforfeiture standard may be substituted for the Commissioners 1961 Standard Industrial Mortality Table or the Commissioners 1961 Industrial Extended Term Insurance Table.

For policies issued on or after the operative date of the valuation manual the valuation manual shall provide the Commissioners Standard mortality table for use in determining the minimum nonforfeiture standard that may be substituted for the Commissioners 1961 Standard Industrial Mortality Table or the Commissioners 1961 Industrial Extended Term Insurance Table. If the commissioner approves by regulation any Commissioners Standard industrial mortality table adopted by the National Association of Insurance Commissioners for use in determining the minimum nonforfeiture standard for policies issued on or after the operative date of the valuation manual then that minimum nonforfeiture standard supersedes the minimum nonforfeiture standard provided by the valuation manual.

(ix) For purposes of this subsection, the term "operative date of the valuation manual" means the January 1 of the first calendar year that the valuation manual as defined in section 58 of P.L.2014, c.81 (C.17B:19-1.1) is effective.

The nonforfeiture interest rate is defined below:

(1) For policies issued prior to the operative date of the valuation manual, the nonforfeiture interest rate per annum for any policy issued in a particular calendar year shall be equal to 125% of the calendar year statutory valuation interest rate for such policy as defined in the standard valuation law, paragraph (x) of subsection a. of N.J.S.17B:19-8, rounded to nearer 1/4 of 1%.

(2) For policies issued on or after the operative date of the valuation manual the nonforfeiture interest rate per annum for any policy issued in a particular calendar year shall be provided by the valuation manual.

(x) Notwithstanding any other provisions in this code (Title 17B) to the contrary, any refiling of nonforfeiture values or their methods of computation for any previously approved policy forms which involves only a change in the interest rate or mortality table used to compute nonforfeiture values shall not require refiling of any other provisions of that policy form.

(xi) After the effective date of this subsection, any insurer may file with the commissioner a written notice of its election to comply, with respect to any category of insurance, with the provisions of this subsection after a specified date before January 1, 1989, which shall be the operative date of this subsection for that category of insurance for such insurer. If an insurer makes no such election with respect to any category of insurance, the operative date of this subsection for that category of insurance issued by such insurer shall be January 1, 1989.

i. In the case of any plan of life insurance which provides for future premium determination, the amounts of which are to be determined by the insurer based on then estimates of future experience, or in the case of any plan of life insurance which is of such a nature that minimum values cannot be determined by the methods described in the preceding subsections of this section, then:

the commissioner must be satisfied that the benefits provided under the plan are substantially as favorable to policyholders and insureds as the minimum benefits otherwise required by the preceding subsections of this section;

the commissioner must be satisfied that the benefits and the pattern of premiums of that plan are not such as to mislead prospective policyholders or insureds;

the cash surrender values and paid-up nonforfeiture benefits provided by such plan must not be less than the minimum values and benefits required for the plan computed by a method consistent with the principles of this standard nonforfeiture law for life insurance, as determined by regulations promulgated by the commissioner.

j. Any cash surrender value and any paid-up nonforfeiture benefit, available under the policy in the event of default in a premium payment due at any time other than on the policy anniversary, shall be calculated with allowance for the lapse of time and the payment of fractional premiums beyond the last preceding policy or contract anniversary. All values referred to in subsections c., d., g., h. and i. may be calculated upon the assumption that any death benefit is payable at the end of the policy year of death. The net value of any paid-up additions, other than paid-up term additions, shall be not less than the amounts used to provide such additions. Notwithstanding the provisions of subsection c., additional benefits payable (1) in the event of death or dismemberment by accident or accidental means, (2) in the event of total and permanent disability, (3) as reversionary annuity or deferred reversionary annuity benefits, (4) as term insurance benefits provided by a rider or supplemental policy provision to which, if issued as a separate policy, this section would not apply, (5) as term insurance on the life of a child or on the lives of children provided in a policy on the life of a parent of the child, if such term insurance expires before the child's age is 26, is uniform in amount after the child's age is one, and has not become paid-up by reason of the death of a parent of the child, and (6) as other policy benefits additional to life insurance and endowment benefits, and premiums for all such additional benefits, shall be disregarded in ascertaining cash surrender values and nonforfeiture benefits required by this section, and no such additional benefits shall be required to be included in any paid-up nonforfeiture benefits. Notwithstanding the provisions of subsection c., additional benefits providing the privilege to purchase additional insurance benefits at some future time without furnishing evidence of insurability, and premiums therefor, may, with the consent of the commissioner, be disregarded in ascertaining cash surrender values and nonforfeiture benefits required by this section, and no such additional benefits shall be required to be included in any paid-up nonforfeiture benefits.

k. This subsection shall apply to all policies issued on or after January 1, 1985. Any cash surrender value available under the policy in the event of default in a premium payment due on any policy anniversary shall be in an amount which does not differ by more than 2/10 of 1% of either the amount of insurance, if the insurance be uniform in amount, or the average amount of insurance at the beginning of each of the first 10 policy years, from the sum of (a) the greater of zero and the basic cash value hereinafter specified and (b) the present value of any existing paid-up additions less the amount of any indebtedness to the insurer under the policy.

The basic cash value shall be equal to the present value, on such anniversary, of the future guaranteed benefits which would have been provided by the policy, excluding any existing paid-up additions and before deduction of any indebtedness to the insurer, if there had been no default, less the then present value of the nonforfeiture factors, as hereinafter defined, corresponding to premiums which would have fallen due on and after such anniversary. Provided, however, that the effects on the basic cash value of supplemental life insurance or annuity benefits or of family coverage, as described in subsection c. or subsection g., whichever is applicable shall be the same as are the effects specified in subsection c. or subsection g., whichever is applicable on the cash surrender values defined therein.

The nonforfeiture factor for each policy year shall be an amount equal to a percentage of the adjusted premium for the policy year, as defined in subsection g. or h., whichever is applicable. Except as required by the next succeeding sentence of this paragraph, such percentage:

shall be the same percentage for each policy year between the second policy anniversary and the later of the fifth policy anniversary and the first policy anniversary at which there is available under the policy a cash surrender value in an amount, before including any paid-up additions and before deducting any indebtedness, of at least 2/10 of 1% of either the amount of insurance, if the insurance be uniform in amount, or the average amount of insurance at the beginning of each of the first 10 policy years; and

shall be such that no percentage after the later of the two policy anniversaries specified in the preceding item may apply to fewer than 5 consecutive policy years.

Provided, that no basic cash value may be less than the value which would be obtained if the adjusted premiums for the policy, as defined in subsection g., or h., whichever is applicable, were substituted for the nonforfeiture factors in the calculation of the basic cash value.

All adjusted premiums and present values referred to in this subsection shall for a particular policy be calculated on the same mortality and interest bases as are used in demonstrating the policy's compliance with the other sections of this amendatory and supplementary act. The cash surrender values referred to in this subsection shall include any endowment benefits provided for by the policy.

Any cash surrender value available other than in the event of default in a premium payment due on a policy anniversary, and the amount of any paid-up nonforfeiture benefit available under the policy in the event of default in a premium payment shall be determined in a manner consistent with that specified for determining the appropriate minimum amounts in subsections a., c., d., g., h. and i. The amounts of any cash surrender values and of any paid-up nonforfeiture benefits granted in connection with additional benefits such as those listed as items (1) through (6) in subsection j. shall conform with the principles of this subsection.

l. This section shall not apply to any of the following:

reinsurance,

group insurance,

annuity contract,

single premium pure endowment contract or single premium reversionary annuity contract,

term policy of uniform amount, which provides no guaranteed nonforfeiture or endowment benefits, or renewal thereof, of 20 years or less expiring before age 71, for which uniform premiums are payable during the entire term of the policy,

term policy of decreasing amount which provides no guaranteed nonforfeiture or endowment benefits, on which each adjusted premium, calculated as specified in subsections g. and h. is less than the adjusted premium so calculated on a term policy of uniform amount, or renewal thereof, which provides no guaranteed nonforfeiture endowment benefits, issued at the same age and for the same initial amount of insurance and for a term of 20 years or less expiring before age 71, for which uniform premiums are payable during the entire term of the policy,

policy which provides no guaranteed nonforfeiture or endowment benefits, for which no cash surrender value, if any, or present value of any paid-up nonforfeiture benefit, at the beginning of any policy year, calculated as specified in subsections c., g., and h. exceeds 2 1/2 % of the amount of insurance at the beginning of the same policy year,

policy which shall be delivered outside this State through an agent or other representative of the insurer issuing the policy.

For the purposes of determining the applicability of this section, the age at expiry for a joint term life insurance policy shall be the age at expiry of the oldest life.

§ 17B:25-20 Standard nonforfeiture law for individual deferred annuities.

5. This section shall be known as the standard nonforfeiture law for individual deferred annuities.

a. No contract of annuity or pure endowment, except as stated in subsection p., shall be issued or delivered in this State on or after January 1, 1972 and before the operative date of this section as defined in subsection o., unless it shall contain in substance the following provisions, or corresponding provisions which in the opinion of the commissioner are at least as favorable to the defaulting or surrendering contract holder:

(1) That, in the event of default in any stipulated payment, the insurer will grant a paid-up nonforfeiture benefit on a plan stipulated in the contract, effective as of such due date, of such value as may be hereinafter specified.

(2) A statement of the mortality tables, if any, and interest rates used in calculating the paid-up nonforfeiture benefits available under the contract, together with a table showing either the cash surrender value, if any, or the paid-up nonforfeiture benefit, if any, available on each anniversary of the contract either during the first 20 contract years or during the term of stipulated payments, whichever is shorter, such benefits to be calculated upon the assumption that there are no dividends or paid-up additions credited to the contract and that there is no indebtedness to the insurer on the contract.

(3) A statement that the paid-up nonforfeiture benefits available under the contract are not less than the minimum benefits required by or pursuant to the insurance law of the state in which the contract is delivered; an explanation of the manner in which the paid-up nonforfeiture benefits are altered by the existence of any paid-up additions credited to the contract or any indebtedness to the insurer on the contract; if a detailed statement of the method of computation of the paid-up nonforfeiture benefits shown in the contract is not stated therein, a statement that such method of computation has been filed with the insurance supervisory official of the state in which the contract is delivered; and a statement of the method to be used in calculating the paid-up nonforfeiture benefit available under the contract on any contract anniversary beyond the last anniversary for which such benefits are consecutively shown in the contract.

If an insurer shall provide for the payment of a cash surrender value, it shall reserve the right to defer the payment of such value for a period of six months after demand therefor with surrender of the contract.

Notwithstanding the requirements of this subsection, any deferred annuity contract may provide that if the annuity allowed under any paid-up nonforfeiture benefit would be less than $120.00 annually, the insurer may at its option grant a cash surrender value in lieu of such paid-up nonforfeiture benefit of such amount as may be required by subsection c.

b. Any paid-up nonforfeiture benefit available under any annuity or pure endowment contract referred to in subsection a. in the event of default in a stipulated payment due on any contract anniversary, shall be such that its present value as of such anniversary shall be an amount not less than the excess, if any, of the present value, on such anniversary, of the future guaranteed benefits which would have been provided for by the contract, including any existing paid-up additions, if there had been no default, over the sum of (1) the then present value of the adjusted stipulated payments as defined in subsection d. corresponding to stipulated payments which would have fallen due on and after such anniversary, and (2) the amount of any indebtedness to the insurer on the contract. In determining the benefits referred to in this subsection and in calculating the adjusted stipulated payments referred to in subsection d. in the case of annuity contracts under which an election may be made to have annuity payments commence at optional dates, the annuity payments shall be deemed to commence at a date which shall be the latest permitted by the contract for the commencement of such payments but not later than the contract anniversary nearest the annuitant's seventieth birthday or the tenth anniversary of the contract, whichever is later; and the stipulated payments shall be deemed to be payable for the longest period during which they would be payable if election were made to have the annuity payments commence at such date.

c. Any cash surrender value allowed by any annuity or pure endowment contract referred to in subsection a. and the present value under any optional provision, of future benefits commencing on the due date of the stipulated payment in default shall each be at least equal to the then present value of the minimum paid-up nonforfeiture benefit required by subsection b.

d. The adjusted stipulated payments for any annuity or pure endowment contract referred to in subsection a. shall be calculated on an annual basis and shall be such uniform percentage of the respective stipulated payments specified in the contract for each contract year that the present value, at the date of issue of the contract, of all such adjusted stipulated payments shall be equal to the sum of (1) the then present value of the future guaranteed benefits provided for by the contract; (2) 20% of the adjusted stipulated payment for the first contract year; and (3) 2% of the adjusted stipulated payment for the first contract year for each year not exceeding 20 during which stipulated payments are payable.

All adjusted stipulated payments and present values referred to in this section shall for annuity and pure endowment contracts be calculated on the basis of (1) the applicable rates of interest, not exceeding 3 1/2% per annum, specified in the contract for calculating cash surrender values, if any, and paid-up nonforfeiture benefits; and (2) the 1937 Standard Annuity Mortality Table, or the Annuity Mortality Table for 1949, Ultimate, or any modification of either of these tables approved by the commissioner or any other table approved by the commissioner; provided that, in the case of annuity or pure endowment contracts issued after the operative date for the insurer of paragraph (ix) of subsection a. of the standard valuation law, N.J.S.17B:19-8, the 3 1/2% maximum interest rate specified in item (1) of this paragraph shall be increased to 4 1/2%, and, if the applicable rates of interest specified in the contract for calculating cash surrender values, if any, and paid-up nonforfeiture benefits exceed 3 1/2%, there shall be substituted for the mortality tables specified in item (2) the 1971 Individual Annuity Mortality Table, or any modification of this table approved by the commissioner or any other table approved by the commissioner.

e. Any cash surrender value and any paid-up nonforfeiture benefit, available under any contract referred to in subsection a. in the event of default in the payment of a stipulated payment due at any time other than on the contract anniversary, shall be calculated with allowance for the lapse of time and the payment of fractional stipulated payments beyond the last preceding contract anniversary. All values referred to in subsections b. to d. inclusive, may be calculated upon the assumption that any death benefit is payable at the end of the contract year of death. The net value of any paid-up additions shall be not less than the dividends used to provide such additions. Notwithstanding the provisions of subsection b., additional benefits payable (1) in the event of total and permanent disability, (2) as reversionary annuity or deferred reversionary annuity benefits, and (3) as other policy benefits additional to pure endowment, and annuity benefits, and premiums for all such additional benefits, shall be disregarded in ascertaining cash surrender values and nonforfeiture benefits required by this section, and no such additional benefits shall be required to be included in any paid-up nonforfeiture benefits. Notwithstanding the provisions of subsection b., additional benefits providing the privilege to purchase additional annuity benefits at some future time without furnishing evidence of insurability, and stipulated payments therefor, may, with the consent of the commissioner, be disregarded in ascertaining cash surrender values and nonforfeiture benefits required by this section, and no such additional benefits shall be required to be included in any paid-up nonforfeiture benefits.

f. In the case of contracts issued on or after the operative date of this section as defined in subsection o., no contract of annuity, except as stated in subsection p., shall be delivered or issued for delivery in this State unless it contains in substance the following provisions, or corresponding provisions which in the opinion of the commissioner are at least as favorable to the contract holder, upon cessation of payment of considerations under the contract:

(1) That upon cessation of payment of considerations under a contract, the insurer will grant a paid-up annuity benefit on a plan stipulated in the contract of such value as is specified in subsections h., i., j., k. and m.

(2) If a contract provides for a lump sum settlement at maturity, or at any other time, that upon surrender of the contract at or prior to the commencement of any annuity payments, the insurer will pay in lieu of any paid-up annuity benefit a cash surrender benefit of such amount as is specified in subsections h., i., k. and m. The insurer shall reserve the right to defer the payment of such cash surrender benefit for a period of six months after demand therefor with surrender of the contract.

(3) A statement of the mortality table, if any, and interest rates used in calculating any minimum paid-up annuity, cash surrender or death benefits that are guaranteed under the contract, together with sufficient information to determine the amounts of such benefits.

(4) A statement that any paid-up annuity, cash surrender or death benefits that may be available under the contract are not less than the minimum benefits required by any statute of the state in which the contract is delivered and an explanation of the manner in which such benefits are altered by the existence of any additional amounts credited by the insurer to the contract, any indebtedness to the insurer on the contract or any prior withdrawals from or partial surrenders of the contract.

Notwithstanding the requirements of this subsection, any deferred annuity contract may provide that if no considerations have been received under a contract for a period of two years and the portion of the paid-up annuity benefit at maturity on the plan stipulated in the contract arising from considerations paid prior to such period would be less than $20.00 monthly, the insurer may at its option terminate such contract by payment in cash of the then present value of such portion of the paid-up annuity benefit, calculated on the basis of the mortality table, if any, and interest rate specified in the contract for determining the paid-up annuity benefit, and by such payment shall be relieved of any further obligation under such contract.

g. The minimum values as specified in subsections h., i., j., k. and m. of any paid-up annuity, cash surrender or death benefits available under an annuity contract referred to in subsection f., shall be based upon minimum nonforfeiture amounts as defined in this subsection:

(1) With respect to contracts providing for flexible considerations, the minimum nonforfeiture amount at any time at or prior to the commencement of any annuity payments shall be equal to an accumulation up to that time at a rate of interest of 3% per annum of percentages of the net considerations (as hereinafter defined) paid prior to such time; decreased by the sum of any prior withdrawals from or partial surrenders of the contract accumulated at a rate of interest of 3% per annum and the amount of any indebtedness to the insurer on the contract, including interest due and accrued; and increased by any existing additional amounts credited by the insurer to the contract. The net considerations for a given contract year used to define the minimum nonforfeiture amount shall be an amount not less than zero and shall be equal to the corresponding gross considerations credited to the contract during that contract year less an annual contract charge of $30.00 and less a collection charge of $1.25 per consideration credited to the contract during that contract year. The percentages of net considerations shall be 65% of the net consideration for the first contract year and 87 1/2% of the net considerations for the second and later contract years. Notwithstanding the provisions of the preceding sentence, the percentage shall be 65% of the portion of the total net consideration for any renewal contract year which exceeds by not more than two times the sum of those portions of the net considerations in all prior contract years for which the percentage was 65%.

(2) With respect to contracts providing for fixed scheduled considerations, minimum nonforfeiture amounts shall be calculated on the assumption that considerations are paid annually in advance and shall be defined as for contracts with flexible considerations which are paid annually with two exceptions:

(a) The portion of the net consideration for the first contract year to be accumulated shall be the sum of 65% of the net consideration for the first contract year plus 22 1/2% of the excess of the net consideration for the first contract year over the lesser of the net considerations for the second and third contract years.

(b) The annual contract charge shall be the lesser of (i) $30.00 or (ii) 10% of the gross annual consideration.

(3) With respect to contracts providing for a single consideration, minimum nonforfeiture amounts shall be defined as for contracts with flexible considerations except that the percentage of net consideration used to determine the minimum nonforfeiture amount shall be equal to 90% and the net consideration shall be the gross consideration less a contract charge of $75.00.

(4) Notwithstanding any other provision of this subsection to the contrary, for any contract issued on or after the effective date of P.L.2003, c.152 and before the 730th day after that effective date, the interest rate at which net consideration shall be accumulated for purposes of determining minimum nonforfeiture amounts shall be 1 1/2% per annum.

h. Any paid-up annuity benefit available under a contract referred to in subsection f. shall have a present value on the date annuity payments are to commence at least equal to the minimum nonforfeiture amount on that date. Such present value shall be computed using the mortality table, if any, and the interest rate specified in the contract for determining the minimum paid-up annuity benefits guaranteed in the contract.

i. For contracts referred to in subsection f. which provide cash surrender benefits, such cash surrender benefits available prior to maturity shall not be less than the present value as of the date of surrender of that portion of the maturity value of the paid-up annuity benefit which would be provided under the contract at maturity arising from considerations paid prior to the time of cash surrender reduced by the amount appropriate to reflect any prior withdrawals from or partial surrenders of the contract, such present value being calculated on the basis of an interest rate not more than 1% higher than the interest rate specified in the contract for accumulating the net considerations to determine such maturity value; decreased by the amount of any indebtedness to the insurer on the contract, including interest due and accrued; and increased by any existing additional amounts credited by the insurer to the contract. In no event shall any cash surrender benefit be less than the minimum nonforfeiture amount at that time. The death benefit under such contracts shall be at least equal to the cash surrender benefit.

j. For contracts referred to in subsection f. which do not provide cash surrender benefits, the present value of any paid-up annuity benefit available as a nonforfeiture option at any time prior to maturity shall not be less than the present value of that portion of the maturity value of the paid-up annuity benefit provided under the contract arising from considerations paid prior to the time the contract is surrendered in exchange for, or changed to, a deferred paid-up annuity, such present value being calculated for the period prior to the maturity date on the basis of the interest rate specified in the contract for accumulating the net considerations to determine such maturity value, and increased by any existing additional amounts credited by the insurer to the contract. For contracts referred to in subsection f. which do not provide any death benefits prior to the commencement of any annuity payments, such present values shall be calculated on the basis of such interest rate and the mortality table specified in the contract for determining the maturity value of the paid-up annuity benefit. However, in no event shall the present value of a paid-up annuity benefit be less than the minimum nonforfeiture amount at that time.

k. This subsection k. shall apply to the determination of the benefits calculated under subsections i. and j. of this section.

(1) In the case of annuity contracts for which the maturity date is stated, that maturity date shall not be after the later of: (a) the anniversary of the contract next following the annuitant's seventieth birthday; or (b) the tenth anniversary of the contract. In the case of annuity contracts under which an election may be made to have annuity payments begin at optional maturity dates, the maturity date shall be deemed to be the latest date for which election is permitted by the contract, but shall not be deemed to be later than the latest date permitted for an annuity contract with a stated maturity date.

(2) The amount of the benefits calculated under subsections i. and j. of this section on or after the stated or deemed maturity date shall not be reduced by any surrender charge. The amount of the benefits calculated under subsections i. and j. of this section on or after the stated or deemed maturity date shall not be less than the greater of: (a) the present value of annuity benefits available on or after the maturity date, computed according to the assumptions stated in subsection h. of this section; and (b) the amount available on or after the maturity date to be applied to the purchase of an annuity on a basis stated in the contract.

(3) Contracts providing for flexible considerations may have separate surrender charge schedules associated with each consideration, provided that the nonforfeiture values are at least as great as they would be if each consideration had been a separate single consideration contract based on the requirements of paragraph (3) of subsection g. of this section. For the purpose of determining the maturity date, the tenth anniversary of the contract shall be determined separately for each consideration.

The provisions of P.L.2005, c.45 shall apply notwithstanding section 1 of P.L.2001, c.237 (C.17B:25-18.4), shall take precedence over that section of law, and shall apply to annuity contracts regardless of whether the requirements of that section have been met.

l. Any contract referred to in subsection f. which does not provide cash surrender benefits or does not provide death benefits at least equal to the minimum nonforfeiture amount prior to the commencement of any annuity payments shall include a statement in a prominent place in the contract that such benefits are not provided.

m. Any paid-up annuity, cash surrender or death benefits available at any time, other than on the contract anniversary under any contract with fixed scheduled considerations referred to in subsection f. shall be calculated with allowance for the lapse of time and the payment of any scheduled considerations beyond the beginning of the contract year in which cessation of payment of considerations under the contract occurs.

n. For any contract referred to in subsection f. which provides, within the same contract by rider or supplemental contract provision, both annuity benefits and life insurance benefits that are in excess of the greater of cash surrender benefits or a return of the gross considerations with interest, the minimum nonforfeiture benefits shall be equal to the sum of the minimum nonforfeiture benefits for the annuity portion and the minimum nonforfeiture benefits, if any, for the life insurance portion computed as if each portion were a separate contract. Notwithstanding the provisions of subsections h., i., j., k. and m., additional benefits payable (1) in the event of total and permanent disability, (2) as reversionary annuity or deferred reversionary annuity benefits, or (3) as other policy benefits additional to life insurance, endowment, and annuity benefits, and considerations for all such additional benefits, shall be disregarded in ascertaining the minimum nonforfeiture amounts, paid-up annuity, cash surrender and death benefits that may be required by this section. The inclusion of such additional benefits shall not be required in any paid-up benefits, unless such additional benefits separately would require minimum nonforfeiture amounts, paid-up annuity, cash surrender and death benefits.

o. After January 1, 1981, any insurer may file with the commissioner a written notice of its election to comply with the provisions of this section after a specified date before January 1, 1983. After the filing of such notice, then upon such specified date, which shall be the operative date of this section for such insurer, the provisions of subsections f. through n. shall become operative with respect to annuity contracts thereafter issued by such insurer. If an insurer makes no such election, the operative date of this section for such insurer shall be January 1, 1983.

p. This section shall not apply to any reinsurance, group annuity purchased in connection with one or more retirement plans or plans of deferred compensation established or maintained by or for one or more employers (including partnerships or sole proprietorships), employee organizations, or any combination thereof, other than plans providing individual retirement accounts or individual retirement annuities under Section 408 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.408), as amended, nor to any premium deposit fund, variable annuity, investment annuity, immediate annuity, any deferred annuity contract after annuity payments have commenced, or reversionary annuity, nor to any contract which shall be delivered outside this State through an agent or other representative of the insurer issuing the contract. The requirements of subsections a. to e. of this section shall not apply to any group annuity, single premium pure endowment, or single stipulated payment annuity.

§ 17B:25-20.1 Supersedure of standard nonforfeiture law, certain.

13. Effective on the second anniversary of the effective date of the "Indexed Standard Nonforfeiture Law for Individual Deferred Annuities," P.L.2005, c.194 (C.17B:25-21 et al.), the standard nonforfeiture law for individual deferred annuities as provided in section 5 of P.L.1981, c.285 (C.17B:25-20) shall continue to govern a contract of annuity issued pursuant thereto, but shall not apply to, and shall be superseded with respect to, a contract of annuity subject to the provisions of the "Indexed Standard Nonforfeiture Law for Individual Deferred Annuities," P.L.2005, c.194 (C.17B:25-21 et al.) as provided therein.

§ 17B:25-21 Short title.

1. This act shall be known and may be cited as the "Indexed Standard Nonforfeiture Law for Individual Deferred Annuities."

§ 17B:25-22 Inapplicability of act.

2. This act shall not apply to any reinsurance, group annuity purchased under a retirement plan or plan of deferred compensation established or maintained by an employer (including a partnership or sole proprietorship) or by an employee organization, or by both, other than a plan providing individual retirement accounts or individual retirement annuities under section 408 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.408), as now or hereafter amended, premium deposit fund, variable annuity, investment annuity, immediate annuity, any deferred annuity contract after annuity payments have commenced, or reversionary annuity, nor to any contract which shall be delivered outside this State through an agent or other representative of the company issuing the contract.

§ 17B:25-23 Required provisions for contract of annuity.

3. a. No contract of annuity to which this act applies shall be delivered or issued for delivery in this State on or after the second anniversary of the effective date of this act, or any earlier date as elected by the company pursuant to section 14 of this act, unless it contains in substance the following provisions, or corresponding provisions which in the opinion of the Commissioner of Banking and Insurance are at least as favorable to the contract holder, upon cessation of payment of considerations under the contract:

(1) That upon cessation of payment of considerations under a contract, or upon the written request of the contract owner, the company shall grant a paid-up annuity benefit on a plan stipulated in the contract of that value provided by sections 5, 6, 7, 8 and 10 of this act;

(2) If a contract provides for a lump sum settlement at maturity, or at any other time, that upon surrender of the contract at or prior to the commencement of any annuity payments, the company shall pay in lieu of a paid-up annuity benefit a cash surrender benefit in the amount provided by sections 5, 6, 8 and 10 of this act. The company may reserve the right to defer the payment of the cash surrender benefit for a period not to exceed six months after demand therefor with surrender of the contract after making written request and receiving written approval of the commissioner. The request shall address the necessity and equitableness to all policyholders of the deferral;

(3) A statement of the mortality table, if any, and interest rates used in calculating any minimum paid-up annuity, cash surrender or death benefits that are guaranteed under the contract, together with sufficient information to determine the amounts of the benefits; and

(4) A statement that any paid-up annuity, cash surrender or death benefits that may be available under the contract are not less than the minimum benefits required by any statute of the state in which the contract is delivered and an explanation of the manner in which the benefits are altered by the existence of any additional amounts credited by the company to the contract, any indebtedness to the company on the contract or any prior withdrawals from or partial surrenders of the contract.

b. Notwithstanding the requirements of this section, a deferred annuity contract may provide that if no considerations have been received under a contract for a period of two full years and the portion of the paid-up annuity benefit at maturity on the plan stipulated in the contract arising from prior considerations paid would be less than $20 monthly, the company may at its option terminate the contract by payment in cash of the then present value of the portion of the paid-up annuity benefit, calculated on the basis of the mortality table, if any, and interest rate specified in the contract for determining the paid-up annuity benefit, and by this payment shall be relieved of any further obligation under the contract.

§ 17B:25-24 Minimum values.

4. The minimum values provided by sections 5, 6, 7, 8 and 10 of this act of any paid-up annuity, cash surrender or death benefits available under an annuity contract shall be based upon minimum nonforfeiture amounts as defined in this section.

a. (1) The minimum nonforfeiture amount at any time at or prior to the commencement of any annuity payments shall be equal to an accumulation up to that time at rates of interest as indicated in subsection b. of this section of the net considerations, as defined in paragraph (2) of this subsection, paid prior to that time, decreased by the sum of subparagraphs (a) through (d) below:

(a) Any prior withdrawals from or partial surrenders of the contract accumulated at rates of interest as indicated in subsection b. of this section;

(b) An annual contract charge of $50, accumulated at rates of interest as indicated in subsection b. of this section;

(c) Any premium tax paid by the company for the contract, accumulated at rates of interest as indicated in subsection b. of this section; and

(d) The amount of any indebtedness to the company on the contract, including interest due and accrued.

(2) The net considerations for a given contract year used to define the minimum nonforfeiture amount shall be an amount equal to 87.5% of the gross considerations credited to the contract during that contract year, except that in the case of a single premium contract, net considerations shall consist of 90% of the gross considerations credited to the contract during that contract year.

b. The interest rate used in determining minimum nonforfeiture amounts shall be an annual rate of interest determined as the lesser of 3% per annum or the following, which shall be specified in the contract if the interest rate will be reset:

(1) The five-year Constant Maturity Treasury Rate reported by the Federal Reserve Board as of a date, or average over a period, rounded to the nearest 1/20th of one percent, specified in the contract no longer than 15 months prior to the contract issue date or redetermination date under paragraph (4) of this section;

(2) Reduced by 125 basis points;

(3) Where the resulting interest rate is not less than 1% per annum; and

(4) The interest rate shall apply for an initial period, and may be redetermined for additional periods. The redetermination date, basis and period, if any, shall be stated in the contract. The basis is the date or average over a specified period that produces the value of the five-year Constant Maturity Treasury Rate to be used at each redetermination date.

c. During the period or term that a contract provides a substantive participation in an equity indexed benefit, it may increase the reduction described in paragraph (2) of subsection b. of this section by up to an additional 100 basis points to reflect the value of the equity index benefit. The present value at the contract issue date, and at each redetermination date thereafter, of the additional reduction shall not exceed the market value of the benefit. The commissioner may require a demonstration that the present value of the additional reduction does not exceed the market value of the benefit. If that demonstration is not acceptable to the commissioner, the commissioner may disallow or limit the additional reduction.

d. The commissioner may adopt rules to implement the provisions of subsection c. of this section which provide for further adjustments to the calculation of minimum nonforfeiture amounts for contracts that provide substantive participation in an equity index benefit and for other contracts that the commissioner determines adjustments are justified.

§ 17B:25-25 Paid-up annuity benefit.

5. Any paid-up annuity benefit available under a contract shall be such that its present value on the date annuity payments are to commence is at least equal to the minimum nonforfeiture amount on that date. Present value shall be computed using the mortality table, if any, and the interest rates specified in the contract for determining the minimum paid-up annuity benefits guaranteed in the contract.

§ 17B:25-26 Cash surrender benefits, determination of present value.

6. For contracts that provide cash surrender benefits, the cash surrender benefits available prior to maturity shall not be less than the present value as of the date of surrender of that portion of the maturity value of the paid-up annuity benefit that would be provided under the contract at maturity arising from considerations paid prior to the time of cash surrender, reduced by the amount appropriate to reflect any prior withdrawals from or partial surrenders of the contract, which present value shall be calculated on the basis of an interest rate not more than 1% higher than the interest rate specified in the contract for accumulating the net considerations to determine maturity value, decreased by the amount of any indebtedness to the company on the contract, including interest due and accrued, and increased by any existing additional amounts credited by the company to the contract. In no event shall any cash surrender benefit be less than the minimum nonforfeiture amount at that time. The death benefit under such contracts shall be at least equal to the cash surrender benefit.

§ 17B:25-27 Determination of present value.

7. For contracts that do not provide cash surrender benefits, the present value of any paid-up annuity benefit available as a nonforfeiture option at any time prior to maturity shall not be less than the present value of that portion of the maturity value of the paid-up annuity benefit provided under the contract arising from considerations paid prior to the time the contract is surrendered in exchange for, or changed to, a deferred paid-up annuity, such present value being calculated for the period prior to the maturity date on the basis of the interest rate specified in the contract for accumulating the net considerations to determine maturity value, and increased by any additional amounts credited by the company to the contract. For contracts that do not provide any death benefits prior to the commencement of any annuity payments, present values shall be calculated on the basis of that interest rate and the mortality table specified in the contract for determining the maturity value of the paid-up annuity benefit. However, in no event shall the present value of a paid-up annuity benefit be less than the minimum nonforfeiture amount at that time.

§ 17B:25-28 Determination of benefits.

8. a. For the purpose of determining the benefits calculated under sections 6 and 7 of this act, in the case of annuity contracts for which the maturity date is stated, that maturity date shall not be after the later of: (1) the anniversary of the contract next following the annuitant's seventieth birthday; or (2) the tenth anniversary of the contract. In the case of annuity contracts under which an election may be made to have annuity payments begin at optional maturity dates, the maturity date shall be deemed to be the latest date for which election is permitted by the contract, but shall not be deemed to be later than the latest date permitted for an annuity contract with a stated maturity date.

b. The amount of benefits calculated under sections 6 and 7 of this act on or after the stated or deemed maturity date shall not be reduced by any surrender charge. The amount of the benefits calculated under sections 6 and 7 of this act on or after the stated or deemed maturity date shall not be less than the greater of: (1) the present value of annuity benefits available on or after the maturity date, computed according to the assumptions stated in section 5 of this act; or (2) the amount available on or after the maturity date to be applied to the purchase of an annuity on a basis stated in a contract.

c. Contracts providing for flexible considerations may have separate surrender charge schedules associated with each consideration, provided that the nonforfeiture values are at least as great as they would be if each consideration had been a separate single consideration contract based on the requirements of subsection a. of section 4 of this act. For the purpose of determining the maturity date, the tenth anniversary of the contract shall be determined separately for each consideration.

d. (1) The difference between an annuity contract's greater present value, utilized for determining any paid-up annuity benefit, and referred to as the contract's accumulation value, and its lesser present value, utilized when an annuitant withdraws from the contract, and referred to as the contract's withdrawal value, on or after the date of maturity, shall not be considered to be a surrender charge for the purposes of this section if:

(a) the accumulation value of the contract:

(i) is never available in a lump sum , and is paid out in substantially equal payments over a period of not less than five years or the surviving lifetime of the annuitant's life, whichever period is shorter ; and

(ii) for the contract period prior to the date of maturity and during the period, on or after the date of maturity, of any annuity payments, credits a fixed rate of at least 1% more than the rate credited to the withdrawal value, or credits a rate that provides substantive participation in an equity indexed benefit with an estimated expected value of at least 1% more than the rate credited to the withdrawal value; and

(b) the separately defined withdrawal value of the contract:

(i) equals, at maturity, not less than the minimum value of the contract as defined in section 4 of P.L.2005, c.194 (C.17B:25-24), plus any premium load; and

(ii) accumulates, from maturity and later, at the minimum rate as defined in section 4 of P.L.2005, c.194 (C.17B:25-24).

(2) For the purpose of this subsection, the Department of Banking and Insurance may approve other methods of providing enhanced value to the accumulation value of a contract in comparison to the withdrawal value of the contract. Any method approved by the department shall be reasonably determined to provide an enhanced value to the contract's accumulation value which is at least as favorable to the contract holder as the accumulation value provided by the provisions of this subsection.

The provisions of this section shall apply notwithstanding section 1 of P.L.2001, c.237 (C.17B:25-18.4), shall take precedence over that section of law, and shall apply to annuity contracts regardless of whether the requirements of that section have been met.

§ 17B:25-29 Notice of benefits not provided in contract.

9. A contract that does not provide cash surrender benefits or does not provide death benefits at least equal to the minimum nonforfeiture amount prior to the commencement of any annuity payments shall include a statement in a prominent place in the contract that those benefits are not provided.

§ 17B:25-30 Benefits allowance for lapse of time and payments beyond schedule.

10. Any paid-up annuity, cash surrender or death benefits available at any time, other than on the contract anniversary under any contract with fixed scheduled considerations, shall be calculated with allowance for the lapse of time and the payment of any scheduled considerations beyond the beginning of the contract year in which cessation of payment of considerations under the contract occurs.

§ 17B:25-31 Minimum nonforfeiture benefits.

11. For a contract which provides, within the same contract by rider or supplemental contract provision, both annuity benefits and life insurance benefits that are in excess of the greater of cash surrender benefits or a return of the gross considerations with interest, the minimum nonforfeiture benefits shall be equal to the sum of the minimum forfeiture benefits for the annuity portion and the minimum nonforfeiture benefits, if any, for the life insurance portion computed as if each portion were a separate contract. Notwithstanding the provisions of sections 5, 6, 7, 8 and 10 of this act, additional benefits payable in the event of total and permanent disability, as reversionary annuity or deferred reversionary annuity benefits, or as other policy benefits additional to life insurance, endowment and annuity benefits, and considerations for all such additional benefits, shall be disregarded in ascertaining the minimum nonforfeiture amounts, paid-up annuity, cash surrender and death benefits that may be required by this act. The inclusion of those benefits shall not be required in any paid-up benefits unless the additional benefits separately would require minimum nonforfeiture amounts, paid-up annuity, cash surrender and death benefits.

§ 17B:25-32 Rules.

12. The Commissioner of Banking and Insurance may adopt rules to implement the provisions of this act pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

§ 17B:25-33 Effective date, applicability.

14. This act shall take effect immediately and shall apply as follows:

a. Before the second anniversary of the effective date of this act, on a contract form-by-contract form basis, to those annuity contracts for which the company has filed a notice of election of applicability with the Commissioner of Banking and Insurance. A company that elects not to file using the "Indexed Standard Forfeiture Law for Individual Deferred Annuities," P.L.2005, c.194 (C.17B:25-21 et al.), may continue to use contract forms which use the interest rate of 1 1/2% per annum for minimum nonforfeiture values as specified by paragraph (4) of subsection g. of section 5 of P.L.1981, c.285 (C.17B:25-20).

b. In all other instances, to all annuity contracts issued by the company on or after the second anniversary of the effective date.

§ 17B:25-34 Findings, declarations relative to certain annuity products.

1. The Legislature finds and declares that it is a valid public purpose to set forth standards and procedures regarding annuity products directly solicited to consumers to: prevent the fraudulent and misleading marketing of annuity products by insurers, brokers, and agents; provide standards for the disclosure of information about annuity products so that consumers understand the basic features of these products; ensure that annuity products ultimately issued to consumers are suitable to appropriately address their insurance needs and financial objectives; and enhance oversight over annuity products, including enforcement against violations, through the Department of Banking and Insurance.

§ 17B:25-35 Definitions relative to certain annuity products.

2. As used in this act, except as otherwise specified:

"Annuity" means an annuity as defined by N.J.S.17B:17-5 directly solicited to a consumer.

"Consumer" means a natural person who resides in this State.

"Deferred annuity" means an annuity with the first income payment due no earlier than one year from the date of issue and the annuity is not an immediate annuity.

"Determinable element" means a benefit, value, credit, or charge under an annuity that is guaranteed at issue, but its amount is not determined until after issue.

"Direct-response solicitation" means a solicitation solely through mail, telephone, the Internet, or other mass communication media.

"Fixed annuity" means an annuity under which the charges and other considerations provided for the annuity, less any amount charged against these considerations, earns interest at a rate: (1) set by the insurer; or (2) in a manner specified in the annuity, which manner may include, but is not limited to, the use of a stock market or other outside index.

"Generic name" means a short title which is descriptive of the charges and benefit patterns of an annuity, or endorsement or rider to the annuity.

"Guaranteed element" means a benefit, value, credit, or charge under an annuity that is guaranteed and the amount determined at issue.

"Immediate annuity" means an annuity with the first income payment due not more than 13 months from the date of issue.

"Insurer" means any corporation, association, partnership, reciprocal exchange, interinsurer, Lloyd's insurer, fraternal benefit society or other person licensed to engage in the business of insurance in this State.

"Insurance producer" means a person licensed to sell, solicit, or negotiate insurance pursuant to the "New Jersey Insurance Producer Licensing Act of 2001," P.L.2001, c.210 (C.17:22A-26 et al.).

"Negotiate" means the act of conferring directly with or offering advice directly to a consumer as the purchaser or prospective purchaser of a particular annuity concerning any of the substantive benefits, terms or conditions of the annuity, provided that the person engaged in that act either: sells annuities or obtains annuities from insurers for purchasers.

"Non-guaranteed element" means a benefit, value, credit, or charge under an annuity that is not guaranteed and the amount not determined at issue.

"Owner" means the person to whom an annuity is presently or prospectively payable by the terms of the annuity, except when the annuity declares some other person to be the owner thereof, or the individual certificate holder in the case of a group annuity.

"Sell" means to exchange an annuity by any means, for money or its equivalent, on behalf of an insurer.

"Solicit" means attempting to sell an annuity or asking or urging a consumer to apply for a particular annuity from a particular insurer.

"Variable annuity" means an annuity under which the insurer invests, for the annuity owner, the charges and other considerations provided for the annuity, less any amount charged against these considerations, into a separate account, based upon the annuity owner's stated level of investment risk, and which annuity may lose some or all of the owner's investment.

§ 17B:25-36 Use of certain terms regulated; exceptions.

3. a. (1) Consistent with the unfair trade practices set forth in N.J.S.17B:30-1 et seq., an insurance producer, or an agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer in accordance with section 32 of P.L.1997, c.322 (C.17:44B-32), or an insurer, if no producer or non-licensed society agent, representative or member is involved, shall not use a certification, professional designation, or form of advertising expressing or implying in an untrue, deceptive, misleading, or false manner that the producer, non-licensed society agent, representative or member, or insurer has special education, training, or experience in advising or servicing senior citizens or retirees in connection with the solicitation, negotiation, or sale of an annuity, or its value or suitability, either directly or indirectly, including through a publication or writing, or by issuing or promulgating an analysis or report relating to an annuity.

(2) The provisions of this section do not apply to:

(a) a title or designation conferred through an academic degree, certifying the completion of a course of study from an accredited institution of higher education, so long as the title or designation is not used in an untrue, deceptive, misleading, or false manner in connection with the solicitation, negotiation, or sale of an annuity; or

(b) a professional job title presented by an employer or other organization that is licensed or registered by a state or federal financial services regulatory agency, including any agency that regulates financial institutions, insurers, investment companies as defined under the "Investment Company Act of 1940," title I of Pub.L.76-768 (15 U.S.C.s.80a-1 et seq.), investment advisers as defined under the "Investment Advisers Act of 1940," title II of Pub.L.76-768 (15 U.S.C.s.80b-1 et seq.), and broker-dealers, and that indicates seniority or standing within the employer or other organization's operation or specifies an area of specialization recognized by that employer or other organization, so long as the professional job title is not used in an untrue, deceptive, misleading, or false manner in connection with the solicitation, negotiation, or sale of an annuity.

b. An untrue, deceptive, misleading, or false use of a certification, designation, or form of advertising shall include, but is not limited to:

(1) the use of a certification or professional designation not actually earned or otherwise available for use;

(2) the use of a nonexistent or self-conferred certification or professional designation;

(3) the use of a certification or professional designation that expresses or implies a level of occupational qualification obtained through education, training, or experience, but which is not actually obtained; and

(4) (a) the use of a certification or professional designation obtained from a certifying or designating organization that:

(i) is primarily engaged in the business of instruction in sales or marketing;

(ii) does not have reasonable standards or procedures for assuring the competency of a holder of its certificate or professional designation;

(iii) does not have reasonable standards or procedures for monitoring and disciplining a holder of its certificate or professional designation for improper or unethical conduct; or

(iv) does not have reasonable continuing education requirements for a holder of its certificate or professional designation in order to maintain the certification or designation; however

(b) there shall be a rebuttable presumption that the use of a certification or professional designation obtained from a certifying or designating organization is not in violation of this section if the certificate or professional designation issued to the holder does not apply primarily to sales or marketing and is accredited by:

(i) the American National Standards Institute, or its successor;

(ii) the National Commission for Certifying Agencies, or its successor;

(iii) any organization recognized as an accrediting agency by the United States Department of Education pursuant to section 496 of the "Higher Education Act of 1965," Pub.L.89-329 (20 U.S.C.s.1099b); or

(iv) any other organization approved by the commissioner by regulation.

c. In order to determine a violation of this section, the commissioner may consider the use of one or more words, combination of words, or acronyms representing these words, and the manner or context of their use with respect to a certification, professional designation, or form of advertising, including, but not limited to, "senior," "retirement," "elder," or words of similar import, "certified," "registered," "chartered," or words of similar import, and "adviser," "specialist," "consultant," "planner," or words of similar import.

§ 17B:25-37 Certain annuities excluded; annuities buyer's guide; annuity contract disclosure statement.

4. a. An annuity, for purposes of this section, concerning disclosure requirements, shall not include any annuity directly solicited to a consumer, that is:

(1) an annuity that serves as a funding vehicle for an employee welfare, pension, profit-sharing, or deferred compensation plan established or maintained by an employer or other plan sponsor, and which is funded in whole or in part by that employer or other plan sponsor;

(2) a variable annuity subject to the provisions of N.J.S.17B:28-1 et seq.;

(3) a charitable annuity established in accordance with N.J.S.17B:17-13.1;

(4) a structured settlement subject to the provisions of the "Structured Settlement Protection Act," P.L.2001, c.139 (C.2A:16-63 et seq.); or

(5) a funeral insurance policy defined by section 24 of P.L.1993, c.147 (C.17B:17-5.1).

b. The commissioner shall approve, by regulation, a document, including all subjects and language contained therein, for distribution to a consumer by an insurance producer, or an agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer in accordance with section 32 of P.L.1997, c.322 (C.17:44B-32), or an insurer, to serve as a buyer's guide regarding annuities, which may be substantially similar to any annuities buyer's guide prepared by the National Association of Insurance Commissioners, or its successor, and shall include, but not be limited to, a description of various kinds of annuities, standard features of annuities, including the 10-day cancellation period for consumers required by section 6 of this act and any other consumer cancellation period required by law, and information concerning the negotiation and sale of annuities. The commissioner shall make the approved buyer's guide available to consumers on the department's Internet website.

c. The commissioner shall approve, by regulation, the form of an annuity contract disclosure statement, which shall be a separate document from the annuity, for distribution to a consumer by an insurance producer, non-licensed society agent, representative or member, or an insurer.

(1) The annuity contract disclosure statement shall include, but not be limited to:

(a) the issuing insurer's name and address;

(b) the generic name of the annuity, the insurer's product name, if different, and annuity form number, and the same information for any rider or endorsement to the annuity;

(c) a statement that the product is an annuity, accompanied by a definition of annuity;

(d) a summary describing each guaranteed, non-guaranteed, and determinable element of the annuity and any rider or endorsement, including:

(i) any charge, by dollar amount or percentage, and other considerations provided for the annuity, with an explanation of their application under the contract;

(ii) any fixed or variable crediting interest rate, and information concerning the method of its calculation and the duration of any rate period;

(iii) each income payment option;

(iv) any death benefit, and the method of its calculation;

(v) the availability of withdrawing from the insurer any portion of the annuity's contract value;

(vi) any value reduction on the annuity or benefits provided by the annuity resulting from a withdrawal set forth in sub-subparagraph (v) of this subparagraph (d), or resulting from a surrender of the annuity, including any surrender subject to the provisions of section 5 of P.L.1981, c.285 (C.17B:25-20) or the "Indexed Standard Nonforfeiture Law for Individual Deferred Annuities," P.L.2005, c.194 (C.17B:25-21 et seq.);

(e) a summary of the federal tax status of the annuity, and any tax penalty applicable based upon a withdrawal or surrender set forth in sub-subparagraphs (v) and (vi) of subparagraph (d) of this paragraph;

(f) a summary of the 10-day cancellation period for consumers required by section 6 of this act and any other consumer cancellation period required by law, or any greater cancellation period provided under the terms of the annuity, along with the cancellation procedure; and

(g) a statement that the annuity and the solicitation, negotiation, and sale of the annuity are subject to regulatory oversight by the department, accompanied by appropriate contact information for the department's consumer assistance services.

(2) The annuity contract disclosure statement shall comply with the language simplification standards of the "Life and Health Insurance Policy Language Simplification Act," P.L.1979, c.167 (C.17B:17-17 et seq.).

d. (1) An insurance producer, non-licensed society agent, representative or member, or an insurer, if no producer or non-licensed society agent, representative or member is involved, shall provide a consumer who applies for an annuity a copy of the buyer's guide and an annuity contract disclosure statement as set forth in subsections b. and c. of this section, to be delivered no later than five business days after receipt of the application.

(2) If a direct-response solicitation occurs via the Internet, the provisions of paragraph (1) for supplying the buyer's guide and the annuity contract disclosure statement shall be satisfied:

(a) by making the documents available, in printable form, to consumers on the issuing insurer's Internet website, and providing notice to the consumer of their availability; and

(b) by allowing consumers to request, through the issuing insurer's Internet website, mailed copies of the documents, so long as the insurer provides the documents no later than five business days after receipt of the application.

(3) If the buyer's guide and the annuity contract disclosure statement are not provided to the consumer in accordance with this section, the consumer shall have a period of not less than 15 days after receipt of any annuity purchased, or longer if provided by the terms of the annuity, to cancel the annuity, and receive from the insurer a prompt refund of any account value of the annuity, including any contract fees or other charges, by mailing or otherwise surrendering the annuity together with a written request for cancellation. The cancellation period provided by this paragraph shall run concurrently with the cancellation period provided by section 6 of this act, or as provided under any other provision of law.

§ 17B:25-38 Certain annuities excluded, information recorded; determination as to suitability of annuity for consumer; system of supervision.

5. a. An annuity, for purposes of this section concerning the suitability of an annuity for a particular consumer, shall not include any annuity directly solicited to a consumer, that is:

(1) an annuity that serves as a funding vehicle for an employee welfare, pension, profit-sharing, or deferred compensation plan established or maintained by an employer or other plan sponsor, and which is funded in whole or in part by that employer or other plan sponsor;

(2) a structured settlement subject to the provisions of the "Structured Settlement Protection Act," P.L.2001, c.139 (C.2A:16-63 et seq.); or

(3) a funeral insurance policy defined by section 24 of P.L.1993, c.147 (C.17B:17-5.1).

b. (1) An insurance producer, or an agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer in accordance with section 32 of P.L.1997, c.322 (C.17:44B-32), or an insurer, if no producer or non-licensed society agent, representative or member is involved, shall not negotiate or sell an annuity to a consumer unless the producer, non-licensed society agent, representative or member, or insurer has reasonable grounds for believing that the annuity is suitable for the consumer, on the basis of the facts disclosed by the consumer as to the consumer's investments, other insurance products, financial situation and objectives.

(2) The insurance producer, non-licensed society agent, representative or member, or insurer shall, prior to selling an annuity negotiated with a consumer, make reasonable efforts to obtain, and record on a form prescribed by the commissioner, information concerning:

(a) the consumer's financial status;

(b) the consumer's tax status;

(c) the consumer's investment objectives;

(d) any other information considered to be relevant by the producer, non-licensed society agent, representative or member, or insurer to provide the reasonable grounds for believing the annuity is suitable for the consumer; and

(e) the consumer's acknowledgement:

(i) that the annuity and the solicitation, negotiation, and sale of the annuity concerning its suitability are subject to regulatory oversight by the department; and

(ii) of receipt of appropriate contact information for the department's consumer assistance services.

(3) The reasonable grounds for an insurance producer, non-licensed society agent, representative or member, or insurer for believing the annuity is suitable for the consumer shall be based upon all relevant information and circumstances of the consumer actually obtained or known, and recorded, during the time of any negotiation or offer of sale on the annuity.

(4) (a) The insurance producer, non-licensed society agent, representative or member, or insurer shall not have any obligation to a consumer concerning the suitability of an annuity under this subsection:

(i) for merely soliciting a consumer to apply for a particular type of annuity through a direct-response solicitation, occurring prior to any negotiation or attempt to sell the annuity;

(ii) if the consumer, upon negotiating or attempting to sell the annuity, refuses to provide the relevant information requested pursuant to paragraph (2) of this subsection, or fails to provide complete or accurate information; or

(iii) if the consumer chooses to obtain an annuity other than the annuity negotiated and offered for sale.

(b) With respect to any variable annuity, the insurance producer, non-licensed society agent, representative or member, or insurer shall be deemed to have complied with the provisions of this subsection if the producer, non-licensed society agent, representative or member, or insurer complies with any rules of conduct pertaining to consumer suitability promulgated by the Financial Industry Regulatory Authority, or its successor, and approved by the United States Securities and Exchange Commission in accordance with section 19(b)(1) of the "Securities Exchange Act of 1934," Pub.L.73-291 (15 U.S.C. s.78s(b)(1)).

c. (1) An insurer shall establish and maintain a system of supervision, or contract with a third party to establish and maintain a system, concerning the negotiation and sale of annuities directly negotiated and sold by the insurer, to assure compliance with the consumer suitability requirements set forth in subsection b. of this section. Any third party insurance producer or non-licensed society agent, representative or member authorized to act on behalf of the insurer shall adopt the insurer's system of supervision for its own employees and contracted persons who negotiate and sell annuities, or establish and maintain a system to assure compliance with the consumer suitability requirements set forth in subsection b. of this section.

(2) A system of supervision shall include, but not be limited to:

(a) A written set of procedures concerning the negotiation and sale of annuities; and

(b) Periodic reviews of information as set forth by the commissioner in regulation, to assist in detecting and preventing violations of subsection b. of this section.

(3) Whenever an insurer authorizes a third party insurance producer or non-licensed society agent, representative or member to act on its behalf, the insurer shall make reasonable inquiry to assure that this third party establishes and maintains the system of supervision required by paragraph (1) of this subsection. The reasonable inquiry by the insurer shall include:

(a) Obtaining a certification, at least annually, from the third party insurance producer or non-licensed society agent, representative or member, signed by the third party, or an officer, director, or supervisory or managerial employee of that third party with responsibility for the system of supervision, which may be made available as a representation, in printable form to the insurer, on the third party's Internet website, stating the system complies with the provisions of paragraph (1) of this subsection, or stating that it is not presently in compliance and including specific criteria to be implemented to achieve compliance; and

(b) Periodic reviews of information as set forth by the commissioner in regulation, to assist in detecting and preventing violations of subsection b. of this section.

§ 17B:25-39 Cancellation provision for certain annuities.

6. An annuity directly solicited to a consumer, except for any annuity that is excluded pursuant to the provisions of section 5 of this act, shall not be delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the commissioner after the effective date of this act, unless the annuity includes provisions or has attached to it a notice stating that during a period of not less than 10 days after the date the initial owner receives the annuity, the owner may cancel the annuity and receive from the insurer a prompt refund of any account value of the annuity, including any contract fees or other charges, by mailing or otherwise surrendering the annuity together with a written request for cancellation.

§ 17B:25-40 Certain annuities excluded; report to owner.

7. a. An annuity, for purposes of this section, shall not include any annuity directly solicited to a consumer that is excluded pursuant to the provisions of section 4 of this act.

b. (1) An insurer shall provide the owner of an annuity with a report, at least annually, on information concerning the annuity which includes, but is not limited to:

(a) the beginning and end date of the current report period;

(b) the total amount of charges and other considerations provided for the annuity, any amount charged against the annuity's contract value, and interest credited;

(c) the accumulation value, based upon the charges and other considerations provided for the annuity, less any charge against the annuity's contract value, plus interest credited;

(d) the cash surrender value, calculated as the greater of the accumulation value as set forth in subparagraph (c) of this paragraph less any applicable surrender charge, or the annuity's minimum guaranteed contract value; and

(e) the amount owed on any outstanding loan borrowed by the owner against the annuity's contract value as of the end of the current report period.

(2) The insurer shall provide this report:

(a) at the beginning and during the accumulation period prior to maturity on a deferred annuity; and

(b) at the beginning and during the payout period, for which income payments occur at or after maturity, on any annuity with changes to any non-guaranteed element.

§ 17B:25-41 Collection, maintenance of information.

8. Any information required to be collected and maintained in order to fulfill the requirements of this act shall be done in accordance with the insurance information practice provisions of P.L.1985, c.179 (C.17:23A-1 et seq.).

§ 17B:25-42 Violations, penalties.

9. a. A violation of this act shall be a violation of N.J.S.17B:30-1 et seq.

b. Pursuant to the authority provided to the commissioner under N.J.S.17B:30-1 et seq., the commissioner may, upon finding a violation occurred or is occurring, order:

(1) an insurer to take reasonably appropriate corrective action regarding any consumer harmed by a violation relating to an annuity issued by the insurer; or

(2) a third party insurance producer, or an agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer in accordance with section 32 of P.L.1997, c.322 (C.17:44B-32), who is authorized to act on behalf of the insurer, to take reasonably appropriate corrective action regarding any consumer harmed by a violation relating to an annuity negotiated and sold by the insurance producer or non-licensed society agent, representative or member.

c. The commissioner may, as permitted under N.J.S.17B:30B-1 et seq., alter, modify, or set aside, in whole or in part, any order concerning a penalty for a violation, if the corrective action ordered pursuant to subsection b. of this section occurs promptly to the satisfaction of the commissioner.

Chapter 26

§ 17B:26-1 Filing of forms

a. No health insurance policy, or application, if a written application is required and is to be made a part of the policy, or printed rider or endorsement for use with the policy, shall be delivered or issued for delivery in this State unless the form has been filed with the commissioner for approval in accordance with the provisions of section 16 of P.L.1995, c.73 (C.17B:25-18.2).

b. (Deleted by amendment, P.L.1995, c.73.)

c. If a form is disapproved by the commissioner during the 60-day period, it may not be delivered or issued for delivery unless it is resubmitted and approved in accordance with the provisions of subsections b., c. and d., of section 16 of P.L.1995, c.73 (C.17B:25-18.2). Such disapproval shall be subject to review in accordance with the procedure described in the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder. Any such form which is filed by the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith.

d. (Deleted by amendment, P.L.1995, c.73.)

e. (Deleted by amendment, P.L.1995, c.73.)

f. This section shall not apply to documents which relate only to the manner of distribution of benefits or to the reservation of rights and benefits under health insurance policies and which are used at the request of the individual policyholder.

g. No form shall be filed by the commissioner in accordance with this section until the classification of risks and premium rates, if any, pertaining to such form have been submitted to the commissioner. If such a classification of risks and premium rates are submitted to the commissioner later than the submission of the form to which they pertain, the 60-day period specified in subsection c. of this section shall commence with the date such classification of risks and premium rates are submitted to the commissioner.

h. The disapproval by the commissioner of any form may be on the ground that:

(1) the benefits are unreasonable in relation to the premium charged, or

(2) such form contains provisions which are unjust, unfair, inequitable, misleading, contrary to law or to the public policy of this State, or

(3) the policy is sold in such a manner as to mislead the insured, or

(4) insurance under such policy is being solicited by means of advertising, communication or dissemination of information which involves misleading or inadequate description of the provisions of the policy, specifying particulars.

i. The commissioner may exempt from the requirements of this section for so long as he deems proper any insurance document or form or type thereof to which, in his opinion, this section may not practicably be applied, or the filing of which is, in his opinion, not desirable or necessary for the protection of the public.

§ 17B:26-2 Form of policy; requirements.

a. No such policy of insurance shall be delivered or issued for delivery to any person in this State unless:

(1) The entire money and other considerations therefor are expressed therein; and

(2) The time at which the insurance takes effect and terminates is expressed therein; and

(3) It purports to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyholder, any two or more eligible members of that family, including husband, wife, dependent children or any children under a specified age which shall not exceed 19 years, and any other person dependent upon the policyholder; and

(4) The style, arrangement, and overall appearance of the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than 10-point with a lower-case unspaced alphabet length not less than 120-point (the "text" shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description if any, and captions and subcaptions); and

(5) The exceptions and reductions of indemnity are set forth in the policy and, except those which are set forth in sections 17B:26-3 to 17B:26-31 inclusive, are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as "exceptions," or "exceptions and reductions," provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; and

(6) Each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and

(7) It contains no provision purporting to make any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the commissioner.

b. A policy under which coverage of a dependent of the policyholder terminates at a specified age shall, with respect to an unmarried child covered by the policy prior to the attainment of age 19, who is incapable of self-sustaining employment by reason of intellectual disability or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon such policyholder for support and maintenance, not so terminate while the policy remains in force and the dependent remains in such condition, if the policyholder has within 31 days of such dependent's attainment of the limiting age submitted proof of such dependent's incapacity as described herein. The foregoing provisions of this paragraph shall not require an insurer to insure a dependent who is a child with an intellectual disability or physical handicap where the policy is underwritten on evidence of insurability based on health factors set forth in the application or where such dependent does not satisfy the conditions of the policy as to any requirement for evidence of insurability or other provisions of the policy, satisfaction of which is required for coverage thereunder to take effect. In any such case, the terms of the policy shall apply with regard to the coverage or exclusion from coverage of such dependent.

c. Notwithstanding any provision of a policy of health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides for reimbursement for any optometric service which is within the lawful scope of practice of a duly licensed optometrist, the insured under such policy shall be entitled to reimbursement for such service, whether the said service is performed by a physician or duly licensed optometrist.

d. If any policy is issued by an insurer domiciled in this State for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the commissioner that any such policy is not subject to approval or disapproval by such official, the commissioner may by ruling require that such policy meet the standards set forth in subsection a. of this section and in sections 17B:26-3 to 17B:26-31 inclusive.

e. Notwithstanding any provision of a policy of health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides for reimbursement for any psychological service which is within the lawful scope of practice of a duly licensed psychologist, the insured under such policy shall be entitled to reimbursement for such service, whether the said service is performed by a physician or duly licensed psychologist.

f. Notwithstanding any provision of a policy of health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed chiropractor, the insured under such policy or the chiropractor rendering such service shall be entitled to reimbursement for such service, when the said service is performed by a chiropractor. The foregoing provision shall be liberally construed in favor of reimbursement of chiropractors.

g. All individual health insurance policies which provide coverage for a family member or dependent of the insured on an expense incurred basis shall also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of that insured from the moment of birth.

(1) The coverage for newly born children shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

(2) If payment of a specific premium is required to provide coverage for a child, the policy may require that notification of birth of a newly born child and payment of the required premium must be furnished to the insurer within 90 days after the date of birth in order to have the coverage continue beyond such 90-day period.

h. All individual health insurance policies which provide coverage on an expense incurred basis but do not provide coverage for a family member or dependent of the insured on an expense incurred basis shall nevertheless provide for coverage of newborn children of the insured which shall commence with the moment of birth of each child and shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, provided application therefor and payment of the required premium are made to the insurer to include in said policy coverage the same or similar to that of the insured, described in g. (1) above 90 days from the date of a newborn child.

i. Whenever, pursuant to the provisions of an individual or group contract issued by an insurer, the former spouse of a named insured is no longer entitled to coverage as an individual dependent by reason of divorce, separate coverage for such former spouse shall be made available by the insurer on an individual non-group basis under the following conditions:

(1) Application for such non-group coverage shall be made to the insurer by or on behalf of such former spouse no later than 31 days following the date his or her coverage under the prior certificate or contract terminated.

(2) No new evidence of insurability shall be required in connection with the application for such non-group coverage, but any health exception, limitation, or exclusion applicable to said former spouse under the prior coverage may, at the option of the insurer, be carried over to the new non-group coverage.

(3) The effective date of the new coverage shall be the day following the date on which such former spouse's coverage under the prior certificate or contract terminated.

(4) The benefits provided under the non-group coverage issued to such former spouse shall be at least equal to the basic benefits provided in contracts then being issued by the insurer to acceptable new non-group applicants of the same age and family status.

§ 17B:26-2.1a Reconstructive breast surgery; benefits

1. Every health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses, and, under any policy providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the policy.

§ 17B:26-2.1b Health insurance policies

Every health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this amendatory and supplementary act, shall offer coverage for maternity care without regard to marital status to subscribers or other persons covered thereunder for expenses incurred in pregnancy and childbirth. The coverage for the expenses of pregnancy and childbirth shall be provided to the same extent as the hospitalization benefits are provided in the policy for any other covered illness. If a fixed amount is specified in the policy for surgery, the fixed amount for a pregnancy-related surgical procedure shall be commensurate with the fixed amount payable for a surgical procedure of comparable difficulty and severity.

§ 17B:26-2.1c Benefits for equipment for home treatment of hemophilia

Every health insurance policy providing hospital expense benefits to any policy holder or other person covered thereunder for expenses incurred in connection with the treatment of routine bleeding episodes associated with hemophilia shall provide benefits for expenses incurred in connection with the purchase of blood products and blood infusion equipment required for home treatment of routine bleeding episodes associated with hemophilia when the home treatment program is under the supervision of a State approved hemophilia treatment center. The benefits shall be provided to the same extent as for any sickness under the policy.

As used in this act, "blood product" includes, but is not limited to, Factor VIII, Factor IX and cryoprecipitate; and "blood infusion equipment" includes, but is not limited to, syringes and needles.

Participation in a home treatment program shall not preclude further or additional treatment or care at any eligible facility if the number of home treatments, in accordance with a ratio of home treatments to benefit days established by regulation by the Commissioner of Insurance, does not exceed the total number of benefit days provided for any other sickness under the policy.

§ 17B:26-2.1d Individual health insurance policy to pay benefits for treatment of Wilm's tumor

Every individual health insurance policy providing hospital or medical expense benefits shall provide benefits to any named insured or other person covered thereunder for expenses incurred in the treatment of Wilm's tumor, including autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed experimental or investigational. These benefits shall be provided to the same extent as for any other sickness under the policy.

§ 17B:26-2.1e Individual health insurance policy, mammogram examination benefits.

4. a. No individual health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting:

(1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and

(2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the insurer of the medical necessity of the additional screening and diagnostic testing.

b. These benefits shall be provided to the same extent as for any other sickness under the policy.

c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1f Individual health insurance benefits for certain nursing services

1. a. Notwithstanding any provision of a policy of individual health insurance, whenever such a policy provides for reimbursement for any service which is within the lawful scope of practice of a duly registered professional nurse who is not being paid a salary by a health care provider for the service so performed, a person covered under that individual health insurance policy or the registered professional nurse rendering the service shall be entitled to reimbursement for the service.

b. This act shall exclude salaried services which are already reimbursed and shall not be construed to affect or impair hospital procedures for billing in-hospital nursing care. The practice of nursing shall be deemed to be within the provisions of chapter 26 of Title 17B of the New Jersey Statutes and duly registered professional nurses shall have those privileges and benefits in the scope of their practice as are afforded thereunder to licensed physicians and surgeons in the scope of their practice.

c. This section shall apply to any individual health insurance policy: (1) delivered or issued for delivery in this State on or after the effective date of this act; or (2) under which the insurer has reserved the right to change the premium.

§ 17B:26-2.1g Individual health insurance policy, benefits for "off-label" drugs required

5. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et al.), no individual health insurance policy which provides benefits for expenses incurred in prescribing drugs approved by the federal Food and Drug Administration shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the policy provides benefits to any policyholder or other person covered thereunder for expenses incurred in prescribing a drug for a treatment for which it has not been approved by the Food and Drug Administration if the drug is recognized as being medically appropriate for the specific type of treatment for which the drug has been prescribed in one of the following established reference compendia:

(1) the American Medical Association Drug Evaluations;

(2) the American Hospital Formulary Service Drug Information;

(3) the United States Pharmacopoeia Drug Information;

or, it is recommended by a clinical study or review article in a major-peer reviewed professional journal.

b. Notwithstanding the provisions of this section, coverage shall not be required for any experimental or investigational drug or any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed. The benefits provided pursuant to this section shall be provided to the same extent as other benefits under the policy for drugs prescribed for a treatment approved by the Food and Drug Administration.

c. This section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.

d. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.

§ 17B:26-2.1h Individual health insurer, benefits for health promotion

6. a. Every individual policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.1999, c.339, shall provide benefits to each person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:

(1) For all persons 20 years of age and older, annual tests to determine blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level;

(2) For all persons 35 years of age or older, a glaucoma eye test every five years;

(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;

(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;

(5) For all women 20 years of age or older, a pap smear every two years;

(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 4 of P.L.1991, c.279 (C.17B:26-2.1e);

(7) For all adults, recommended immunizations; and

(8) For all persons 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination and seat belt usage in motor vehicles.

Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the insurer shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.

b. Every individual health care policy offered for sale in this State by an insurer pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. of this section in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no insurer shall be required to provide payment for benefits for a left-sided colon examination in excess of $150.

c. The Commissioner of Banking and Insurance, in consultation with the Department of the Treasury, shall annually adjust the threshold amounts provided by subsection b. of this section in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which the adjustment is made.

d. The requirements of this section shall apply only to health insurers which issue or deliver primary health insurance coverage in this State providing hospital or medical expense benefits. Primary health insurance coverage shall not include the following plans, policies, or contracts: accident only, credit, disability, long-term care, Medicare supplement coverage, CHAMPUS supplement coverage, coverage for Medicare services pursuant to a contract with the United States government, coverage for Medicaid services pursuant to a contract with the State, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.), or hospital confinement indemnity coverage.

e. This section shall apply to all individual health insurance policies in which the carrier has reserved the right to change the premium.

f. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

§ 17B:26-2.1i Requirements for individual health insurer providing benefits for pharmacy services.

4. a. Notwithstanding any other provision of law to the contrary, no individual health insurance policy which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the policy:

(1) Permits the insured, at the time of issuance, amendment or renewal, to select benefit coverage allowing the insured to choose a pharmacy or pharmacist for the provision of prescription drugs or pharmacy services, provided that any pharmacist or pharmacy selected by the insured is registered pursuant to R.S.45:14-1 et seq.;

(2) Provides that no pharmacy or pharmacist shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the policy provides for coverage by contracted or preferred providers for pharmaceutical services, provided the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the policy;

(3) Provides that no copayment, fee, or other condition shall be imposed upon an insured selecting a participating or contracting pharmacist or pharmacy that is not also equally imposed upon all insureds selecting a participating or contracting pharmacist or pharmacy;

(4) (a) Provides that no insured shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;

(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and

(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days;

(5) Sets forth the auditing procedures to be used by the insurer and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist and the auditor. No audit by an insurer shall include a review of any document relating to any person or prescription plan other than those reimbursable by the insurer;

(6) Provides that the insurer, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the insured for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law;

(7) The provisions of P.L.1999, c.395 shall apply to all policies delivered. issued or renewed on or after the effective date of P.L.1999, c.395.

b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any policy.

c. This section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1j Benefits for certain cancer treatments

4. In addition to benefits provided under regulations adopted pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), an insurer shall offer under every individual policy providing health insurance coverage delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance, on or after the effective date of this act to provide benefits for the treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants when performed by institutions approved by the National Cancer Institute or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Benefits for such treatment shall be provided to the same extent as for any other illness under the policy.

The offer required pursuant to this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium. Nothing in this section shall be construed to limit an insurer in adjusting premium amounts, or providing for reasonable deductibles or copayments, with respect to benefits provided pursuant to this section.

§ 17B:26-2.1k Coverage for birth and natal care; health insurance policy

4. a. Every policy that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide coverage for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

b. Notwithstanding the provisions of subsection a. of this section, a policy that provides coverage for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child.

c. Every insurer shall provide notice to policyholders regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the policyholder; (2) the yearly informational packet sent to the policyholder; or (3) January 1, 1996.

§ 17B:26-2.1l Coverage, diabetes treatment, individual health insurance policy.

4. a. Every individual health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide benefits to any person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist: blood glucose monitors and blood glucose monitors for the legally blind; test strips for glucose monitors and visual reading and urine testing strips; insulin; injection aids; cartridges for the legally blind; syringes; insulin pumps and appurtenances thereto; insulin infusion devices; and oral agents for controlling blood sugar Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35 per 30-day supply. The provisions of this subsection shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this subsection shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this subsection shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

b. Each individual health insurance policy shall also provide benefits for expenses incurred for diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of their diabetic condition, including information on proper diet. Benefits provided for self-management education and education relating to diet shall be limited to visits medically necessary upon the diagnosis of diabetes; upon diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Diabetes self-management education shall be provided by a dietitian registered by a nationally recognized professional association of dietitians or a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators or a registered pharmacist in the State qualified with regard to management education for diabetes by any institution recognized by the board of pharmacy of the State of New Jersey.

c. The benefits required by this section shall be provided to the same extent as for any other sickness under the policy.

d. This section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.

e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

f. The Commissioner of Banking and Insurance may, in consultation with the Commissioner of Health, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), promulgate and periodically update a list of additional diabetes equipment and related supplies that are medically necessary for the treatment of diabetes and for which benefits shall be provided according to the provisions of this section.

§ 17B:26-2.1m Coverage for minimum inpatient care following mastectomy by individual hospital, medical expense benefits policy

4. a. Every individual policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide coverage for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The policy shall not require a health care provider to obtain authorization from the insurer for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

The provisions of this section shall not be construed to: require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the insurer under the policy. The benefits shall be provided to the same extent as for any other sickness under the policy.

The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

§ 17B:26-2.1n Applicability of Health Care Quality Act

21. Notwithstanding the provisions of chapter 26 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy meets the requirements of P.L.1997, c.192 (C.26:2S-1 et al.) and regulations adopted thereto. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1o Coverage for treatment of inherited metabolic diseases by individual health insurance policy.

4. No individual health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the policy provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.

The benefits shall be provided to the same extent as for any other medical condition under the policy.

The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1p Health insurance policy to cover certain audiology, speech-language pathology services.

4. Notwithstanding any other provision of chapter 26 of Title 17B of the New Jersey Statutes, benefits shall not be denied to any eligible individual for eligible services, as determined by the terms of the policy or as otherwise required by law, when the services are determined by a physician to be medically necessary and are performed or rendered to that individual by a licensed audiologist or speech-language pathologist within the scope of practice. The practices of audiology and speech-language pathology shall be deemed to be within the provisions of chapter 26 of Title 17B of the New Jersey Statutes and duly licensed audiologists and speech-language pathologists shall have such privileges and benefits in the scope of their practice under that act as are afforded thereunder to licensed physicians and surgeons in the scope of their practice.

§ 17B:26-2.1q Coverage for treatment of domestic violence injuries by individual health insurance policy.

4. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.), no individual health insurance policy providing hospital or medical expense benefits shall contain any provision which denies benefits for expenses incurred in the treatment of an injury or injuries sustained as the result of domestic violence as defined in section 3 of P.L.1991, c.261 (C.2C:25-19), to a named insured or other person covered thereunder. Benefits shall be provided to the same extent as for any other treatment under the policy. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1r Coverage for certain dental procedures for the severely disabled or child age five or under by individual health insurance policy

4. a. No individual health insurance policy providing hospital or medical benefits shall be delivered, issued, executed or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this amendatory and supplementary act, unless the policy provides benefits to any person covered thereunder who is severely disabled or a child age five or under for expenses incurred for: (1) general anesthesia and hospitalization for dental services; or (2) a medical condition covered by the contract which requires hospitalization or general anesthesia for dental services rendered by a dentist regardless of where the dental services are provided.

b. An individual health insurance policy may require prior authorization of hospitalization for dental services in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.

c. This section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1s Individual health insurers to provide coverage for mental health conditions, substance use disorders; collaborative care model.

4. a. (1) Every individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide coverage for mental health conditions and substance use disorders under the same terms and conditions as provided for any other sickness under the contract and shall meet the requirements of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. s.18031(j), and any amendments to, and federal guidance or regulations issued under that act, including 45 C.F.R. Parts 146 and 147 and 45 C.F.R. s.156.115(a)(3).

Coverage provided pursuant to this section shall include benefits delivered through the psychiatric Collaborative Care Model.

(2) As used in this section:

"Mental health condition" means a condition defined to be consistent with generally recognized independent standards of current medical practice referenced in the current version of the Diagnostic and Statistical Manual of Mental Disorders.

"Psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method wherein a primary care provider and a care manager collaborate with a psychiatric consultant to provide care to a patient. "Psychiatric Collaborative Care Model" shall include those benefits that are billed using the following list of Current Procedural Terminology (CPT) codes, which list shall be updated by the Commissioner of Banking and Insurance whenever the codes are altered or supplemented:

(a) 99492 - Initial psychiatric collaborative care management;

(b) 99493 - Subsequent psychiatric collaborative care management; and

(c) 99494 - Initial or subsequent psychiatric collaborative care management, additional time.

"Same terms and conditions" means that the insurer cannot apply more restrictive non-quantitative limitations, such as utilization review and other criteria or more quantitative limitations such as copayments, deductibles, aggregate or annual limits or benefit limits to mental health condition and substance use disorder benefits than those applied to substantially all other medical or surgical benefits.

"Substance use disorder" means a disorder defined to be consistent with generally recognized independent standards of current medical practice referenced in the most current version of the Diagnostic and Statistical Manual of Mental Disorders.

b. (Deleted by amendment, P.L.2019, c.58)

c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

d. Nothing in this section shall reduce the requirement for an insurer to provide benefits pursuant to section 4 of P.L.2017, c.28 (C.17B:26-2.1hh).

§ 17B:26-2.1t Coverage for hemophilia services by individual health insurers

3. Notwithstanding the provisions of chapter 26 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the policy meets the requirements of sections 1 and 2 of P.L.2000, c.121 (C.26:2S-10.1 and C.26:2S-10.2) and the regulations adopted thereto. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1u Individual policy to provide coverage for colorectal cancer screening.

4. a. Every individual policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S. 17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any named insured or other person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recently published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person.

b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force.

c. The benefits shall be provided to the same extent as for any other medical condition under the policy.

d. The provisions of this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1v Individual health insurer prescription drug plans to cover certain infant formulas.

5. An individual health insurer which provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a policy that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits under the policy for expenses incurred in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula.

The benefits shall be provided to the same extent as for any other prescribed items under the policy.

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1w Policy issued under Chapter 26 of Title 17B required to cover certain out-of-network services.

3. Notwithstanding the provisions of chapter 26 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy meets the requirements of P.L.2001, c.367 (C.26:2S-6.1 et al.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1x Individual health insurer to offer coverage for domestic partner.

50. An individual health insurer that provides hospital or medical expense benefits under a policy that is delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to a covered person for a covered person's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3).

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1y Individual health insurer, coverage for contraceptives.

5. a. An individual health insurer that provides hospital or medical expense benefits shall provide coverage under every policy delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:

(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:

(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.

(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration.

(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.

(2) Voluntary male and female sterilization.

(3) Patient education and counseling on contraception.

(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:

(a) Management of side effects;

(b) Counseling for continued adherence to a prescribed regimen;

(c) Device insertion and removal;

(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and

(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.

b. The coverage provided shall include prescriptions for dispensing contraceptives for:

(1) (Deleted by amendment, P.L.2021, c.376)

(2) up to a 12-month period at one time.

c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the policy, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.

(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).

d. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.

§ 17B:26-2.1z Individual health insurance policies to provide benefits for orthotic and prosthetic appliances.

4. a. Every individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

(2) an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, if the covered person's physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports.

As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3), "licensed podiatrist" has the meaning assigned to it in R.S.45:5-1 et seq., and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18).

b. On and after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), an individual health insurance policy shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the policy.

d. The provisions of this section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1aa Individual health insurance policy to provide coverage for hearing aids, cochlear implant for covered persons.

5. a. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for medically necessary expenses incurred in the purchase of a hearing aid or cochlear implant for a covered person, as provided in this section.

b. A policy shall provide coverage that includes the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. An insurer may limit the benefit provided in this section to one hearing aid for each hearing-impaired ear every 24 months.

c. An individual health insurance policy shall provide coverage of the cost of treatment related to cochlear implants, including procedures for the implantation of cochlear devices and costs for any parts, attachments, or accessories of the device, including replacement of obsolete external cochlear implant processors.

d. The benefits shall be provided to the same extent as for any other condition under the policy.

e. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1bb Individual health insurance policy to provide installment payments to obstetrical provider for maternity services.

4. a. Every individual health insurance policy that provides benefits for maternity services, and that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide for reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a covered person's pregnancy.

b. For the purposes of this section, "obstetrical provider licensed in New Jersey" means:

(1) an obstetrician/gynecologist licensed by the State Board of Medical Examiners; or

(2) a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife.

c. This section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1cc Individual health insurance policy to provide benefits for treatment of autism or other developmental disability.

4. Notwithstanding any other provision of law to the contrary, every individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

a. The insurer shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability.

b. When the insured's primary diagnosis is autism or another developmental disability, the insurer shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.

c. When the insured is under 21 years of age and the insured's primary diagnosis is autism, the insurer shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.

(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the policy, but shall not be subject to limits on the number of visits that an insured may make to a provider of behavioral interventions.

(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

(3) (a) The maximum benefit amount for an insured in any calendar year through 2011 shall be $36,000.

(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

(c) The adjusted maximum benefit amount shall apply to a policy that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

(d) Notwithstanding the provisions of this paragraph to the contrary, an insurer shall not be precluded from providing a benefit amount for an insured in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the insurer to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The insurer may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the insurer and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.

e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to an insured.

f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

g. The coverage required under this section may be subject to utilization review, including periodic review, by the insurer of the continued medical necessity of the specified therapies and interventions.

h. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1dd Individual health insurance policy to provide coverage for oral anticancer medications.

4. a. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis no less favorable than the policy provides for intravenously administered or injected anticancer medications.

b. Pursuant to subsection a. of this section, coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medications.

c. An individual health insurance policy shall not achieve compliance with the provisions of this section by imposing an increase in patient cost sharing, including any copayment, deductible or coinsurance, for anticancer medications, whether intravenously administered or injected or orally administered, that are covered under the policy as of the effective date of this act.

d. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1ee Individual health insurance policy to provide coverage for sickle cell anemia.

5. Every individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for medical expenses incurred by a covered person for the treatment of sickle cell anemia and, if the policy provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the policy shall provide coverage for prescription drug expenses incurred by a covered person for the treatment of sickle cell anemia.

The benefits shall be provided to the same extent as for any other medical condition under the policy.

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1ff Individual health insurer to provide coverage for prescription eye drops.

4. a. An individual health insurer which provides hospital or medical expense benefits that include coverage for prescription eye drops under a policy delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services, provided that:

(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and

(2) the refill requested by the insured or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.

b. The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1gg Individual health insurance policy, contract, coverage for synchronization of prescribed medications.

4. a. Every individual health insurance policy or contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall, on at least one occasion per year for each covered person:

(1) apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a 30 days' supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person's chronic medications;

(2) provide coverage for a drug prescribed for the treatment of a chronic illness dispensed in accordance with a plan among the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and

(3) determine dispensing fees based exclusively on the total number of prescriptions dispensed; dispensing fees shall not be prorated or based on the number of the days' supply of medication prescribed or dispensed.

b. This section shall apply to all policies in which the insurer has reserved the right to change the premium.

c. This section shall not apply to prescriptions for opioid analgesics. "Opioid analgesic" means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

§ 17B:26-2.1hh Individual health insurance policy to provide benefits for treatment of substance use disorder.

4. a. An individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide unlimited benefits for inpatient and outpatient treatment of substance use disorder at in-network facilities. The services for the treatment of substance use disorder shall be prescribed by a licensed physician, licensed psychologist, or licensed psychiatrist and provided by licensed health care professionals or licensed or certified substance use disorder providers in licensed or otherwise State-approved facilities, as required by the laws of the state in which the services are rendered.

b. The benefits for the first 180 days per plan year of inpatient and outpatient treatment of substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. The facility shall notify the insurer of both the admission and the initial treatment plan within 48 hours of the admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, an insurer shall provide necessary exceptions to their network to ensure admission in a treatment facility within 24 hours.

c. Providers of treatment for substance use disorder to persons covered under a covered policy shall not require pre-payment of medical expenses during this 180 days in excess of applicable co-payment, deductible, or co-insurance under the policy.

d. The benefits for outpatient visits shall not be subject to concurrent or retrospective review of medical necessity or any other utilization management review.

e. (1) The benefits for the first 28 days of an inpatient stay during each plan year shall be provided without any retrospective review or concurrent review of medical necessity and medical necessity shall be as determined by the covered person's physician.

(2) The benefits for days 29 and thereafter of inpatient care shall be subject to concurrent review as defined in this section. A request for approval of inpatient care beyond the first 28 days shall be submitted for concurrent review before the expiration of the initial 28-day period. A request for approval of inpatient care beyond any period that is approved under concurrent review shall be submitted within the period that was previously approved. No insurer shall initiate concurrent review more frequently than at two-week intervals. If an insurer determines that continued inpatient care in a facility is no longer medically necessary, the insurer shall within 24 hours provide written notice to the covered person and the covered person's physician of its decision and the right to file an expedited internal appeal of the determination pursuant to an expedited process pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.5, as applicable. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered person and the covered person's physician. If the determination is to uphold the denial, the covered person and the covered person's physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.6, as applicable. An independent utilization review organization shall make a determination within 24 hours. If the insurer's determination is upheld and it is determined continued inpatient care is not medically necessary, the insurer shall remain responsible to provide benefits for the inpatient care through the day following the date the determination is made and the covered person shall only be responsible for any applicable co-payment, deductible and co-insurance for the stay through that date as applicable under the policy. The covered person shall not be discharged or released from the inpatient facility until all internal appeals and independent utilization review organization appeals are exhausted. For any costs incurred after the day following the date of determination until the day of discharge, the covered person shall only be responsible for any applicable cost-sharing, and any additional charges shall be paid by the facility or provider.

f. (1) The benefits for the first 28 days of intensive outpatient or partial hospitalization services shall be provided without any retrospective review of medical necessity and medical necessity shall be as determined by the covered person's physician.

(2) The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization services shall be subject to a retrospective review of the medical necessity of the services.

g. Benefits for inpatient and outpatient treatment of substance use disorder after the first 180 days per plan year shall be subject to the medical necessity determination of the insurer and may be subject to prior authorization or, retrospective review and other utilization management requirements.

h. Medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health.

i. The benefits for outpatient prescription drugs to treat substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements.

j. The first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange provided in this subsection.

k. Except as stated above, the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.

l. The benefits required by this section are to be provided to all covered persons with a diagnosis of substance use disorder. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this section.

m. The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium.

n. The Attorney General's Office shall be responsible for overseeing any violations of law that may result from P.L.2017, c.28 (C.17:48-6nn et al.), including fraud, abuse, waste, and mistreatment of covered persons. The Attorney General's Office is authorized to adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations to implement any of the provisions of P.L.2017, c.28 (C.17:48-6nn et al.).

o. The provisions of this section shall not apply to an individual health insurance policy which, pursuant to a contract between the insurer and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the "Family Health Care Coverage Act," P.L.2005, c.156 (C.30:4J-8 et seq.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.

p. As used in this section:

"Concurrent review" means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and as appropriate, the discharge plans.

"Substance use disorder" is as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include substance use withdrawal.

§ 17B:26-2.1ii Individual health insurance policy to provide coverage regardless of gender identity, expression.

4. a. Notwithstanding any other law or regulation to the contrary, an individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance on or after the effective date of this act, shall not contain any provision that discriminates, and the insurer shall not discriminate, on the basis of a covered person's or prospective covered person's gender identity or expression or on the basis that the covered person or prospective covered person is a transgender person.

b. The discrimination prohibited by this section shall include:

(1) denying, cancelling, limiting or refusing to issue or renew a policy on the basis of a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person;

(2) demanding or requiring a payment or premium that is based in whole or in part on a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person;

(3) designating a covered person's or prospective covered person's gender identity or expression, or the fact that a covered person or prospective covered person is a transgender person, as a preexisting condition for which coverage will be denied or limited; or

(4) denying or limiting coverage, or denying a claim, for services including but not limited to the following, due to a covered person's gender identity or expression or for the reason that the covered person is a transgender person:

(a) health care services related to gender transition if coverage is available for those services under the policy when the services are not related to gender transition, including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training; or

(b) health care services that are ordinarily or exclusively available to individuals of one sex when the denial or limitation is due only to the fact that the covered person is enrolled as belonging to the other sex or has undergone, or is in the process of undergoing, gender transition.

c. For the purposes of this section:

"Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's assigned sex at birth.

"Gender identity" means a person's internal sense of their own gender, regardless of the sex the person was assigned at birth.

"Gender transition" means the process of changing a person's outward appearance, including physical sex characteristics, to accord with the person's actual gender identity.

"Transgender person" means a person who identifies as a gender different from the sex assigned to the person at birth.

d. The provisions of this section shall apply to those individual health insurance policies in which the insurer has reserved the right to change the premium.

e. Nothing in this section shall preclude the insurer from performing utilization review, including periodic review of the medical necessity of a particular service.

§ 17B:26-2.1jj Individual health insurance policy to cover digital tomosynthesis of the breast.

4. a. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in conducting digital tomosynthesis to detect or screen for breast cancer in women 40 years of age and over; and for diagnostic purposes in women of any age.

b. In the case of digital tomosynthesis conducted to detect or screen for breast cancer in women 40 years of age and over, no deductible, coinsurance or other cost sharing shall be applied; and in the case of digital tomosynthesis conducted for diagnostic purposes in women of any age, the same deductibles, coinsurance, and other cost sharing as apply to similar services under the policy shall be applied.

c. This section shall apply to those individual health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1kk Individual health insurance policy to provide coverage for donated human breast milk.

4. a. An individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the provision of pasteurized donated human breast milk, which may include human milk fortifiers if indicated by the prescribing licensed medical practitioner, provided that:

(1) the covered person is an infant under the age of six months;

(2) the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health ; and

(3) a licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or

(4) a licensed medical practitioner has issued an order for an infant who meets any of the following conditions:

(a) a body weight below healthy levels determined by the licensed medical practitioner;

(b) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or

(c) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health.

b. The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium.

c. Nothing in this section shall preclude the insurer from performing utilization review, including periodic review of the medical necessity of a particular service.

d. The benefits shall be provided to the same extent as for any other prescribed items under the policy.

e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the insurer shall not be required to provide coverage of expenses pursuant to this section.

§ 17B:26-2.1ll Individual health insurer to provide coverage for breastfeeding support.

4. a. An individual health insurer policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2019, c.343 (C.17:48-6ss et al.), shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for health plan enrollees, with no cost-sharing.

b. Coverage of breastfeeding equipment shall include:

(1) Purchase of a single-user breast pump, subject to the following conditions:

(a) A policy shall cover the purchase of a double electric breast pump. If an enrollee requests a manual pump in lieu of the double electric breast pump, the health plan shall cover the purchase of a manual pump.

(b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding.

(c) A policy shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph.

(d) Coverage shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the plan enrollee.

(e) Coverage for breast pumps shall include repair or replacement if necessary.

(2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions:

(a) When recommended by a licensed health care provider, a policy shall provide coverage for a multi-user breast pump.

(b) An individual health insurer may determine whether a rental or purchase is covered.

(c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump.

(d) An individual health insurer may require a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump.

(3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider.

(4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the individual health insurer cannot ensure an enrollee receives breastfeeding equipment within 48 hours, an enrollee may purchase the equipment and the health plan shall reimburse all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts.

(5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the individual health insurer shall reimburse all out-of-pocket rental expenses incurred by an enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment.

c. Coverage of comprehensive lactation counseling and lactation consultation shall include:

(1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions:

(a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits.

(b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need.

(2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need.

(3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups.

(4) A policy shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting.

(5) An individual health insurer shall not impose medical management techniques not described in this section.

d. Except as otherwise authorized pursuant to this section, an individual health insurer shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided.

e. As used in this section:

"Cost-sharing" means deductible, co-insurance or co-payments, or similar charges.

"Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump.

"Lactation consultant" means an individual who is an International Board Certified Lactation Consultant.

"Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services.

Lactation care and services shall include, but not be limited to:

(1) lactation assessment through the systematic collection of subjective and objective data;

(2) analysis of data and creation of a plan of care;

(3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider;

(4) evaluation of outcomes;

(5) provision of lactation education to parents and health care providers; and

(6) the recommendation and use of assistive devices.

"Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as:

(1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding;

(2) acting as an advocate for breastfeeding as the norm for feeding infants and young children;

(3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals;

(4) using principles of adult education when teaching clients, health care providers, and others in the community; and

(5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately.

"Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is:

(1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or

(2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice.

"Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication.

f. This section shall apply to those policies in which the individual health insurer has reserved the right to change the premium.

§ 17B:26-2.1mm Individual health insurer policy to cover preventive services.

4. a. An individual health insurer policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage, without requiring any cost sharing, for the following preventive services:

(1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;

(2) immunizations that have in effect a recommendation from the Department of Health, which shall in making its recommendations consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians;

(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

(4) with respect to women, any additional preventive care and screenings not described in paragraph (1) as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

b. (1) Except as provided in paragraph (2) of this subsection, nothing in this section shall:

(a) require a policy which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or

(b) preclude a policy which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider.

(2) If a policy does not have in its network a provider who can provide an item or service described in subsection a. of this section, the policy shall cover the item or service when performed by an out-of-network provider and shall not impose cost sharing with respect to that item or service.

c. (1) A policy shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued.

(2) (a) Except as provided in subparagraph (b) of this paragraph, a policy that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year.

(b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section.

d. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

e. With respect to an annual wellness visit for a covered member who is over three years of age, a carrier is required to cover only one wellness visit per plan year or calendar year, as provided for under the policy, but may not impose a waiting period for the wellness visit.

§ 17B:26-2.1nn Individual health insurance policy to provide certain coverage for prescription drugs.

4. a. Notwithstanding any other provision of law to the contrary, an insurer that offers an individual health insurance policy that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, shall ensure that at least 25 percent of all plans, or at least one plan if the carrier offers less than four plans, offered by the carrier in each rating area and in each of the bronze, silver, gold, and platinum levels of coverage, in the individual market pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), shall conform with the following:

(1) (a) a policy that provides a silver, gold, or platinum level of coverage, as defined in 45 C.F.R. s.156.140, shall limit a covered person's cost-sharing, including any copayment or coinsurance, for prescription drugs, including specialty drugs, to no more than $150 per month for each prescription drug for up to a 30-day supply of any single drug;

(b) a policy that provides a bronze level of coverage, as defined in 45 C.F.R. s.156.140, shall ensure that any required covered person's cost-sharing, including any copayment or coinsurance, does not exceed $250 per month for each prescription drug for up to a 30-day supply of any single drug;

(c) a policy that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall be exempt from the requirements of subparagraphs (a) and (b) of this paragraph;

(2) except as provided in paragraph (3) of this subsection, the limits described in paragraph (1) of this subsection shall apply at any point in the benefit design, including before and after any applicable deductible is reached; and

(3) for prescription drug benefits offered in conjunction with a high-deductible health plan, the policy shall not provide prescription drug benefits until the expenditures applicable to the deductible under the plan have met the amount of the minimum annual deductibles in effect for self-only and family coverage under section 223(c)(2)(A)(i) of the federal Internal Revenue Code (26 U.S.C. s.223(c)(2)(A)(i)) for self-only and family coverage, respectively. Once the foregoing expenditure amount has been met under the plan, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in paragraph (1) of this subsection.

b. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1oo Individual health insurance policy to cover adolescent depression screenings.

4. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service.

The benefits shall be provided to the same extent as for any other condition under the policy, except that the insurer shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance.

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1pp Individual policy to cover newborn home nurse visitation.

8. a. No individual health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159). The policy shall:

(1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159);

(2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant;

(3) ensure that the policy does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and

(4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing:

(a) a value-based payment methodology;

(b) an invoice claim process;

(c) a capitated payment arrangement;

(d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or

(e) any other payment arrangement agreed to by the insurer and an agency or organization providing services under the program.

b. Any copayment, coinsurance, or deductible that may be required pursuant to the policy for such services shall be waived.

c. An individual health insurance policy that is subject to the provisions of this section shall submit to the Department of Banking and Insurance, in a form and manner prescribed by the department, a report on the claims submitted for services provided under the newborn home nurse visitation program.

The information contained in the report shall be shared with the Department of Children and Families and used by that department to assess the newborn home nurse visitation program pursuant to subsection a. of section 4 of P.L.2021, c.187 (C.26:2H-161).

d. (1) Except as provided in paragraphs (2) and (3) of this subsection, the contract shall specify that no deductible, coinsurance, copayment, or any other cost-sharing requirement may be imposed on the coverage required pursuant to this section.

(2) An individual health insurance policy that qualifies as a high deductible health plan shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement permitted for a high deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).

(3) An individual health insurance policy that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement to the extent permitted for a catastrophic plan under federal law.

e. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:26-2.1qq Individual health insurance policy, coverage, epinephrine auto-injector device.

11. An individual health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide coverage for at least one epinephrine auto-injector device, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of an epinephrine auto-injector device shall not be subject to any deductible, and no copayment or coinsurance for the purchase of an epinephrine auto-injector device shall exceed $25 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

Nothing in this section shall prevent an individual health insurer from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section.

§ 17B:26-2.1rr Individual health insurance policy, coverage, prescription asthma inhaler.

12. An individual health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide benefits to a person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

Nothing in this section shall prevent an individual health insurer from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section.

§ 17B:26-2.1ss Biomarker precision medical testing coverage, individual health insurance policies.

4. a. Each individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes or is approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for biomarker precision medical testing, as defined by subsection g. of this section.

b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of an insured when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for an insured's disease or condition is recognized by:

(1) labeled indications for an FDA-approved or -cleared test;

(2) indicated tests for an FDA-approved drug;

(3) actions to address warnings and precautions on FDA-approved drug labels;

(4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or

(5) nationally recognized clinical practice guidelines.

c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of an insured.

d. (1) If utilization review is required, a carrier shall provide a decision pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.).

(2) The insured and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the insured shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination.

e. The benefits shall be provided to the same extent as for any other medical condition under the contract, including determinations of clinical review criteria used for utilization review of health care services along with copayment, deductible, and coinsurance provisions.

f. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

g. As used in this section:

"Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression.

"Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing.

"Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. The guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.

§ 17B:26-2.1tt Individual health insurance policy, HIV preexposure prophylaxis, HIV postexposure prophylaxis.

6. a. (1) Except as provided in paragraph (2) of this subsection, no individual health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L.2025, c.196 (C.45:14-67.13) without requiring prior authorization or step therapy.

(2) If the federal Food and Drug Administration has authorized or approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the policy to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.

b. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the individual health insurance policy to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:

(1) the service or procedure is within the scope of practice of the treating pharmacist; and

(2) the service or procedure would otherwise be covered under the policy if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.

c. An individual health insurance policy shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the policy to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.

d.An individual health insurance policy shall not:

(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and

(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L.2025, c.196 (C.45:14-67.13) in excess of a 90-day supply for a single patient within a given two year period.

e. Nothing in this section shall be construed to require an individual health insurance policy to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.

f. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

g. As used in this section:

“HIV preexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12).

“HIV postexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12).

“Step therapy” means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits coverage for the prophylaxis.

§ 17B:26-2.1uu Benefits provided under individual policies.

4. a. Every individual policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S. 17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2025, c.200 (C. 17:48-6bbb et al.), shall provide benefits to any named insured or other person covered thereunder for expenses incurred in obtaining medically necessary treatment for women with a diagnosis of perimenopause, menopause, and symptoms associated with perimenopause and menopause, including, but not limited to:

(1) hormonal therapies such as hormone replacement therapy and bioidentical hormone treatments;

(2) non-hormonal treatments, including medications to manage perimenopause and menopausal symptoms;

(3) behavioral health care services;

(4) pelvic floor physical therapy;

(5) bone health treatments, including screenings and medications due to hormonal changes related to perimenopause and menopause;

(6) preventative services that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force for early detection and treatment of health conditions related to perimenopause and menopause such as osteoporosis and cancer; and

(7) counseling and education regarding menopause management.

b. Every individual policy shall provide clear and accessible information to insureds regarding covered perimenopause and menopause treatments.

c. The benefits shall be provided to the same extent as for any other medical condition under the policy.

d. The provisions of this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium.

e. As used in this section:

“Menopause” means the permanent end of a female’s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period.

“Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles.

§ 17B:26-2.2 Second surgical opinions; definitions

As used in this act:

a. "Elective surgical procedure" means any nonemergency surgical procedure which may be scheduled at the convenience of the patient or the surgeon without jeopardizing the patient's life or causing serious impairment to the patient's bodily functions.

b. "Second surgical opinion" means an opinion of an eligible physician based on that physician's examination of a person for the purpose of evaluating the medical advisability of that person undergoing an elective surgical procedure. The examinations must be performed after another physician licensed to practice medicine and surgery has proposed to perform such surgical procedure on the person but prior to the performance of such surgical procedure.

c. "Eligible physician" means a physician licensed to practice medicine and surgery who holds the rank of Diplomate of an American Board (M.D.) or Certified Specialist (D.O.) in the surgical or medical specialty for which surgery is proposed.

§ 17B:26-2.3 Policy benefits for second surgical opinion

Any insurer issuing an individual insurance policy in accordance with chapter 26 of Title 17B of the New Jersey Statutes which provides coverage of surgical operations performed on a person while confined in a hospital as an inpatient shall make available under the policy benefits for a second surgical opinion for elective surgical procedures which would require inpatient admission to a hospital.

§ 17B:26-2.4 Benefit payments

Benefits for a second surgical opinion shall include payment for the second surgical opinion services of an eligible physician and for essential laboratory and X-ray services incidental thereto, either as a benefit under the individual policy or, at the insurer's option, as an additional benefit offered to the prospective policyholder at issue of a policy. Benefit payments may be limited to second surgical opinion services of eligible physicians who have agreed to participate in an insurer's second surgical opinion program. The benefits shall be reasonably related to amounts payable under the policy for covered surgical procedures.

§ 17B:26-2.5 Third surgical opinion

If a second surgical opinion does not confirm that a proposed elective surgical procedure is medically advisable, benefits must be provided under the policy for a third surgical opinion in the same manner as for the second opinion.

§ 17B:26-2.6 Excluded surgical procedures

The second surgical opinion benefit provisions of a policy may exclude benefits while the patient is confined in a hospital as an inpatient, any surgical procedures not covered by the policy and surgical procedures in the following categories: cosmetic surgery, dental surgery, and podiatric surgery.

§ 17B:26-2.7 Payment for opinion services of physician

If a physician who furnishes a second or third surgical opinion also performs the surgical procedure, the policy need not provide payment for the second or third opinion services of that physician.

§ 17B:26-2.8 Application of act

This act shall apply to all contracts in which the insurer has reserved the right to change the premium.

§ 17B:26-3 Required provisions

Except as provided in section 17B:26-28 each such policy delivered or issued for delivery to any person in this State shall contain the provisions specified in sections 17B:26-4 to 17B:26-15 inclusive, in words in which the same appear in the applicable sections; provided, however, that the insurer may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the commissioner which are in each instance not less favorable in any respect to the insured or the owner, if other than the insured. Such provisions shall be preceded individually by the appropriate caption appearing in each of such sections or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve.

§ 17B:26-3.1 Cancellation of policy within 10 days after receipt

Except as provided in N.J.S. 17B:26-28, each health insurance policy, other than group and blanket insurance, delivered or issued for delivery to any person in this State shall contain a provision or have attached to it a notice as follows:

Cancellation during first 10 days: During a period of 10 days after the date the policyholder receives the policy, the policyholder may cancel the policy and receive from the insurer a prompt refund of any premium paid therefor, including any policy fees or other charges, by mailing or otherwise surrendering the policy to the insurer together with a written request for cancellation.

§ 17B:26-3.2 Individual health insurance policy, exclusion, rates, terms based on genetic information prohibited

14. Every individual health insurance policy providing hospital and medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall not exclude any person or eligible dependent and shall not establish any rates or terms therefor on the basis of an actual or expected health condition or on the basis of any genetic characteristic. For the purposes of this section, "genetic characteristic" means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with statistically increased risk of development of a disease, disorder or syndrome.

§ 17B:26-4 Entire contract; changes

There shall be a provision as follows:

Entire contract; changes: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.

§ 17B:26-5 Time limit on certain defenses

There shall be a provision as follows:

Time limit on certain defenses:

a. After 2 years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such 2-year period.

(1) The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial 2-year period, nor to limit the application of sections 17B:26-17 to 17B:26-21, inclusive, in the event of misstatement with respect to age or occupation or other insurance.

(2) A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (a) until at least age 50 or, (b) in the case of a policy issued after age 44, for at least 5 years from its date of issue, may contain in lieu of the foregoing the following provision (from which the clause in parentheses may be omitted at the insurer's option) under the caption " Incontestable " :

After this policy has been in force for a period of 2 years during the lifetime of the insured, (excluding any period during which the insured is disabled) it shall become incontestable as to the statements contained in the application.

b. No claim for loss incurred or disability (as defined in the policy) commencing after 2 years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss and existed prior to the effective date of coverage of this policy.

§ 17B:26-6 Grace period

There shall be a provision as follows:

Grace period: A grace period of (insert a number not less than "7" for weekly premium policies, "10" for monthly premium policies and "31" for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force.

a. A policy which contains a cancellation provision may add, at the end of the above provision:

Subject to the right of the insurer to cancel in accordance with the cancellation provision hereof.

b. A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision:

Unless not less than 5 days prior to the premium due date the insurer has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.

§ 17B:26-7 Reinstatement

There shall be a provision as follows:

Reinstatement: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.

(The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums a. until at least age 50 or, b. in the case of a policy issued after age 44, for at least 5 years from its date of issue.)

§ 17B:26-8 Notice of claim

There shall be a provision as follows:

Notice of claim: Written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at (insert the location of such office as the insurer may designate for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.

(In a policy providing a loss-of-time benefit which may be payable for at least 2 years, an insurer may at its option insert the following between the first and second sentences of the above provision:

Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least 2 years, he shall, at least once in every 6 months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of 6 months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured's right to any indemnity which would otherwise have accrued during the period of 6 months preceding the date on which such notice is actually given.)

§ 17B:26-9 Claim forms

There shall be a provision as follows:

Claim forms: The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.

§ 17B:26-9.1 Health insurer to receive, transmit transactions relative to individual policies electronically; standards.

5. a. Within 180 days of the adoption of a timetable for implementation pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health insurer or its agent or a subsidiary that processes health care benefits claims as a third party administrator, shall demonstrate to the satisfaction of the Commissioner of Banking and Insurance that it will adopt and implement all of the standards to receive and transmit health care transactions electronically, according to the corresponding timetable, and otherwise comply with the provisions of this section, as a condition of its continued authorization to do business in this State.

The Commissioner of Banking and Insurance may grant extensions or waivers of the implementation requirement when it has been demonstrated to the commissioner's satisfaction that compliance with the timetable for implementation will result in an undue hardship to a health insurer, or its agent, its subsidiary or its covered persons.

b. Within 12 months of the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health insurer or its agent or a subsidiary that processes health care benefits claims as a third party administrator shall use the standard health care enrollment and claim forms in connection with all individual policies issued, delivered, executed or renewed in this State.

c. Twelve months after the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health insurer or its agent shall require that health care providers file all claims for payment for health care services. A covered person who receives health care services shall not be required to submit a claim for payment, but notwithstanding the provisions of this subsection to the contrary, a covered person shall be permitted to submit a claim on his own behalf, at the covered person's option. All claims shall be filed using the standard health care claim form applicable to the policy.

d. For the purposes of this subsection, "substantiating documentation" means any information specific to the particular health care service provided to a covered person.

(1) Effective 180 days after the effective date of P.L.1999, c.154, a health insurer or its agent, hereinafter the payer, shall remit payment for every insured claim submitted by a covered person or health care provider, no later than the 30th calendar day following receipt of the claim by the payer or no later than the time limit established for the payment of claims in the Medicare program pursuant to 42 U.S.C. s.1395u(c)(2)(B), whichever is earlier, if the claim is submitted by electronic means, and no later than the 40th calendar day following receipt if the claim is submitted by other than electronic means, if:

(a) the health care provider is eligible at the date of service;

(b) the person who received the health care service was covered on the date of service;

(c) the claim is for a service or supply covered under the health benefits plan;

(d) the claim is submitted with all the information requested by the payer on the claim form or in other instructions that were distributed in advance to the health care provider or covered person in accordance with the provisions of section 5 of P.L.2023, c.296 (C.17B:30-55.4); and

(e) the payer has no reason to believe that the claim has been submitted fraudulently.

(2) If all or a portion of the claim is not paid within the time frames provided in paragraph (1) of this subsection because:

(a) the claim submission is incomplete because the required substantiating documentation has not been submitted to the payer;

(b) the diagnosis coding, procedure coding, or any other required information to be submitted with the claim is incorrect;

(c) the payer disputes the amount claimed; or

(d) there is strong evidence of fraud by the provider and the payer has initiated an investigation into the suspected fraud,

the payer shall notify the health care provider, by electronic means and the covered person in writing within 30 days of receiving an electronic claim, or notify the covered person and health care provider in writing within 40 days of receiving a claim submitted by other than electronic means, that:

(i) the claim is incomplete with a statement as to what substantiating documentation is required for adjudication of the claim;

(ii) the claim contains incorrect information with a statement as to what information must be corrected for adjudication of the claim;

(iii) the payer disputes the amount claimed in whole or in part with a statement as to the basis of that dispute; or

(iv) the payer finds there is strong evidence of fraud and has initiated an investigation into the suspected fraud in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16).

(3) If all or a portion of an electronically submitted claim cannot be adjudicated because the diagnosis coding, procedure coding or any other data required to be submitted with the claim was missing, the payer shall electronically notify the health care provider or its agent within seven days of that determination and request any information required to complete adjudication of the claim.

(4) Any portion of a claim that meets the criteria established in paragraph (1) of this subsection shall be paid by the payer in accordance with the time limit established in paragraph (1) of this subsection.

(5) A payer shall acknowledge receipt of a claim submitted by electronic means from a health care provider, no later than two working days following receipt of the transmission of the claim.

(6) If a payer subject to the provisions of P.L.1983, c.320 (C.17:33A-1 et seq.) has reason to believe that a claim has been submitted fraudulently, it shall investigate the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or refer the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16).

(7) Payment of an eligible claim pursuant to paragraphs (1) and (4) of this subsection shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means and on or before the 40th calendar day following receipt of a claim submitted by other than electronic means.

If payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of paragraph (2) or paragraph (3) of this subsection, the claims payment shall be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, for claims submitted by electronic means and the 40th calendar day for claims submitted by other than electronic means, following receipt by the payer of the required documentation or information or modification of an initial submission.

If payment is withheld on all or a portion of a claim by a payer pursuant to paragraph (2) or (3) of this subsection and the provider is not notified within the time frames provided for in those paragraphs, the claim shall be deemed to be overdue.

(8) (a) No payer that has reserved the right to change the premium shall deny payment on all or a portion of a claim because the payer requests documentation or information that is not specific to the health care service provided to the covered person.

(b) No payer shall deny payment on all or a portion of a claim while seeking coordination of benefits information unless good cause exists for the payer to believe that other insurance is available to the covered person. Good cause shall exist only if the payer's records indicate that other coverage exists. Routine requests to determine whether coordination of benefits exists shall not be considered good cause.

(c) In the event payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of this paragraph, the claims payment shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means or on or before the 40th calendar day following receipt of a claim submitted by other than electronic means.

(9) An overdue payment shall bear simple interest at the rate of 12% per annum. The interest shall be paid to the health care provider at the time the overdue payment is made. The amount of interest paid to a health care provider for an overdue claim shall be credited to any civil penalty for late payment of the claim levied by the Department of Human Services against a payer that does not reserve the right to change the premium.

(10) With the exception of claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits, no payer shall seek reimbursement for overpayment of a claim previously paid pursuant to this section later than 18 months after the date the first payment on the claim was made. No payer shall seek more than one reimbursement for overpayment of a particular claim. At the time the reimbursement request is submitted to the health care provider, the payer shall provide written documentation that identifies the error made by the payer in the processing or payment of the claim that justifies the reimbursement request. No payer shall base a reimbursement request for a particular claim on extrapolation of other claims, except under the following circumstances:

(a) in judicial or quasi-judicial proceedings, including arbitration;

(b) in administrative proceedings;

(c) in which relevant records required to be maintained by the health care provider have been improperly altered or reconstructed, or a material number of the relevant records are otherwise unavailable; or

(d) in which there is clear evidence of fraud by the health care provider and the payer has investigated the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), and referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16).

(11) (a) In seeking reimbursement for the overpayment from the health care provider, except as provided for in subparagraph (b) of this paragraph, no payer shall collect or attempt to collect:

(i) the funds for the reimbursement on or before the 45th calendar day following the submission of the reimbursement request to the health care provider;

(ii) the funds for the reimbursement if the health care provider disputes the request and initiates an appeal on or before the 45th calendar day following the submission of the reimbursement request to the health care provider and until the health care provider's rights to appeal set forth under paragraphs (1) and (2) of subsection e. of this section are exhausted; or

(iii) a monetary penalty against the reimbursement request, including but not limited to, an interest charge or a late fee.

The payer may collect the funds for the reimbursement request by assessing them against payment of any future claims submitted by the health care provider after the 45th calendar day following the submission of the reimbursement request to the health care provider or after the health care provider's rights to appeal set forth under paragraphs (1) and (2) of subsection e. of this section have been exhausted if the payer submits an explanation in writing to the provider in sufficient detail so that the provider can reconcile each covered person's bill.

(b) If a payer has determined that the overpayment to the health care provider is a result of fraud committed by the health care provider and the payer has conducted its investigation and reported the fraud to the Office of the Insurance Fraud Prosecutor as required by law, the payer may collect an overpayment by assessing it against payment of any future claim submitted by the health care provider.

(12) No health care provider shall seek reimbursement from a payer or covered person for underpayment of a claim submitted pursuant to this section later than 18 months from the date the first payment on the claim was made, except if the claim is the subject of an appeal submitted pursuant to subsection e. of this section or the claim is subject to continual claims submission. No health care provider shall seek more than one reimbursement for underpayment of a particular claim.

e. (1) A health insurer or its agent, hereinafter the payer, shall establish an internal appeal mechanism to resolve any dispute raised by a health care provider regardless of whether the health care provider is under contract with the payer regarding compliance with the requirements of this section or compliance with the requirements of sections 5 through 15 of P.L.2023, c.296 (C.17B:30-55.4 through 17B:30-55.14). No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of an appeal pursuant to this subsection. The payer shall conduct the appeal at no cost to the health care provider.

A health care provider may initiate an appeal on or before the 90th calendar day following receipt by the health care provider of the payer's claims determination, which is the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance which shall describe the type of substantiating documentation that must be submitted with the form. The payer shall conduct a review of the appeal and notify the health care provider of its determination on or before the 30th calendar day following the receipt of the appeal form. If the health care provider is not notified of the payer's determination of the appeal within 30 days, the health care provider may refer the dispute to arbitration as provided by paragraph (2) of this subsection.

If the payer issues a determination in favor of the health care provider, the payer shall comply with the provisions of this section and pay the amount of money in dispute, if applicable, with accrued interest at the rate of 12% per annum, on or before the 30th calendar day following the notification of the payer's determination on the appeal. Interest shall begin to accrue on the day the appeal was received by the payer.

If the payer issues a determination against the health care provider, the payer shall notify the health care provider of its findings on or before the 30th calendar day following the receipt of the appeal form and shall include in the notification written instructions for referring the dispute to arbitration as provided by paragraph (2) of this subsection.

The payer shall report annually to the Commissioner of Banking and Insurance the number of appeals it has received and the resolution of each appeal.

(2) Any dispute regarding the determination of an internal appeal conducted pursuant to paragraph (1) of this subsection may be referred to arbitration as provided in this paragraph. The Commissioner of Banking and Insurance shall contract with a nationally recognized, independent organization that specializes in arbitration to conduct the arbitration proceedings.

Any party may initiate an arbitration proceeding on or before the 90th calendar day following the receipt of the determination which is the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance. No dispute shall be accepted for arbitration unless the payment amount in dispute is $1,000 or more, except that a health care provider may aggregate his own disputed claim amounts for the purposes of meeting the threshold requirements of this subsection. No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of arbitration pursuant to this subsection.

(3) The arbitrator shall conduct the arbitration proceedings pursuant to the rules of the arbitration entity, including rules of discovery subject to confidentiality requirements established by State or federal law.

(4) An arbitrator's determination shall be:

(a) signed by the arbitrator;

(b) issued in writing, in a form prescribed by the Commissioner of Banking and Insurance, including a statement of the issues in dispute and the findings and conclusions on which the determination is based; and

(c) issued on or before the 30th calendar day following the receipt of the required documentation.

The arbitration shall be nonappealable and binding on all parties to the dispute.

(5) If the arbitrator determines that a payer has withheld or denied payment in violation of the provisions of this section, the arbitrator shall order the payer to make payment of the claim, together with accrued interest, on or before the 10th business day following the issuance of the determination. If the arbitrator determines that a payer has withheld or denied payment on the basis of information submitted by the health care provider and the payer requested, but did not receive, this information from the health care provider when the claim was initially processed pursuant to subsection d. of this section or reviewed under internal appeal pursuant to paragraph (1) of this subsection, the payer shall not be required to pay any accrued interest.

(6) If the arbitrator determines that a health care provider has engaged in a pattern and practice of improper billing and a refund is due to the payer, the arbitrator may award the payer a refund, including interest accrued at the rate of 12% per annum. Interest shall begin to accrue on the day the appeal was received by the payer for resolution through the internal appeals process established pursuant to paragraph (1) of this subsection.

(7) The arbitrator shall file a copy of each determination with and in the form prescribed by the Commissioner of Banking and Insurance.

f. As used in this section, "insured claim" or "claim" means a claim by a covered person for payment of benefits under an insured policy for which the financial obligation for the payment of a claim under the policy rests upon the health insurer.

g. Any person found in violation of this section with a pattern and practice as determined by the Commissioner of Banking and Insurance shall be liable to a civil penalty as set forth in section 17 of P.L.2005, c.352 (C.17B:30-55).

§ 17B:26-10 Proofs of loss

There shall be a provision as follows:

Proofs of loss: Written proof of loss must be furnished to the insurer at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the insurer is liable and in case of claim for any other loss within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than 1 year from the time proof is otherwise required.

§ 17B:26-11 Time of payment of claims

There shall be a provision as follows:

Time of payment of claims: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.

§ 17B:26-12 Payment of claims

There shall be a provision as follows:

Payment of claims: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.

(The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer:

a. If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $ (insert an amount which shall not exceed $1,000.00) to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.

b. Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.)

§ 17B:26-13 Physical examinations and autopsy

There shall be a provision as follows:

Physical examinations and autopsy: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.

§ 17B:26-14 Legal actions

There shall be a provision as follows:

Legal actions: No action at law or in equity shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.

§ 17B:26-15 Change of beneficiary

There shall be a provision as follows:

Change of beneficiary: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.

(The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the insurer's option.)

§ 17B:26-16 Optional policy provisions

Except as provided in section 17B:26-28, no policy of health insurance delivered or issued for delivery to any person in this State shall contain provisions respecting the matters set forth in sections 17B:26-17 to 17B:26-27 inclusive, unless such provisions are in the words in which the same appear in the applicable section; provided, however, that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the commissioner which is not less favorable in any respect to the insured or the owner, if other than the insured. Any such provision contained in the policy shall be preceded individually by the caption appearing in the appropriate section or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve.

§ 17B:26-17 Change of occupation

There may be a provision as follows:

Change of occupation: If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the State official having supervision of insurance in the State where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such State prior to the occurrence of the loss or prior to the date of proof of change in occupation.

§ 17B:26-18 Misstatement of age

There may be a provision as follows:

Misstatement of age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.

§ 17B:26-19 Other insurance in this insurer

There may be a provision as follows:

Other insurance in this insurer: If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for (insert type of coverage or coverages) in excess of $ (insert maximum limit of indemnity or indemnities) the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate.

or, in lieu thereof:

Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies.

§ 17B:26-20 Insurance with other insurers

There may be a provision as follows:

Insurance with other insurers: If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the "like amount" of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.

(If the foregoing policy provision is included in a policy which also contains the next following policy provision there shall be added to the caption of the foregoing provision the phrase "--Expense Incurred Benefits." The insurer may, at its option, include in this provision a definition of "other valid coverage," approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other State of the United States or any province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition such term shall not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workmen's compensation or employer's liability statute) whether provided by a governmental agency or otherwise shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage." )

§ 17B:26-21 Insurance with other insurers

There may be a provision as follows:

Insurance with other insurers: If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy,) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro-rata portion for the indemnities thus determined.

(If the foregoing policy provision is included in a policy which also contains the next preceding policy provision there shall be added to the caption of the foregoing provision the phrase "--Other Benefits." The insurer may, at its option, include in this provision a definition of "other valid coverage," approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other State of the United States or any province of Canada, and to any other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition such term shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workmen's compensation or employer's liability statute) whether provided by a governmental agency or otherwise shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage." )

§ 17B:26-22 Relation of earnings to insurance

There may be a provision as follows:

Relation of earnings to insurance: If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of two hundred dollars or the sum of the monthly benefit specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.

(The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums a. until at least age 50, or b. in the case of a policy issued after age 44, for at least five years from its date of issue. The insurer may, at its option, include in this provision a definition of "valid loss of time coverage," approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other State of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the commissioner or any combination of such coverages. In the absence of such definition such terms shall not include any coverage provided for such insured pursuant to any compulsory benefit statute (including any workmen's compensation or employer's liability statute), or benefits provided by union welfare plans or by employer or employee benefit organizations.)

§ 17B:26-23 Unpaid premium

There may be a provision as follows:

Unpaid premium: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.

§ 17B:26-24 Cancellation

There may be a provision as follows:

Cancellation: The insurer may cancel this policy at any time by written notice delivered to the insured, or mailed to his last address as shown by the records of the insurer, stating when, not less than five days thereafter, such cancellation shall be effective; and after the policy has been continued beyond its original term the insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in such notice.

In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the State official having supervision of insurance in the State where the insured resided when the policy was issued. If the insurer cancels, the earned premium shall be computed pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.

§ 17B:26-25 Conformity with State statutes

There may be a provision as follows:

Conformity with State statutes: Any provision of this policy which, on its effective date, is in conflict with the statutes of the State in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.

§ 17B:26-26 Illegal occupation

There may be a provision as follows:

Illegal occupation: The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.

§ 17B:26-27 Intoxicants and narcotics

There may be a provision as follows:

Intoxicants and narcotics: The insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.

§ 17B:26-28 Inapplicable or inconsistent provisions

If any provision of sections 17B:26-3 to 17B:26-31, inclusive, is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy the insurer, with the approval of the commissioner, shall omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of the provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

§ 17B:26-29 Order of certain policy provisions

The provisions which are the subject of sections 17B:26-3 to 17B:26-27, inclusive, or any corresponding provisions which are used in lieu thereof in accordance with such sections, shall be printed in the consecutive order of the provisions in such sections or, at the option of the insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.

§ 17B:26-30 Third party ownership

The word "insured," as used in this chapter, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.

§ 17B:26-31 Requirements of other jurisdictions

a. Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this State, may contain any provision which is not less favorable to the insured or the owner, if other than the insured, than the provisions of this chapter and which is prescribed or required by the law of the State under which the insurer is organized.

b. Any policy of a domestic insurer may, when issued for delivery in any other State or country, contain any provision permitted or required by the laws of such other State or country.

§ 17B:26-32 Other policy provisions

No policy provision which is not subject to sections 17B:26-3 to 17B:26-31, inclusive, of this chapter shall make a policy, or any portion thereof, less favorable in any respect to the insured or the owner, if other than the insured, than the provisions thereof which are subject to this chapter.

§ 17B:26-33 Policy conflicting with this chapter

A policy delivered or issued for delivery to any person in this State in violation of this chapter shall be held valid but shall be construed as provided in this chapter. When any provision in a policy subject to this chapter is in conflict with any provision of this chapter, the rights, duties and obligations of the insurer, the insured or the owner, if other than the insured, shall be governed by the provisions of this chapter.

§ 17B:26-34 Time limit on certain defenses with respect to reinstatement

A policy provision complying with the requirements of section 17B:26-5, relating to a time limit on certain defenses, shall also apply to any reinstatement of the policy except that the period of time established by such provision shall commence with the date of the reinstatement instead of the date of issue of the policy.

§ 17B:26-35 Waiver of rights of insurer

The acknowledgment by any insurer of the receipt of notice given under any policy covered by this chapter, or the furnishing of forms for filing proofs of loss, or the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.

§ 17B:26-36 Age limit

If any policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which premium has been accepted. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.

§ 17B:26-37 Scope of chapter

Nothing in this chapter shall apply to or affect a. any policy of workmen's compensation insurance or any policy of liability insurance with or without supplementary coverage therein as authorized by section 17:28-1; or b. any policy or contract of reinsurance; or c. any blanket or group policy of insurance; or d. life insurance or annuity contracts, or contracts supplemental thereto, which contain only such provisions relating to health insurance as (1) providing for additional benefits in event of death by accident or accidental means or in event of dismemberment or loss of sight, or (2) safeguarding such insurance or annuity against lapse or giving a special surrender value or special benefit or an annuity in the event that the insured or the annuitant shall become totally and permanently disabled.

§ 17B:26-38 Penalty

Any person who delivers or issues for delivery to any person in this State any policy in willful violation of the provisions of this chapter shall be liable to a penalty not exceeding $500.00 for each offense to be collected by the commissioner in the name of the State in a summary proceeding in accordance with the Penalty Enforcement Law (N.J.S. 2A:58-1 et seq.).

§ 17B:26-39 Legislative findings and declarations

The Legislature hereby finds and declares that the high cost of hospital care necessitates the establishment of alternative means of caring for patients who need some professional health care, but who do not need to remain hospitalized. Home health care, therefore, is a necessary and desirable means of providing professional services to patients, consistent with the following objectives:

a. Rehabilitation of the patient in order to assist in the development of independent living capabilities;

b. Rehabilitation of the patient in order to attain reduction of physical or mental disability.

§ 17B:26-40 Definitions

As used in this act:

a. "Home health care" means those nursing and other home health care services rendered to a person in his place of residence, under the following conditions:

(1) On a part-time and intermittent basis, except when full-time or 24-hour services are needed on a short-term basis;

(2) If continuing hospitalization would otherwise have been required if home health care were not provided;

(3) Pursuant to a physician's order and under a plan of care established by the responsible physician in collaboration with a home health care provider, which plan shall be periodically reviewed and approved by said physician. All care plans shall be established within 14 days following the commencement of home health care.

b. "Home health care services" means any of the following services necessary for achievement of the care plan set forth for the patient:

(1) Nursing care;

(2) Physical therapy;

(3) Occupational therapy;

(4) Medical social work;

(5) Nutrition services;

(6) Speech therapy;

(7) Home health aide services;

(8) Medical appliances and equipment, drugs, and medications, laboratory services and special meals, to the extent such items and services would have been covered under the policy if the covered person had been in a hospital;

(9) Any diagnostic or therapeutic service, including surgical services, performed in a hospital outpatient department, a doctor's office or any other licensed health care facility, provided such service would have been covered under the policy if performed as inpatient hospital services.

C. "Home health care provider" means a home health care agency which is certified to participate as a home health agency under Title XVIII of the Social Security Act or a proprietary agency licensed by the Commissioner of Health. At such time as home health agency licensure standards are promulgated pursuant to P.L.1971, c. 136 and 138, home health care providers shall be licensed agencies.

§ 17B:26-41 Home health care; requirement for provisions for coverage

Notwithstanding any provision of a policy of health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides coverage for inpatient hospital care or skilled nursing facility care, it shall also provide coverage for home health care.

§ 17B:26-42 Benefits

Every policy shall provide benefits required by section 3 without a separate deductible or coinsurance provision for the home health care benefit. For the purpose of determining the benefits for home health care, each visit by a member of a home health care team shall be considered as one home health care visit. The policy may contain a limitation on the number of home health care visits, but no policy may provide for less than 60 home health care visits in any calendar year or in any continuous period of 12 months.

§ 17B:26-43 Direct reimbursement to home health care providers

The State Commissioner of Insurance, after consultation with the State Commissioner of Health, shall provide for a system of direct reimbursement to home health care providers for services rendered pursuant to this act.

§ 17B:26-44 Regulations

The State Commissioner of Insurance, after consultation with the State Commissioner of Health, is hereby empowered and directed to promulgate regulations necessary to effectuate the provisions of this act.

§ 17B:26-44.1 Policy provision for reimbursement of dental services; payment regardless of discipline of provider

Notwithstanding any provision of a policy or individual health insurance contract hereafter delivered, issued for delivery, amended, renewed or ratified in this State, whenever such a policy or contract provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed dentist, the following provisions shall apply:

a. A person covered under such policy or contract shall be entitled to reimbursement for such service regardless of whether the service is performed by a duly licensed physician or duly licensed dentist.

b. Equal reimbursement rates shall be paid for services performed, regardless of the discipline of the provider of the service.

§ 17B:26-44.2 Application to policy or contract not limited to reimbursement of specific types of duly licensed health care professionals other than dentists

The provisions of section 1 of this act shall also apply to any policy or contract of individual health insurance already delivered or issued for delivery in this State, if such policy or contract does not limit reimbursement to specific types of duly licensed health care professionals other than dentists.

§ 17B:26-44.3 Renewal date; policy with reservation of right to change premium

For the purposes of this act, a policy or contract in which the company has reserved the right to change the premium shall be considered renewed as of the date on which the premium is changed or is subject to change.

§ 17B:26-44.4 Alternative dental coverage; original coverage restricted to limited number of providers

Each employer or other organization which employs or has 25 or more employees or members during the full preceding calendar year and which contributes to a health insurance contract which restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers, shall also offer its employees and their eligible dependents and members and members' eligible dependents at the time a dental benefits plan is offered or renewed the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist.

§ 17B:26-44.5 Employer contribution

An employer or other organization shall be required to pay for or contribute towards the provision of alternative coverage an amount equal to the premium or cost which it pays or contributes to the health insurance contract for dental services which limits the number of providers of dental services.

§ 17B:26-44.6 Rules and regulations

Within 120 days of the effective date of this act, the Commissioner of the Department of Insurance shall promulgate rules and regulations necessary to effectuate the purpose of this act, including procedures for notice to covered persons, employers and other organizations of the provisions of this act.

§ 17B:26-45 Minimum standards for form, content and sale of individual health insurance; regulations

a. The commissioner of insurance shall issue such regulations as he shall deem necessary or desirable to establish minimum standards, including standards for full and fair disclosure, for the form, content and sale of individual health insurance issued pursuant to chapter 26 of Title 17B of the New Jersey Statutes. Such regulations shall apply to all, any portion, or reasonable classifications of such insurance, other than conversion policies pursuant to a contractual conversion privilege.

b. The purposes of such minimum standards shall include any or all of the following: (1) reasonable standardization and simplification of language, terms and coverages to facilitate understanding and comparisons; (2) elimination of provisions which may be misleading or unreasonably confusing in connection with either the purchase of such insurance or the settlement of claims; (3) elimination of deceptive practices in connection with the sale of such insurance; (4) elimination of provisions which may be contrary to the health care needs of the public; (5) elimination of coverages which are so limited in scope as to be of no substantial economic value to the holders thereof; and (6) elimination of unfair renewal practices which are contrary to the health care needs and economic well-being of the public.

c. Any such regulations shall be promulgated in accordance with the Administrative Procedure Act (P.L.1968, c. 410, C. 52:14B-1 et seq.).

d. The department shall transmit copies of all rules and regulations adopted pursuant to this act to the Senate and General Assembly on a day on which both houses shall be meeting in the course of a regular or special session. The provisions of the "Administrative Procedure Act" or any other law to the contrary notwithstanding no such rule or regulation shall take effect if, within 60 days of the date of its transmittal to the Senate and General Assembly, the legislature shall pass a concurrent resolution stating in substance that the Legislature does not favor such proposed rule or regulation.

e. 120 days after the effective date of a regulation which has been adopted pursuant to this section, all policies of insurance previously filed with the commissioner which are not in compliance with the regulation shall be deemed to be withdrawn from filing and disapproved. No new policy of insurance shall be delivered or issued for delivery in this State until such new policy has been filed with the commissioner.

§ 17B:26-46 Violations; penalty; collection and enforcement

If, after notice and hearing, the commissioner finds that an insurance company, agent or broker or any other person has violated the provisions of this act or any regulation promulgated pursuant to this act, he may, in addition to any other penalty, impose a penalty not exceeding $2,000.00 for each such violation, which penalty shall be collected and enforced pursuant to the law (N.J.S. 2A:58-1 et seq.).

§ 17B:26-47 Injunction

The commissioner may, through the Attorney General of this State, institute an action in the Superior Court to enjoin and restrain any insurer who has entered into a policy which does not conform to the regulations promulgated pursuant to this act or an insurer or any other person who has attempted to induce entry into any such policy or whose method of sale is in violation of the regulations promulgated pursuant to this act. The court may proceed in the action in a summary manner.

Chapter 26A

§ 17B:26A-1 Definitions

1. For the purposes of this act:

a. "Applicant" means:

(1) In the case of an individual medicare supplement policy, the person who seeks to contract for insurance benefits, and

(2) In the case of a group medicare supplement policy, the proposed certificate holder.

b. "Certificate" means any certificate issued under a group medicare supplement policy, which certificate has been delivered or issued for delivery in this State.

c. "Commissioner" means the Commissioner of Insurance.

d. "Medicare" means the program established by the "Health Insurance for the Aged Act," Title XVIII of the "Social Security Act," Pub.L. 89-97, as then constituted or later amended (42 U.S.C. s.1395 et seq.).

e. "Medicare supplement policy" means a group or individual insurance policy or certificate which is advertised, marketed, designed primarily as, or is otherwise held out to be, a supplement to reimbursements under medicare for the hospital, medical or surgical expenses of persons eligible for medicare, other than a policy issued pursuant to a contract under 42 U.S.C. s.1395l or 42 U.S.C. s.1395mm or a policy issued under a demonstration project authorized pursuant to the "Health Insurance for the Aged Act," 42 U.S.C. s.1395 et seq. The term does not include a policy issued to one or more employers or labor organizations, or to the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or combination thereof, or for members or former members, or combination thereof, of the labor organizations.

§ 17B:26A-2 Regulations; medicare supplement policies

The commissioner shall issue regulations to establish specific standards for policy provisions of medicare supplement policies, which shall be in addition to and in accordance with applicable laws of this State, and may cover, but shall not be limited to:

a. Terms of renewability;

b. Initial and subsequent conditions of eligibility;

c. Nonduplication of coverage;

d. Probationary periods;

e. Benefit limitations, exceptions and reductions;

f. Elimination periods;

g. Requirements for replacement;

h. Recurrent conditions; and

i. Definition of terms.

§ 17B:26A-3 Prohibited provisions

3. a. No medicare supplement policy shall contain benefits which duplicate any benefits provided by medicare.

b. The commissioner may issue regulations that specify prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed for coverage under a medicare supplement policy.

§ 17B:26A-4 Preexisting condition; denial of claim for losses

Notwithstanding any other provision of law of this State to the contrary, a medicare supplement policy may not deny a claim for losses incurred more than 6 months from the effective date of coverage for a preexisting condition. The policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.

§ 17B:26A-5 Regulations

5. The commissioner shall promulgate regulations to effectuate and enforce the provisions of P.L.1982, c.94 (C. 17B:26A-1 et seq.) and any regulations which are necessary to conform medicare supplement policies and certificates with federal law. These regulations shall include, but not be limited to:

a. Establishment of minimum standards for benefits, claim payments, marketing and reporting practices and compensation arrangements;

b. Establishment of a uniform methodology for calculating and reporting loss ratios, and requiring refunds or credits if the policies or certificates do not meet loss ratio requirements;

c. Establishment of a process for filing of all requests for premium increases and rate changes, which may include public hearings as determined appropriate by the commissioner prior to approval of any premium increases;

d. Assurance of access by the public to policy, premium and loss ratio information; and

e. Establishment of standards for Medicare Select policies and certificates at such time as this State is authorized under federal law to authorize Medicare Select policies and certificates.

§ 17B:26A-6 Medicare supplement policy or certificate, requirements

6. a. No insurer shall deliver or issue for delivery to a resident of this State a medicare supplement policy or certificate, or any application, rider or endorsement to be used in connection with the issuance or renewal of any such policy or certificate, unless the form has been submitted to and filed by the commissioner pursuant to the provisions of this subsection.

(1) At the expiration of 30 days after submission, such form shall be deemed filed unless prior thereto it has been affirmatively filed or disapproved for filing by the commissioner.

(2) No master policy, certificate or policy, which is disapproved for filing by the commissioner during the 30-day period, may be delivered or issued for delivery in this State unless and until the disapproval for filing is withdrawn. Any disapproval shall be subject to review in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). Any form which is filed by the commissioner or deemed filed may be delivered or issued for delivery in this State until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

(3) The commissioner may extend the 30-day period provided in paragraph (1) of this subsection for not more than 30 additional days by giving written notice of extension before the expiration of the initial 30-day period. In the event of extension, all of the provisions of this subsection, except this provision for extension, relating to the initial 30-day period shall apply to the extended period instead of the initial 30-day period.

(4) The disapproval for filing or the withdrawal of the filing of any form by the commissioner shall state in writing the grounds therefor in such detail as is reasonable to inform the insurer of the reasons for withdrawal or disapproval.

(5) The provisions of this subsection shall not apply to documents which relate only to the manner of distribution of benefits or to the reservation of rights and benefits under the certificate or policy which are used at the request of the individual insured or the policyholder.

(6) The disapproval by the commissioner of any form submitted for filing pursuant to the provisions of this subsection may be on the ground that the form contains provisions which are unjust, unfair, inequitable, misleading, or contrary to law or to the public policy of this State.

b. Any insurer providing medicare supplement insurance in this State shall file annually with the commissioner its rates, rating schedule and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this State. All filings of rates and rating schedules shall demonstrate that the actual and expected losses in relation to premiums comply with the requirements of P.L.1982, c.94 (C.17B:26A-1 et seq.) and any rule or regulation promulgated thereunder.

c. Medicare supplement policies shall be expected to return to policyholders benefits which are reasonable in relation to the premium charged. The commissioner shall issue regulations to establish minimum standards for loss ratios of medicare supplement policies on the basis of paid claim experience and written premiums in accordance with accepted actuarial principles and practices.

§ 17B:26A-7 Outline of coverage, regulations

7. a. In order to provide for full and fair disclosure in the sale of medicare supplement policies, no medicare supplement policy or certificate shall be delivered or issued for delivery in this State unless an outline of coverage is delivered to the applicant at the time application is made.

b. The commissioner shall prescribe the format and content of the outline of coverage required by subsection a. of this section. For the purposes of this section, "format" means style, arrangement and overall appearance, including such items as the size, color and prominence of the font used, paper size and weight and the arrangement of text and captions. The outline of coverage shall include:

(1) A description of the principal benefits and coverage provided in the policy;

(2) (Deleted by amendment, P.L.1992, c.163).

(3) A statement of the renewal provisions, including any reservation by the insurer of a right to change premiums, and disclosure of the existence of any automatic renewal premium increases based on the policyholder's age; and

(4) A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

c. The commissioner may require by regulation the publication of forms and an informational brochure with a standardized format and content, to serve as an aid in the selection of appropriate coverage, if any, by those eligible for medicare, and to aid the consumer in improving his understanding of medicare benefits. Except in the case of direct response solicitation insurance policies, the commissioner may require by regulation that the informational brochure be provided, concurrently with delivery of the outline of coverage, to all prospective insureds eligible for medicare. With respect to direct response solicitation insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insureds eligible for medicare, but in no event later than the time of policy delivery.

d. The commissioner may promulgate regulations for captions or notice requirements for all accident and sickness insurance policies sold to persons eligible for medicare, other than for medicare supplement policies, to inform those prospective insureds that the particular insurance coverage is not a medicare supplement policy.

e. The commissioner may further promulgate regulations to govern the full and fair disclosure of the information in connection with the replacement of insurance policies or certificates by persons eligible for medicare.

§ 17B:26A-8 30-day examination period, refunds

8. Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Refunds made pursuant to this section shall be made in a timely manner and shall be paid directly to the applicant.

§ 17B:26A-9 Applicability

1. Except as otherwise specifically provided:

a. The provisions of P.L.1982, c.94 (C.17B:26A-1 et seq.) shall apply to all medicare supplement policies delivered or issued for delivery in this State and all certificates issued under group medicare supplement policies, which certificates are delivered or issued for delivery in this State.

b. The provisions of P.L.1982, c.94 (C.17B:26A-1 et seq.) shall not apply to health insurance policies, including group conversion policies, provided to medicare eligible persons that are not advertised, marketed, designed primarily as or otherwise held out to be medicare supplement policies.

§ 17B:26A-10 Filing of copies of advertising materials, regulations

8. a. Every insurer shall file with the Department of Insurance a copy of all advertising materials to be used in promoting medicare supplement policies to which residents of this State will have access, and through which the insurer intends, or by implication purports to the reasonable, targeted consumer its intent, to make such policies available for purchase or enrollment in this State. The requirements of this section shall apply to all advertisements in any medium, whether in print or by means of television or radio broadcast. Filings shall be made at least 30 days prior to the date on which the advertisement is to be used in this State, or made accessible to residents of this State.

b. The commissioner may, in the public interest, promulgate regulations governing medicare supplement policy advertising including, but not limited to, specific filing procedures, standards upon which review may be based, celebrity endorsements, unfair practices and review and disapproval procedures.

c. Notwithstanding the provisions of subsection b. of this section, the commissioner may disapprove any advertisement for use in this State at any time if he determines that the advertisement misrepresents the product, misleads the targeted consumer, uses a strategy which involves scare tactics, unnecessarily confusing data or representation, false or fraudulent statements or otherwise violates any applicable laws of this State or regulations promulgated thereunder.

§ 17B:26A-11 Additional remedies

9. In addition to any other applicable penalties for violation of the provisions of Title 17B of the New Jersey Statutes, the commissioner may require any health insurer violating the provisions of P.L.1982, c.94 (C.17B:26A-1 et seq.) to cease marketing any medicare supplement policy or certificate in this State which is related directly or indirectly to the violation, require that insurer to take such action as is necessary to comply with the provisions of that act, or both.

§ 17B:26A-12 Findings, declarations relative to Medicare supplement insurance.

1. The Legislature finds and declares that:

a. As of April 1, 1995, individuals in the State of New Jersey under age 65 who became eligible for Medicare benefits due to a disability or because they suffer from the end stage of renal disease do not have access to Medicare supplement insurance, otherwise known as "Medigap" insurance.

b. Prior to that date only one health insurance carrier in New Jersey offered Medicare supplement insurance contracts to the under 65 population. Unsustainable losses, caused in part by the fact that this carrier was the only carrier providing such coverage, led to the carrier's withdrawal from the Medicare supplement insurance market for the under 65 population on March 31, 1995.

c. Because Medicare supplement insurance pays for many of the health care expenses not covered by Medicare, the absence of Medicare supplement insurance will eventually leave thousands of blind, AIDS, disabled and dialysis patients in New Jersey without any means of secondary insurance to supplement their Medicare coverage. For many of these people with serious illnesses, the 20 percent co-payments and deductibles charged by Medicare will cause financial hardship and emotional distress. If no action is taken, Medicare recipients under 65 years old will be forced to deplete their personal assets and may eventually be forced to resort to Medicaid to supplement their health care needs.

d. Subsequent to the enactment of P.L.1995, c. 229 (C.17B:26A-12 et seq.), section 401 of the Medicare Access and CHIP Reauthorization Act of 2015, Pub. L. 114-10, amended section 1882 of the Social Security Act (42 U.S.C. s.1395ss), prohibiting the issue of Medicare supplement policies that provide coverage of the Medicare Part B deductible to an individual who, on or after January 1, 2020, is a newly eligible Medicare beneficiary, and further specifying that, with respect to newly eligible Medicare beneficiaries, reference to a Medicare supplement policy which has a benefit package classified as Medicare Supplement Plan C shall be deemed, as of January 1, 2020, to be a reference to a Medicare supplement policy which has a benefit package classified as Medicare Supplement Plan D, unless the Secretary of the United States Department of Health and Human Services provides otherwise.

e. Therefore, the Legislature declares that it is in the public interest:

(1) to ensure that Medicare supplement insurance is available to the individuals under 65 years of age who become eligible for Medicare benefits;

(2) to require all health insurance carriers who currently sell Medicare supplement insurance to the age 65 and over population to also offer, at a minimum, Medicare Supplement Plan C coverage to the under age 65 population who become eligible for Medicare prior to January 1, 2020;

(3) to require all health insurance carriers that currently sell Medicare supplement insurance to the age 65 and over population to also offer, at a minimum, Medicare Supplement Plan D coverage to the under age 65 population who become newly eligible on or after January 1, 2020;

(4) to establish a mechanism that will: allow the premiums on those Medicare supplement insurance policies and contracts to remain affordable; encourage insurance carriers to continue to serve or enter this market; and provide for the equitable sharing of any losses;

(5) to ensure that premiums for the more than 200,000 New Jersey residents who have purchased Medicare supplement insurance remain affordable and do not become subject to excessive rate increases; and

(6) that regulations necessary to effectuate the purposes of this act be promulgated by the Commissioner of Banking and Insurance expeditiously due to the urgency of the situation.

§ 17B:26A-13 Medicare supplement plans offered.

2. a. Except as otherwise provided in subsection d. of this section, every carrier issuing or renewing Medicare supplement insurance policies or contracts shall, as a condition of issuing or renewing health benefits plans in this State:

(1) offer and renew, at a minimum, Medicare Supplement Plan C policies or contracts to persons in this State 50 years of age or older who are entitled to Medicare benefits due to disability prior to January 1, 2020;

(2) offer and renew, at a minimum, Medicare Supplement Plan D policies or contracts to persons in this State 50 years of age or older who are newly eligible Medicare beneficiaries on or after January 1, 2020; and

(3) offer and renew Medicare Supplement Plan D policies or contracts to persons in this State 50 years of age or older who are entitled to Medicare benefits due to disability prior to January 1, 2020 if such a person applies for Medicare Supplement Plan D on or after January 1, 2020 but during the six-month period beginning with the first of the month in which the individual is enrolled in Medicare Part B, and the individual is not covered by any other Medicare Supplement Plan.

b. No carrier shall deny or condition the issuance or renewal of a Medicare supplement insurance policy or contract available for sale in this State pursuant to subsection a. of this section nor discriminate in the pricing of such policy or contract because of the health status, claims experience, receipt of health care or medical condition of an applicant if an application for Medicare Supplement Plan C is submitted during the six-month period beginning with the first month in which an individual is enrolled for benefits under Medicare Part B or if the application for Medicare Supplement Plan D is submitted within 12 months beginning with the first month in which an individual is enrolled for benefits under Medicare Part B if the individual is a newly eligible Medicare beneficiary on or after January 1, 2020.

c. Subsections a. and b. of this section shall not be construed as preventing the exclusion of benefits under a policy or contract during the first three months, based on a preexisting condition for which the insured received treatment or was otherwise diagnosed during the six months before the policy or contract became effective, except that the limitation shall not apply to an individual who has, under a prior health benefits policy or contract, with no intervening lapse in coverage, been treated or diagnosed by a physician for a condition under that policy or contract or satisfied a three-month preexisting condition limitation.

d. (1) Notwithstanding the provisions of subsection a. of this section to the contrary, a carrier that does not currently issue or renew individual Medicare supplement insurance policies or contracts and does issue and renew Medicare supplement insurance policies or contracts for groups whose membership in the group is not based on health status, claims experience, receipt of health care or medical condition, shall not be required to provide coverage to persons eligible for Medicare supplement insurance coverage pursuant to subsection a. of this section, other than to members of the group.

(2) No group to which the provisions of paragraph (1) of this subsection apply shall institute an age requirement for participation in the group after June 1, 1995.

e. (1) Rates for Medicare supplement insurance policies or contracts issued pursuant to this section shall be no greater than the lowest rate charged by a carrier for the same type of policies or contracts issued to persons 65 years of age and over and shall be formulated in accordance with the provisions of section 6 of P.L.1982, c.95 (C.17:35C-6) or section 6 of P.L.1982, c.94 (C.17B:26A-6), as appropriate, and any rules or regulations promulgated pursuant thereto.

(2) Following the close of each carrier's accounting year, if the commissioner determines that a carrier's loss ratio for policies or contracts issued pursuant to section 2 or 3 of P.L.1995, c.229 (C.17B:26A-13 or 17B:26A-14) was less than 75% for group policies or contracts or less than 65% for individual policies or contracts for that calendar year, the carrier shall be required to refund to the holders of any policy or contract the difference between the amount of net earned premium it received that year and the amount that would have been necessary to achieve the 75% or 65% loss ratio, as appropriate.

§ 17B:26A-14 Rules, regulations; rates; plan provisions.

3. a. The commissioner shall adopt rules and regulations establishing a plan to provide Medicare Supplement Plan C coverage of the standardized Medicare supplement plans to persons under 50 years of age in this State who are entitled to Medicare benefits due to disability prior to January 1, 2020, and further, establishing a plan to provide Medicare Supplement Plan D coverage to persons in this State under 50 years of age who are entitled, on a newly eligible basis, to Medicare benefits due to disability on or after January 1, 2020.

b. The plan shall not deny or condition the issuance or renewal of a Medicare supplement insurance policy or contract available for sale in this State pursuant to subsection a. of this section nor discriminate in the pricing of such policy or contract because of the health status, claims experience, receipt of health care or medical condition of an applicant if an application for a Medicare Supplement Plan C policy or contract is submitted during the six-month period beginning with the first month in which an individual is enrolled for benefits under Medicare Part B or if the application for a Medicare Supplement Plan D policy or contract is submitted during the 12-month period beginning with the first month in which an individual is enrolled for benefits under Medicare Part B, and a newly eligible Medicare beneficiary on or after January 1, 2020. The plan shall provide that an individual who becomes eligible for Medicare due to disability prior to January 1, 2020 has an opportunity to apply for Medicare Supplement Plan D if the individual applies on or after January 1, 2020, but during the six-month period beginning with the first of the month in which the individual is enrolled for benefits under Medicare Part B, and the individual is not covered by any other Medicare Supplement Plan.

c. Subsections a. and b. of this section shall not be construed as preventing the exclusion of benefits under a policy or contract during the first three months, based on a preexisting condition for which the insured received treatment or was otherwise diagnosed during the six months before the policy or contract became effective.

d. The plan shall provide for the appointment of a contracting carrier to provide the coverage specified in subsection a. of this section. The carrier shall have experience in providing and servicing standardized Medicare supplement insurance policies or contracts to persons in this State.

e. The rates for the plan established pursuant to subsection a. of this section shall be no greater than the lowest rate charged by the contracting carrier for Medicare Supplement Plan C or Medicare Supplement Plan D policies or contracts, as applicable, issued by the contracting carrier to persons pursuant to subsection a. of section 2 of P.L.1995, c.229 (C.17B:26A-13).

f. The plan shall provide for the appointment of a governing board which shall be responsible for implementing the provisions of P.L.1995, c.229 (C.17B:26A-12 et seq.) consistent with the rules and regulations adopted pursuant to subsection a. of this section. The governing board shall include representatives from, among others, the carriers and health maintenance organizations subject to the provisions of section 4 of P.L.1995, c.229 (C.17B:26A-15).

§ 17B:26A-15 Procedures for equitable sharing of losses; conditions; filing statement

4. The plan shall establish procedures for the equitable sharing of any losses incurred by the contracting carrier providing coverage under the plan pursuant to subsection a. of section 3 of this act as follows:

a. By March 1, 1996 and following the close of each calendar year thereafter, on a date established by the commissioner:

(1) (a) every carrier and health maintenance organization issuing health benefits plans or health maintenance organization subscriber contracts in this State shall file with the commissioner its net earned premium in the preceding calendar year ending December 31; and

(b) the contracting carrier issuing Medicare supplement insurance policies or contracts under the plan established pursuant to subsection a. of section 3 of this act shall file with the commissioner its net earned premium on those policies or contracts and the claims paid and the administrative expenses attributable to those policies or contracts in the preceding calendar year ending December 31; and

(2) No later than March 1, 1996 and following the close of each calendar year thereafter, on a date established by the commissioner, a contracting carrier issuing Medicare supplement insurance policies or contracts pursuant to subsection a. of section 3 of this act shall file with the commissioner a statement of any net loss on those policies or contracts in the calendar year ending December 31, along with any supporting information required by the commissioner. For purposes of this subsection, a loss shall occur if the claims paid and reasonable administrative expenses for Medicare supplement insurance policies or contracts issued to individuals under 50 years of age pursuant to subsection a. of section 3 of this act exceed the net earned premium and any investment income thereon.

b. (1) Every carrier and health maintenance organization authorized to provide health benefits plans or health maintenance organization subscriber contracts in this State shall be liable for an assessment to reimburse the contracting carrier issuing Medicare supplement insurance contracts or policies pursuant to subsection a. of section 3 of this act for any net loss incurred by the contracting carrier in the previous year, unless the carrier or health maintenance organization has received an exemption from the commissioner pursuant to paragraph (3) of this subsection.

(2) The assessment of each carrier and health maintenance organization shall be in the proportion that the net earned premium of the carrier or health maintenance organization for all health benefits plans or health maintenance organization subscriber contracts issued or renewed in the calendar year preceding the assessment bears to the net earned premium of all carriers and health maintenance organizations for all health benefits plans or health maintenance organization subscriber contracts issued or renewed in the calendar year preceding the assessment and shall be carried out in a form and manner to be determined by the commissioner.

(3) A carrier or health maintenance organization that is financially impaired may seek from the commissioner an exemption or a deferment in whole or in part from any assessment issued by the commissioner. The commissioner may exempt a carrier or health maintenance organization from an assessment or defer, in whole or in part, the assessment of a carrier or health maintenance organization if, in the opinion of the commissioner, the payment of the assessment would endanger the ability of the carrier or health maintenance organization to fulfill its contractual obligations. If an assessment against a carrier or health maintenance organization is deferred in whole or in part or if the carrier or health maintenance organization is exempt from the assessment, the amount by which the assessment is deferred or the amount that a carrier or health maintenance organization is exempted from paying may be assessed against the other carriers and health maintenance organizations in a manner consistent with the basis for assessment set forth in this section.

c. Payment of an assessment made under this section shall be a condition of issuing health benefits plans and health maintenance organization subscriber contracts in the State for a carrier or health maintenance organization. Failure to pay the assessment shall be grounds for forfeiture of a carrier's or health maintenance organization's authorization to issue health benefits plans and health maintenance organization subscriber contracts in the State, as well as any other penalties permitted by law.

d. Notwithstanding the provisions of this section to the contrary, no carrier or health maintenance organization shall be liable for an assessment to reimburse the contracting carrier pursuant to this section in an amount which exceeds 35% of the net loss of the contracting carrier. To the extent that this limitation results in any unreimbursed loss to the contracting carrier, the unreimbursed loss shall be distributed among all carriers and health maintenance organizations: (1) which owe assessments pursuant to subsection a. of this section; (2) whose assessments do not exceed 35% of the net loss of the contracting carrier; and (3) who have not received an exemption pursuant to paragraph (3) of subsection b. of this section.

§ 17B:26A-16 Audit required, conditions

5. a. Whenever the contracting carrier reports a net loss to the commissioner pursuant to paragraph (2) of subsection a. of section 4 of this act, the related operations of the contracting carrier and any losses incurred by the contracting carrier regarding Medicare supplement insurance policies or contracts issued pursuant to subsection a. of section 3 of this act shall be subject to an audit conducted by a qualified independent certified public accountant prior to the imposition of any assessment pursuant to subsection b. of section 4 of this act.

b. The auditor shall be selected and approved by the governing board of the plan through a competitive bidding process of certified public accountants qualified in New Jersey to perform such audits. The audit shall include:

(1) a review of the handling and accounting of assets and monies of the contracting carrier;

(2) a determination that administrative expenses have been properly allocated and are reasonable;

(3) a review of the internal financial controls of the contracting carrier;

(4) a review of the annual financial report of the contracting carrier; and

(5) a review of the calculation by the commissioner of any assessments for net losses.

c. A copy of the audit and related management letters shall be delivered to the governing board of the plan, to the commissioner and to each carrier and health maintenance organization to which the provisions of this act apply. The audit report shall be reviewed by the governing board of the plan. Upon recommendation of the governing board, the contracting carrier shall implement any recommendations made by the auditor.

§ 17B:26A-17 Definitions.

6. As used in this act:

"Carrier" means an insurance company or service corporation authorized to issue health benefits plans in this State.

"Financially impaired" means a carrier or health maintenance organization which, after the effective date of P.L.1995, c.229 (C.17B:26A-12 et seq.), is not insolvent, but is deemed by the commissioner to be potentially unable to fulfill its contractual obligations, or a carrier or health maintenance organization which is under an order of rehabilitation or conservation by a court of competent jurisdiction.

"Health benefits plan" means a hospital and medical expense insurance policy; hospital service corporation contract, medical service corporation contract or health service corporation contract delivered or issued for delivery in this State.

"Newly eligible" means first eligible for Medicare benefits by reason of age or disability on or after January 1, 2020, in accordance with 42 U.S.C. s.426 or 426-1.

Chapter 27

§ 17B:27-26 Definitions and requirements

Any policy or contract of health insurance which covers more than one person, other than a blanket insurance policy, or a policy issued pursuant to section 17B:26-2a(3), shall be deemed a group health insurance policy. No group health insurance policy may be delivered or issued for delivery in this State unless it conforms to one of the descriptions set forth in sections 17B:27-27 to 17B:27-29, inclusive.

§ 17B:27-27 Employer, trustee, labor union, association groups

A policy issued to an employer or to the trustees of a fund established by one or more employers, or issued to a labor union, or issued to an association formed for purposes other than obtaining such insurance, or issued to the trustees of a fund established by one or more labor unions or by one or more employers and one or more labor unions, insuring employees and members of associations or labor unions.

§ 17B:27-28 Other groups as permitted under group life insurance

Group health insurance may also be provided under a policy issued to cover such other groups as may be covered for group life insurance.

§ 17B:27-29 Discretionary groups

A policy issued to insure any other group which, in the opinion of the commissioner, may be insured for group health insurance in accordance with sound underwriting principles.

§ 17B:27-30 Dependents.

Benefits of group health insurance, except benefits for loss of time on account of disability, may be provided for one or more members of the families or one or more dependents of persons who may be insured under a group policy referred to in section 17B:27-27, 17B:27-28 or 17B:27-29. Any group health insurance policy which contains provisions for the payment by the insurer of benefits for expenses incurred on account of hospital, nursing, medical, or surgical services for members of the family or dependents of a person in the insured group must, subject to payment of the appropriate premium, permit such family members or dependents to have coverage continued for at least 180 days after the death of the person in the insured group, subject to the policy provision as to termination of coverage with respect to family members or dependents for reasons other than the death of the person in the insured group.

All group health insurance policies which provide coverage for a family member or dependent of an insured on an expense incurred basis shall also provide that the benefits applicable for children shall be payable with respect to a newly born child of that insured from the moment of birth. The coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. If payment of a specific premium is required to provide coverage for a child, the policy may require that notification of birth of a newly born child and payment of the required premium must be furnished to the insurer within 90 days after the date of birth in order to have the coverage continue beyond such 90-day period.

All group health insurance policies which provide coverage on an expense incurred basis for the insured but do not provide coverage for a family member or dependent of the insured on an expense incurred basis, except such group policies as provide no dependent coverage whatsoever for the insured's class, shall nevertheless provide for coverage of newborn children of the insured which shall commence with the moment of birth of each child and shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, provided application and payment of the required premium are made to the insurer to include in said policy coverage for a newly born child as described in the previous paragraph of this section within 90 days from the date of birth of a newborn child.

A policy under which coverage of a dependent of an employee or other member of the insured group terminates at a specified age shall, with respect to an unmarried child covered by the policy prior to the attainment of age 19, who is incapable of self-sustaining employment by reason of intellectual disability or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon such employee or member for support and maintenance, not so terminate while the insurance of the employee or member remains in force and the dependent remains in such condition, if the insured employee or member has within 31 days of such dependent's attainment of the termination age submitted proof of such dependent's incapacity as described herein. The foregoing provision of this paragraph shall not require an insurer to insure a dependent who is a child with an intellectual disability or physical handicap of an employee or other member of the insured group where such dependent does not satisfy the conditions of the group policy as to any requirements for evidence of insurability or other provisions as may be stated in the group policy required for coverage thereunder to take effect. In any such case the terms of the policy shall apply with regard to the coverage or exclusion from coverage of such dependent.

§ 17B:27-30.1 Benefits provided by group policy to subscriber's child.

11. a. A policy which provides hospital or medical expense benefits under which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A policy shall not deny coverage for an insured's child on the grounds that:

(1) The child was born out of wedlock;

(2) The child is not claimed as a dependent on the insured's federal tax return;

(3) The child does not reside with the insured or in the insurer's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the policy with respect to the use of specified providers;

(4) The child is married;

(5) The child has or adopts a child; or

(6) The child starts or leaves school.

b. If a child has coverage through a health insurance policy of a noncustodial parent, the insurer shall:

(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child's noncustodial parent's coverage;

(2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and

(3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.

c. When a parent who is the insured is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the insurer shall:

(1) Permit the parent to enroll his child as a dependent, without regard to any open enrollment restrictions;

(2) Permit the child's other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the health insurance policy if the parent who is the insured fails to enroll the child; and

(3) Not terminate coverage of the child unless the parent who is the insured provides the insurer with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage.

§ 17B:27-30.2 Requirements applicable to State Medicaid

12. An insurer shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other insured.

§ 17B:27-30.3 Coverage provided by group health plan to subscriber's child.

15. a. A group health plan as defined in section 607(1) of the "Employee Retirement Income Security Act of 1974," 29 U.S.C.1167(1) which provides hospital or medical expense benefits under which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A plan shall not deny coverage for a covered employee's child on the grounds that:

(1) The child was born out of wedlock;

(2) The child is not claimed as a dependent on the covered employee's federal tax return;

(3) The child does not reside with the covered employee or in the group health plan's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the plan with respect to the use of specified providers;

(4) The child is married;

(5) The child has or adopts a child; or

(6) The child starts or leaves school.

b. If a child has coverage through a group health plan of a noncustodial parent, the plan shall:

(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child's noncustodial parent's coverage;

(2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and

(3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.

c. When a parent who is the covered employee is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the group health plan shall:

(1) Permit the parent to enroll his child as a dependent, without regard to any open enrollment restrictions;

(2) Permit the child's other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the group health plan if the parent who is the covered employee fails to enroll the child; and

(3) Not terminate coverage of the child unless the parent who is the covered employee provides the group health plan with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage.

§ 17B:27-30.4 Requirements applicable to State Medicaid

16. A group health plan as defined in section 607(1) of the "Employee Retirement Income Security Act of 1974," 29 U.S.C.1167(1) shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other covered employee.

§ 17B:27-30.5 Coverage for certain dependents until age 31 by group health insurance policy.

4. a. As used in this section, "dependent" means an insured's child by blood or by law who:

(1) is 30 years of age or younger;

(2) is unmarried;

(3) has no dependent of his own;

(4) is a resident of this State or is enrolled as a full-time student at an accredited public or private institution of higher education; and

(5) (a) is not actually provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan or health benefits plan, or entitled to benefits under Title XVIII of the Social Security Act, Pub.L.74-271 (42 U.S.C. s.1395 et seq.) at the time dependent coverage pursuant to this section begins or will begin; and

(b) there is evidence of prior, creditable coverage or receipt of benefits under a benefits plan or by law as set forth in subparagraph (a) of this paragraph.

b. (1) A group health insurance policy that provides coverage for an insured's dependent under which coverage of the dependent terminates at a specific age on or before the dependent's 30th birthday, and is delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this section of P.L.2008, c.38, shall, upon application of the dependent as set forth in subsection c. of this section, provide coverage to the dependent after that specific age, until the dependent's 31st birthday.

(2) Nothing herein shall be construed to require:

(a) coverage for services provided to a dependent before the effective date of this section of P.L.2008, c.38; or

(b) that an employer or other group policyholder pay all or part of the cost of coverage for a dependent as provided pursuant to this section.

c. (1) A dependent covered by an insured's policy, which coverage under the policy terminates at a specific age on or before the dependent's 30th birthday, may make a written election for coverage as a dependent pursuant to this section, until the dependent's 30th birthday:

(a) within 30 days prior to the termination of coverage at the specific age provided in the policy;

(b) within 30 days after meeting the requirements for dependent status as set forth in subsection a. of this section, when coverage for the dependent under the policy previously terminated; or

(c) during an open enrollment period, as provided pursuant to the policy, if the dependent meets the requirements for dependent status as set forth in subsection a. of this section during the open enrollment period.

(2) (Deleted by amendment, P.L.2008, c.38)

d. (1) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall consist of coverage which is identical to the coverage provided to that dependent prior to the termination of coverage at the specific age provided in the policy. If coverage is modified under the policy for any similarly situated dependents for coverage prior to the termination of coverage at the specific age provided in the policy, the coverage shall also be modified in the same manner for the dependent.

(2) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall not be conditioned upon, or discriminate on the basis of, lack of evidence of insurability.

e. (1) The insured's policy may require payment of a premium by the insured or dependent, as appropriate, subject to the approval of the Commissioner of Banking and Insurance, for any period of coverage relating to a dependent's written election for coverage pursuant to subsection c. of this section. The premium shall not exceed 102% of the applicable portion of the premium previously paid for that dependent's coverage under the policy prior to the termination of coverage at the specific age provided in the policy.

(2) The applicable portion of the premium previously paid for the dependent's coverage under the policy shall be determined pursuant to regulations promulgated by the Commissioner of Banking and Insurance, based upon the difference between the policy's rating tiers for adult and dependent coverage or family coverage, as appropriate, and single coverage, or based upon any other formula or dependent rating tier deemed appropriate by the commissioner which provides a substantially similar result.

(3) Payments of the premium may, at the election of the payor, be made in monthly installments.

f. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following:

(1) the date upon which the dependent is disqualified for dependent status as set forth in subsection a. of this section;

(2) the date upon which coverage ceases under the policy by reason of a failure to make a timely payment of any premium required under the policy by the insured or dependent for coverage provided pursuant to this section. The payment of any premium shall be considered to be timely if made within 30 days after the due date or within a longer period as may be provided for by the policy; or

(3) the date upon which the policy, under which coverage is provided to a dependent, ceases to provide coverage to the insured.

Nothing herein shall be construed to permit an insurer to refuse a written election for coverage by a dependent pursuant to subsection c. of this section, based upon the dependent's prior disqualification pursuant to paragraph (1) of this subsection, other than a disqualification based on age or lack of evidence of prior, creditable coverage or receipt of benefits.

g. Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to an insured by the insurer:

(1) in the certificate of coverage or other equivalent document prepared for insureds and delivered on or about the date of commencement of the insureds' coverage.

(2) (Deleted by amendment, P.L.2008, c.38)

h. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:27-31 "Employees" defined

The policy may provide that the term "employees" shall include as employees of a single employer the employees of one or more subsidiary corporations and the employees, individual proprietors and partners of affiliated corporations, proprietorships and partnerships if the business of the employer and such corporations, proprietorships or partnerships is under common control through stock ownership, contract or otherwise. The policy may provide that the term "employees" shall include the individual proprietor or partners of an individual proprietorship or a partnership. The policy may provide that the term "employees" shall include retired employees. A policy issued to trustees may provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally connected with such trusteeship. A policy issued to the trustees of a fund established by the members of an association of employers may provide that the term "employees" shall include the employees of the association.

§ 17B:27-32 Blanket insurance

a. Any policy or contract of insurance against death or injury resulting from accident or from accidental means which conforms with the description and complies with the requirements contained in one of the following paragraphs shall be deemed a blanket insurance policy.

(1) A policy or contract issued to any railroad, steamship, motor bus or airplane carrier of passengers, which carrier shall be deemed the policyholder, covering a group defined as all persons who may become such passengers and whereby such passengers shall be insured against loss or damage resulting from death or bodily injury either while, or as a result of, being such passengers.

A policy or contract covering accidental death or injury to individuals resulting from airline accidents may also be issued under which premiums are paid from funds of the airline and the benefits are payable to the airline or to a trust established for the purpose of funding payments to persons with claims against the airline by reason of the death or bodily injury of individuals.

(2) A policy or contract issued in the name of any volunteer fire department, first aid or ambulance squad or volunteer police organization which shall be deemed the policyholder and covering all of the members of any such organization against loss from accidents resulting from hazards incidental to duties in connection with such organizations.

(3) A policy or contract issued in the name of any established organization, whether incorporated or not, having community recognition and operating for the welfare of the community and not for profit which shall be deemed the policyholder and covering all volunteer workers who are members of the organization and who serve without pecuniary compensation against loss from accidents occurring while engaged in the actual performance of duties on behalf of such organization.

(4) A policy or contract issued to any employer, who shall be deemed the policyholder, covering any group of employees defined by reference to exceptional hazards incident to such employment, insuring such employees against death or bodily injury resulting while or from being exposed to such exceptional hazards.

(5) A policy or contract issued to a college, school, or other institution of learning or to the head or principal thereof, who or which shall be deemed the policyholder.

(6) A policy or contract issued to and in the name of an incorporated or unincorporated association of persons having a common interest or calling, which association shall be deemed the policyholder, having not less than 50 members, covering all the members of such association, or if part or all of the premium is to be derived from funds contributed by the insured members and if the opportunity to take such insurance is offered to all eligible members, then such policy must cover not less than 75% of any class or classes of members determined by conditions pertaining to membership in the association.

(7) A policy or contract issued to insure any other substantially similar group approved by the commissioner as eligible for insurance under a blanket insurance policy or contract.

b. Nothing contained in this section shall be deemed to affect the legal liability of policyholders for the death of or injury to any such member of such group.

§ 17B:27-33 Standard provisions

No policy of group health or blanket insurance and no certificate thereunder shall be delivered or issued for delivery in this State unless the policy contains in substance all the provisions specified in sections 17B:27-34 to 17B:27-46 following.

§ 17B:27-34 Application; statements

There shall be a provision that a copy of the application, if any, of the policyholder shall be attached to the policy when issued, that all statements made by the policyholder or by the persons insured shall be deemed representations and not warranties, and that no statement made by any person insured shall avoid the insurance or reduce benefits thereunder unless contained in a written instrument signed by the person insured.

§ 17B:27-35 Policy changes

There shall be a provision that no agent has authority to change the policy or to waive any of its provisions and that no change in the policy shall be valid unless approved by an officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer.

§ 17B:27-36 New entrants

There shall be a provision that all new employees or new members, as the case may be, in the groups or classes eligible for such insurance must be added to such eligible groups or classes.

§ 17B:27-36.1 Eligibility for enrollment under policy providing hospital, medical expense benefits.

6. Notwithstanding any other provision of law to the contrary, an insurer shall not consider a person's eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the equivalent statute in another state, when determining the person's eligibility for enrollment in, or the provision of benefits under, a policy providing hospital or medical expense benefits delivered, issued or executed in this State, or approved for issuance in this State by the Commissioner of Insurance.

§ 17B:27-36.2 Group health insurance, policy, exclusion, rates, terms based on genetic information prohibited

15. Every group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall not exclude any person or eligible dependent and shall not establish any rates or terms therefor on the basis of an actual or expected health condition or on the basis of any genetic characteristic. For the purposes of this section, "genetic characteristic" means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with statistically increased risk of development of a disease, disorder or syndrome.

§ 17B:27-37 Payment of premiums

There shall be a provision that all premiums due under the policy shall be remitted by the employer or employers of the persons insured, by the policyholder, or by some other designated person acting on behalf of the association or group insured, to the insurer on or before the due date thereof with such period of grace as may be specified therein.

§ 17B:27-38 Certificate

There shall be a provision that the insurer shall issue to the employer, the policyholder, or other person or association in whose name such policy is issued, for delivery to each employee or member, a certificate setting forth in summary form a statement of the essential features of the insurance coverage, to whom the benefits thereunder are payable, and in substance the provisions of sections 17B:27-39 to 17B:27-46, inclusive of this chapter. This section shall not apply to blanket policies issued pursuant to section 17B:27-32a(1) and 17B:27-32a(3) of this act, nor to group health policies insuring a private plan under the Temporary Disability Benefits Law, if reasonable notice of the benefits provided thereby is furnished to the covered employees by direct notification or by conspicuous posting at the place of employment. If family members or dependents are included in the coverage, only one certificate need be issued for each family unit.

§ 17B:27-39 Age limits

There shall be a provision specifying the ages, if any there be, to which the insurance provided therein shall be limited; and the ages, if any there be, for which additional restrictions are placed on benefits, and the additional restrictions placed on the benefits at such ages.

§ 17B:27-40 Notice of loss

There shall be a provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.

§ 17B:27-41 Proof of loss

There shall be a provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within 90 days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible.

§ 17B:27-42 Forms for proof

There shall be a provision that the insurer will furnish to the person making claim, or to the policyholder for delivery to such person, such forms as are usually furnished by it for filing proof of loss. If the person making claim does not receive such forms before the expiration of 15 days after the insurer receives notice of any claim under the policy, the person making such claim shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made.

§ 17B:27-43 Examination, autopsy

There shall be a provision that the insurer shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law.

§ 17B:27-44 Time of benefit payment

There shall be a provision that all benefits payable under the policy other than benefits for loss of time will be payable not more than 60 days after receipt of proof, and that, subject to due proof of loss, all accrued benefits payable under the policy for loss of time will be paid not later than at the expiration of each period of 30 days during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof.

§ 17B:27-44.2 Health insurer to receive, transmit transactions relative to group policies electronically; standards.

6. a. Within 180 days of the adoption of a timetable for implementation pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health insurer or its agent or a subsidiary that processes health care benefits claims as a third party administrator, shall demonstrate to the satisfaction of the Commissioner of Banking and Insurance that it will adopt and implement all of the standards to receive and transmit health care transactions electronically, according to the corresponding timetable, and otherwise comply with the provisions of this section, as a condition of its continued authorization to do business in this State.

The Commissioner of Banking and Insurance may grant extensions or waivers of the implementation requirement when it has been demonstrated to the commissioner's satisfaction that compliance with the timetable for implementation will result in an undue hardship to a health insurer, or its agent, its subsidiary or its covered persons.

b. Within 12 months of the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health insurer or its agent or a subsidiary that processes health care benefits claims as a third party administrator shall use the standard health care enrollment and claim forms in connection with all group policies issued, delivered, executed or renewed in this State.

c. Twelve months after the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health insurer or its agent shall require that health care providers file all claims for payment for health care services. A covered person who receives health care services shall not be required to submit a claim for payment, but notwithstanding the provisions of this subsection to the contrary, a covered person shall be permitted to submit a claim on his own behalf, at the covered person's option. All claims shall be filed using the standard health care claim form applicable to the policy.

d. For the purposes of this subsection, "substantiating documentation" means any information specific to the particular health care service provided to a covered person.

(1) Effective 180 days after the effective date of P.L.1999, c.154, a health insurer or its agent, hereinafter the payer, shall remit payment for every insured claim submitted by a covered person or health care provider, no later than the 30th calendar day following receipt of the claim by the payer or no later than the time limit established for the payment of claims in the Medicare program pursuant to 42 U.S.C. s.1395u(c)(2)(B), whichever is earlier, if the claim is submitted by electronic means, and no later than the 40th calendar day following receipt if the claim is submitted by other than electronic means, if:

(a) the health care provider is eligible at the date of service;

(b) the person who received the health care service was covered on the date of service;

(c) the claim is for a service or supply covered under the health benefits plan;

(d) the claim is submitted with all the information requested by the payer on the claim form or in other instructions that were distributed in advance to the health care provider or covered person in accordance with the provisions of section 5 of P.L.2023, c.296 (C.17B:30-55.4);and

(e) the payer has no reason to believe that the claim has been submitted fraudulently.

(2) If all or a portion of the claim is not paid within the time frames provided in paragraph (1) of this subsection because:

(a) the claim submission is incomplete because the required substantiating documentation has not been submitted to the payer;

(b) the diagnosis coding, procedure coding, or any other required information to be submitted with the claim is incorrect;

(c) the payer disputes the amount claimed; or

(d) there is strong evidence of fraud by the provider and the payer has initiated an investigation into the suspected fraud,

the payer shall notify the health care provider, by electronic means and the covered person in writing within 30 days of receiving an electronic claim, or notify the covered person and health care provider in writing within 40 days of receiving a claim submitted by other than electronic means, that:

(i) the claim is incomplete with a statement as to what substantiating documentation is required for adjudication of the claim;

(ii) the claim contains incorrect information with a statement as to what information must be corrected for adjudication of the claim;

(iii) the payer disputes the amount claimed in whole or in part with a statement as to the basis of that dispute; or

(iv) the payer finds there is strong evidence of fraud and has initiated an investigation into the suspected fraud in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16).

(3) If all or a portion of an electronically submitted claim cannot be adjudicated because the diagnosis coding, procedure coding or any other data required to be submitted with the claim was missing, the payer shall electronically notify the health care provider or its agent within seven days of that determination and request any information required to complete adjudication of the claim.

(4) Any portion of a claim that meets the criteria established in paragraph (1) of this subsection shall be paid by the payer in accordance with the time limit established in paragraph (1) of this subsection.

(5) A payer shall acknowledge receipt of a claim submitted by electronic means from a health care provider, no later than two working days following receipt of the transmission of the claim.

(6) If a payer subject to the provisions of P.L.1983, c.320 (C.17:33A-1 et seq.) has reason to believe that a claim has been submitted fraudulently, it shall investigate the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or refer the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16).

(7) Payment of an eligible claim pursuant to paragraphs (1) and (4) of this subsection shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means and on or before the 40th calendar day following receipt of a claim submitted by other than electronic means.

If payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of paragraph (2) or paragraph (3) of this subsection, the claims payment shall be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, for claims submitted by electronic means and the 40th calendar day for claims submitted by other than electronic means, following receipt by the payer of the required documentation or information or modification of an initial submission.

If payment is withheld on all or a portion of a claim by a payer pursuant to paragraph (2) or (3) of this subsection and the provider is not notified within the time frames provided for in those paragraphs, the claim shall be deemed to be overdue.

(8) (a) No payer that has reserved the right to change the premium shall deny payment on all or a portion of a claim because the payer requests documentation or information that is not specific to the health care service provided to the covered person.

(b) No payer shall deny payment on all or a portion of a claim while seeking coordination of benefits information unless good cause exists for the payer to believe that other insurance is available to the covered person. Good cause shall exist only if the payer's records indicate that other coverage exists. Routine requests to determine whether coordination of benefits exists shall not be considered good cause.

(c) In the event payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of this paragraph, the claims payment shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means or on or before the 40th calendar day following receipt of a claim submitted by other than electronic means.

(9) An overdue payment shall bear simple interest at the rate of 12% per annum. The interest shall be paid to the health care provider at the time the overdue payment is made. The amount of interest paid to a health care provider for an overdue claim shall be credited to any civil penalty for late payment of the claim levied by the Department of Human Services against a payer that does not reserve the right to change the premium.

(10) With the exception of claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits, no payer shall seek reimbursement for overpayment of a claim previously paid pursuant to this section later than 18 months after the date the first payment on the claim was made. No payer shall seek more than one reimbursement for overpayment of a particular claim. At the time the reimbursement request is submitted to the health care provider, the payer shall provide written documentation that identifies the error made by the payer in the processing or payment of the claim that justifies the reimbursement request. No payer shall base a reimbursement request for a particular claim on extrapolation of other claims, except under the following circumstances:

(a) in judicial or quasi-judicial proceedings, including arbitration;

(b) in administrative proceedings;

(c) in which relevant records required to be maintained by the health care provider have been improperly altered or reconstructed, or a material number of the relevant records are otherwise unavailable; or

(d) in which there is clear evidence of fraud by the health care provider and the payer has investigated the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), and referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16).

(11) (a) In seeking reimbursement for the overpayment from the health care provider, except as provided for in subparagraph (b) of this paragraph, no payer shall collect or attempt to collect:

(i) the funds for the reimbursement on or before the 45th calendar day following the submission of the reimbursement request to the health care provider;

(ii) the funds for the reimbursement if the health care provider disputes the request and initiates an appeal on or before the 45th calendar day following the submission of the reimbursement request to the health care provider and until the health care provider's rights to appeal set forth under paragraphs (1) and (2) of subsection e. of this section are exhausted; or

(iii) a monetary penalty against the reimbursement request, including but not limited to, an interest charge or a late fee.

The payer may collect the funds for the reimbursement request by assessing them against payment of any future claims submitted by the health care provider after the 45th calendar day following the submission of the reimbursement request to the health care provider or after the health care provider's rights to appeal set forth under paragraphs (1) and (2) of subsection e. of this section have been exhausted if the payer submits an explanation in writing to the provider in sufficient detail so that the provider can reconcile each covered person's bill.

(b) If a payer has determined that the overpayment to the health care provider is a result of fraud committed by the health care provider and the payer has conducted its investigation and reported the fraud to the Office of the Insurance Fraud Prosecutor as required by law, the payer may collect an overpayment by assessing it against payment of any future claim submitted by the health care provider.

(12) No health care provider shall seek reimbursement from a payer or covered person for underpayment of a claim submitted pursuant to this section later than 18 months from the date the first payment on the claim was made, except if the claim is the subject of an appeal submitted pursuant to subsection e. of this section or the claim is subject to continual claims submission. No health care provider shall seek more than one reimbursement for underpayment of a particular claim.

e. (1) A health insurer or its agent, hereinafter the payer, shall establish an internal appeal mechanism to resolve any dispute raised by a health care provider regardless of whether the health care provider is under contract with the payer regarding compliance with the requirements of this section or compliance with the requirements of sections 5 through 15 of P.L.2023, c.296 (C.17B:30-55.4 through 17B:30-55.14). No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of an appeal pursuant to this subsection. The payer shall conduct the appeal at no cost to the health care provider.

A health care provider may initiate an appeal on or before the 90th calendar day following receipt by the health care provider of the payer's claims determination, which is the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance which shall describe the type of substantiating documentation that must be submitted with the form. The payer shall conduct a review of the appeal and notify the health care provider of its determination on or before the 30th calendar day following the receipt of the appeal form. If the health care provider is not notified of the payer's determination of the appeal within 30 days, the health care provider may refer the dispute to arbitration as provided by paragraph (2) of this subsection.

If the payer issues a determination in favor of the health care provider, the payer shall comply with the provisions of this section and pay the amount of money in dispute, if applicable, with accrued interest at the rate of 12% per annum, on or before the 30th calendar day following the notification of the payer's determination on the appeal. Interest shall begin to accrue on the day the appeal was received by the payer.

If the payer issues a determination against the health care provider, the payer shall notify the health care provider of its findings on or before the 30th calendar day following the receipt of the appeal form and shall include in the notification written instructions for referring the dispute to arbitration as provided by paragraph (2) of this subsection.

The payer shall report annually to the Commissioner of Banking and Insurance the number of appeals it has received and the resolution of each appeal.

(2) Any dispute regarding the determination of an internal appeal conducted pursuant to paragraph (1) of this subsection may be referred to arbitration as provided in this paragraph. The Commissioner of Banking and Insurance shall contract with a nationally recognized, independent organization that specializes in arbitration to conduct the arbitration proceedings.

Any party may initiate an arbitration proceeding on or before the 90th calendar day following the receipt of the determination which is the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance. No dispute shall be accepted for arbitration unless the payment amount in dispute is $1,000 or more, except that a health care provider may aggregate his own disputed claim amounts for the purposes of meeting the threshold requirements of this subsection. No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of arbitration pursuant to this subsection.

(3) The arbitrator shall conduct the arbitration proceedings pursuant to the rules of the arbitration entity, including rules of discovery subject to confidentiality requirements established by State or federal law.

(4) An arbitrator's determination shall be:

(a) signed by the arbitrator;

(b) issued in writing, in a form prescribed by the Commissioner of Banking and Insurance, including a statement of the issues in dispute and the findings and conclusions on which the determination is based; and

(c) issued on or before the 30th calendar day following the receipt of the required documentation.

The arbitration shall be nonappealable and binding on all parties to the dispute.

(5) If the arbitrator determines that a payer has withheld or denied payment in violation of the provisions of this section, the arbitrator shall order the payer to make payment of the claim, together with accrued interest, on or before the 10th business day following the issuance of the determination. If the arbitrator determines that a payer has withheld or denied payment on the basis of information submitted by the health care provider and the payer requested, but did not receive, this information from the health care provider when the claim was initially processed pursuant to subsection d. of this section or reviewed under internal appeal pursuant to paragraph (1) of this subsection, the payer shall not be required to pay any accrued interest.

(6) If the arbitrator determines that a health care provider has engaged in a pattern and practice of improper billing and a refund is due to the payer, the arbitrator may award the payer a refund, including interest accrued at the rate of 12% per annum. Interest shall begin to accrue on the day the appeal was received by the payer for resolution through the internal appeals process established pursuant to paragraph (1) of this subsection.

(7) The arbitrator shall file a copy of each determination with and in the form prescribed by the Commissioner of Banking and Insurance.

f. As used in this section, "insured claim" or "claim" means a claim by a covered person for payment of benefits under an insured policy for which the financial obligation for the payment of a claim under the policy rests upon the health insurer.

g. Any person found in violation of this section with a pattern and practice as determined by the Commissioner of Banking and Insurance shall be liable to a civil penalty as set forth in section 17 of P.L.2005, c.352 (C.17B:30-55).

§ 17B:27-45 Beneficiary; direct payment to hospitals and other purveyors of services

There shall be a provision that indemnity for loss of life of the insured shall be payable to the beneficiary or beneficiaries designated by the insured, other than the policyholder or an officer thereof as such, or if no beneficiary is designated, to such other person or persons as shall be specified in the policy; and that all other indemnities of the policy are payable to the employee or member, except that, at the request of the employee or member or in the event of his death, payment of benefits to the extent of expenses incurred on account of hospitalization may be made by the insurer to the hospital and except that the group policy may provide that all or any portion of any benefits on account of hospital, nursing, medical or surgical services may, at the insurer's option, be paid directly to the hospital or person rendering such services provided, further, that authorization for any such payments has been obtained from the insured. If a beneficiary is designated, the consent of the beneficiary shall not be requisite to change of beneficiary or to any other changes in the policy or certificate except as may be specifically provided by the policy.

This section shall not apply to a blanket insurance policy issued to an airline under which the benefits are payable to the airline or a trust established by the airline and the premiums are paid from its funds.

§ 17B:27-46 Time limits, suits

There shall be a provision that no action at law or in equity shall be brought to recover on the policy prior to the expiration of 60 days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all unless brought within 3 years from the expiration of the time within which proof of loss is required by the policy.

§ 17B:27-46.1a Reconstructive breast surgery; benefits

1. Every group health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses and, under any policy providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the policy.

§ 17B:27-46.1b Group health insurance policies

Every group health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this amendatory and supplementary act, shall offer coverage for maternity care without regard to marital status to subscribers or other persons covered thereunder for expenses incurred in pregnancy and childbirth. The benefits for the expenses of pregnancy and childbirth shall be provided to the same extent as the hospitalization benefit is provided in the policy for any other covered illness. If a fixed amount is specified in the policy for surgery, the fixed amount for a pregnancy-related surgical procedure shall be commensurate with the fixed amount payable for a surgical procedure of comparable difficulty and severity.

§ 17B:27-46.1c Benefits for purchase of blood products, infusion equipment

Every group health insurance policy providing hospital expense benefits to any policy holder or other person covered thereunder for expenses incurred in connection with the treatment of routine bleeding episodes associated with hemophilia shall provide benefits for expenses incurred in connection with the purchase of blood products and blood infusion equipment required for home treatment of routine bleeding episodes associated with hemophilia when the home treatment program is under the supervision of a State approved hemophilia treatment center. The benefits shall be provided to the same extent as for any sickness under the policy.

As used in this act, "blood product" includes, but is not limited to, Factor VIII, Factor IX and cryoprecipitate; and "blood infusion equipment" includes, but is not limited to, syringes and needles.

Participation in a home treatment program shall not preclude further or additional treatment or care at any eligible facility if the number of home treatments, in accordance with a ratio of home treatments to benefit days established by regulation by the Commissioner of Insurance, does not exceed the total number of benefit days provided for any other sickness under the policy.

§ 17B:27-46.1d Commercial health insurer benefits for preexisting condition

a. Notwithstanding any other provision of law to the contrary, no group health insurance policy issued by an insurer pursuant to the provisions of Chapter 27 of Title 17B of the New Jersey Statutes, shall contain any provision which denies benefits for a preexisting condition to any person becoming a member of that group if: (1) during the period immediately preceding the person's becoming a member of the group the person was enrolled as a member under another group policy issued by the insurer; and (2) the insurer paid benefits for the condition under the group policy in which the person was previously insured.

b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any group policy.

c. This section shall apply to every group contract or policy in which the corporation or insurer has the right to change the premium.

§ 17B:27-46.1e Group health insurance policy to pay benefits for treatment of Wilm's tumor

Every group health insurance policy providing hospital or medical expense benefits shall provide benefits to any named insured or other person covered thereunder for expenses incurred in the treatment of Wilm's tumor, including autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed experimental or investigational. These benefits shall be provided to the same extent as for any other sickness under the policy.

§ 17B:27-46.1f Group health insurance policy, mammogram examination benefits.

5. a. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting:

(1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and

(2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the insurer of the medical necessity of the additional screening and diagnostic testing.

b. These benefits shall be provided to the same extent as for any other sickness under the policy.

c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1g .Group health insurance policy, benefits for "off-label" drugs required

6. a. Except as otherwise provided in P.L.1992, c.162 (C.17B:27A-17 et seq.), no group health insurance policy which provides benefits for expenses incurred in prescribing drugs approved by the federal Food and Drug Administration shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State, on or after the effective date of this act unless the policy provides benefits to any policyholder or other person covered thereunder for expenses incurred in prescribing a drug for a treatment for which it has not been approved by the Food and Drug Administration if the drug is recognized as being medically appropriate for the specific treatment for which the drug has been prescribed in one of the following established reference compendia:

(1) the American Medical Association Drug Evaluations;

(2) the American Hospital Formulary Service Drug Information;

(3) the United States Pharmacopoeia Drug Information;

or, it is recommended by a clinical study or review article in a major-peer reviewed professional journal.

b. Notwithstanding the provisions of this section, coverage shall not be required for any experimental or investigational drug or any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed. The benefits provided pursuant to this section shall be provided to the same extent as other benefits under the policy for drugs prescribed for treatments approved by the Food and Drug Administration.

c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.

d. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.

§ 17B:27-46.1h Group health insurer, benefits for health promotion

7. a. Every group policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.1999, c.339, shall provide benefits to each person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:

(1) For all persons 20 years of age and older, annual tests to determine blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level;

(2) For all persons 35 years of age or older, a glaucoma eye test every five years;

(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;

(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;

(5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 4 of P.L.1995, c.415 (C.17B:27-46.1n);

(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 5 of P.L.1991, c.279 (C.17B:27-46.1f);

(7) For all adults, recommended immunizations; and

(8) For all persons 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination and seat belt usage in motor vehicles.

Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the insurer shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.

b. Every group health care policy offered for sale in this State by an insurer pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no insurer shall be required to provide payment for benefits for a left-sided colon examination in excess of $150.

c. The Commissioner of Banking and Insurance, in consultation with the Department of the Treasury, shall annually adjust the threshold amounts provided by subsection b. of this section in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which the adjustment is made.

d. The requirements of this section shall apply only to health insurers which issue or deliver primary health insurance coverage in this State providing hospital or medical expense benefits. Primary health insurance coverage shall not include the following plans, policies, or contracts: accident only, credit, disability, long-term care, Medicare supplement coverage, CHAMPUS supplement coverage, coverage for Medicare services pursuant to a contract with the United States government, coverage for Medicaid services pursuant to a contract with the State, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.), or hospital confinement indemnity coverage.

e. This section shall apply to all group health insurance policies in which the carrier has reserved the right to change the premium.

f. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

§ 17B:27-46.1i Requirements for group health insurer providing benefits for pharmacy services.

5. a. Notwithstanding any other provision of law to the contrary, no group health insurance policy which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State, on or after the effective date of this act, unless the policy:

(1) Permits the insured, at the time of issuance, amendment or renewal, to select benefit coverage allowing the insured to choose a pharmacy or pharmacist for the provision of prescription drugs or pharmacy services, provided that any pharmacist or pharmacy selected by the insured is registered pursuant to R.S.45:14-1 et seq.;

(2) Provides that no pharmacy or pharmacist shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the policy provides for coverage by contracted or preferred providers for pharmaceutical services, provided the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the policy;

(3) Provides that no copayment, fee, or other condition shall be imposed upon an insured selecting a participating or contracting pharmacist or pharmacy that is not also equally imposed upon all insureds selecting a participating or contracting pharmacist or pharmacy;

(4) (a) Provides that no insured shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;

(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and

(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days;

(5) Sets forth the auditing procedures to be used by the insurer and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist and the auditor. No audit by an insurer shall include a review of any document relating to any person or prescription plan other than those reimbursable by the insurer;

(6) Provides that the insurer, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the insured for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law;

(7) The provisions of P.L.1999, c.395 shall apply to all policies delivered. issued or renewed on or after the effective date of P.L.1999, c.395.

b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any policy.

c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1j Benefits for certain cancer treatments

5. In addition to benefits provided under regulations adopted pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), an insurer shall offer under every group policy providing health insurance coverage delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act to provide benefits for the treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants when performed by institutions approved by the National Cancer Institute or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Benefits for such treatment shall be provided to the same extent as for any other illness under the policy.

The offer required pursuant to this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium. Nothing in this section shall be construed to limit an insurer in adjusting premium amounts, or providing for reasonable deductibles or copayments, with respect to benefits provided pursuant to this section.

§ 17B:27-46.1k Coverage for birth and natal care; group insurance policy

7. a. Every policy that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide benefits for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

b. Notwithstanding the provisions of subsection a. of this section, a policy that provides coverage for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child.

c. Every insurer shall provide notice to policyholders regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the policyholder; (2) the yearly informational packet sent to the policyholder; or (3) January 1, 1996.

§ 17B:27-46.1l Group health insurance policy, child screening, blood lead, hearing loss; immunizations.

3. No group health insurance policy providing hospital or medical expense benefits for groups with more than 50 persons shall be delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in the following:

a. Screening by blood lead measurement for lead poisoning for children, including confirmatory blood lead testing as specified by the Department of Health pursuant to section 7 of P.L.1995, c.316 (C.26:2-137.1); and medical evaluation and any necessary medical follow-up and treatment for lead poisoned children.

b. All childhood immunizations as recommended by the Department of Health, which shall consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians. A health insurer shall notify its policyholders, in writing, of any change in coverage with respect to childhood immunizations and any related changes in premium. Such notification shall be in a form and manner to be determined by the Commissioner of Banking and Insurance.

c. Screening for newborn hearing loss by appropriate electrophysiologic screening measures and periodic monitoring of infants for delayed onset hearing loss, pursuant to P.L.2001, c.373 (C.26:2-103.1 et al.). Payment for this screening service shall be separate and distinct from payment for routine new baby care in the form of a newborn hearing screening fee as negotiated with the provider and facility.

The benefits provided pursuant to this section shall be provided to the same extent as for any other medical condition under the policy, except that a deductible shall not be applied for benefits provided pursuant to this section; however, with respect to a policy that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), a deductible shall not be applied for any benefits provided pursuant to this section that represent preventive care as permitted by that federal law, and shall not be applied as provided pursuant to section 9 of P.L.2005, c.248 (C.17B:27-46.1dd). This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium.

§ 17B:27-46.1m Coverage, diabetes treatment, group health insurance policy.

5. a. Every group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide benefits to any person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist: blood glucose monitors and blood glucose monitors for the legally blind; test strips for glucose monitors and visual reading and urine testing strips; insulin; injection aids; cartridges for the legally blind; syringes; insulin pumps and appurtenances thereto; insulin infusion devices; and oral agents for controlling blood sugar. Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35 per 30-day supply. The provisions of this subsection shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this subsection shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this subsection shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

b. Each group health insurance policy shall also provide benefits for expenses incurred for diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of their diabetic condition, including information on proper diet. Benefits provided for self-management education and education relating to diet shall be limited to visits medically necessary upon the diagnosis of diabetes; upon diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Diabetes self-management education shall be provided by a dietitian registered by a nationally recognized professional association of dietitians or a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators or a registered pharmacist in the State qualified with regard to management education for diabetes by any institution recognized by the board of pharmacy of the State of New Jersey.

c. The benefits required by this section shall be provided to the same extent as for any other sickness under the policy.

d. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.

e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

f. The Commissioner of Banking and Insurance may, in consultation with the Commissioner of Health, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), promulgate and periodically update a list of additional diabetes equipment and related supplies that are medically necessary for the treatment of diabetes and for which benefits shall be provided according to the provisions of this section.

§ 17B:27-46.1n Group health insurance policy, Pap smear benefits

4. No group health insurance policy providing hospital or medical expense benefits for groups with greater than 50 persons shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting a Pap smear. The benefits shall be provided to the same extent as for any other medical condition under the policy.

As used in this section, and notwithstanding the provisions of this section to the contrary, "Pap smear" means an initial Pap smear and any confirmatory test when medically necessary and as ordered by the covered person's physician and includes all laboratory costs associated with the initial Pap smear and any such confirmatory test.

This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium.

§ 17B:27-46.1o Group health insurance policy, prostate cancer testing

4. No group health insurance policy providing hospital or medical expense benefits for groups with greater than 49 persons shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting an annual medically recognized diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors.

The benefits shall be provided to the same extent as for any other medical condition under the policy.

This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium.

§ 17B:27-46.1p Coverage for minimum inpatient care following mastectomy by group policy

5. a. Every group policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide benefits for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The policy shall not require a health care provider to obtain authorization from the insurer for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

The provisions of this section shall not be construed to: require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the insurer under the policy.

The benefits shall be provided to the same extent as for any other sickness under the policy.

The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

§ 17B:27-46.1q Applicability of Health Care Quality Act

22. Notwithstanding the provisions of chapter 27 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy meets the requirements of P.L.1997, c.192 (C.26:2S-1 et al.) and regulations adopted thereto. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1r Coverage for treatment of inherited metabolic diseases by group health insurance policy.

5. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the policy provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.

The benefits shall be provided to the same extent as for any other medical condition under the policy.

The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1s Group health insurer to cover certain audiology, speech-language pathology services.

5. Notwithstanding any other provision of chapter 27 of Title 17B of the New Jersey Statutes, benefits shall not be denied to any eligible individual for eligible services, as determined by the terms of the policy or as otherwise required by law, when the services are determined by a physician to be medically necessary and are performed or rendered to that individual by a licensed audiologist or speech-language pathologist within the scope of practice. The practices of audiology and speech-language pathology shall be deemed to be within the provisions of chapter 27 of Title 17B of the New Jersey Statutes and duly licensed audiologists and speech-language pathologists shall have such privileges and benefits in the scope of their practice under that act as are afforded thereunder to licensed physicians and surgeons in the scope of their practice.

§ 17B:27-46.1t Coverage for treatment of domestic violence injuries by group health insurance policy.

5. Except as otherwise provided in P.L.1992, c.162 (C.17B:27A-17 et seq.), no group health insurance policy providing hospital or medical expense benefits shall contain any provision which denies benefits for expenses incurred in the treatment of an injury or injuries sustained as the result of domestic violence as defined in section 3 of P.L.1991, c.261 (C.2C:25-19), to a named insured or other person covered thereunder. Benefits shall be provided to the same extent as for any other treatment under the policy. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1u Coverage for certain dental procedures for the severely disabled or child age five or under by group health insurance policy

5. a. No group health insurance policy providing hospital or medical benefits shall be delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this amendatory and supplementary act, unless the policy provides benefits to any person covered thereunder who is severely disabled or a child age five or under for expenses incurred for: (1) general anesthesia and hospitalization for dental services; or (2) a medical condition covered by the contract which requires hospitalization or general anesthesia for dental services rendered by a dentist regardless of where the dental services are provided.

b. A group health insurance policy may require prior authorization of hospitalization for dental services in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.

c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1v Group health insurers to provide coverage for mental health conditions, substance use disorders; collaborative care model.

5. a. (1) Every group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide benefits for mental health conditions and substance use disorders under the same terms and conditions as provided for any other sickness under the policy and shall meet the requirements of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. s.18031(j), and any amendments to, and federal guidance or regulations issued under that act, including 45 C.F.R. Parts 146 and 147 and 45 C.F.R. s.156.115(a)(3).

Coverage provided pursuant to this section shall include benefits delivered through the psychiatric Collaborative Care Model.

(2) As used in this section:

"Mental health condition" means a condition defined to be consistent with generally recognized independent standards of current medical practice referenced in the current version of the Diagnostic and Statistical Manual of Mental Disorders.

"Psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method wherein a primary care provider and a care manager collaborate with a psychiatric consultant to provide care to a patient. "Psychiatric Collaborative Care Model" shall include those benefits that are billed using the following list of Current Procedural Terminology (CPT) codes, which list shall be updated by the Commissioner of Banking and Insurance whenever the codes are altered or supplemented:

(a) 99492 - Initial psychiatric collaborative care management;

(b) 99493 - Subsequent psychiatric collaborative care management; and

(c) 99494 - Initial or subsequent psychiatric collaborative care management, additional time.

"Same terms and conditions" means that the insurer cannot apply more restrictive non-quantitative limitations, such as utilization review and other criteria or more quantitative limitations such as copayments, deductibles, aggregate or annual limits or benefit limits to mental health condition and substance use disorder benefits than those applied to substantially all other medical or surgical benefits.

"Substance use disorder" means a disorder defined to be consistent with generally recognized independent standards of current medical practice referenced in the most current version of the Diagnostic and Statistical Manual of Mental Disorders.

b. (Deleted by amendment, P.L.2019, c.59)

c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

d. Nothing in this section shall reduce the requirement for an insurer to provide benefits pursuant to section 5 of P.L.2017, c.28 (C.17B:27-46.1nn).

§ 17B:27-46.1w Coverage for hemophilia services by group health insurers

4. Notwithstanding the provisions of chapter 27 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the policy meets the requirements of sections 1 and 2 of P.L.2000, c.121 (C.26:2S-10.1 and C.26:2S-10.2) and the regulations adopted thereto. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1x Group health insurance policy to provide coverage for treatment of infertility.

4. a. A group health insurance policy which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the policy provides coverage for persons covered under the policy for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The policy shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The policy may provide that coverage for in vitro fertilization shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A policy shall not impose any restriction concerning the coverage of infertility services based on age.

As used in this section:

"Infertility" means a disease, condition, or status characterized by any of the following:

(1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors;

(2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or

(3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.

Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.

"Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications directed by a licensed physician for infertility as defined in this section.

The benefits shall be provided to the same extent as for other medical conditions under the policy, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed.

b. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).

c. This section shall apply to those insurance policies in which the insurer has reserved the right to change the premium.

d. The provisions of this section shall not apply to a group health insurance policy which, pursuant to a contract between the insurer and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.

e. Nothing in this section shall preclude the insurer from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines.

§ 17B:27-46.1y Group policy to provide coverage for colorectal cancer screening.

5. a. Every group policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any named insured or other person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recently published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person.

b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force.

c. The benefits shall be provided to the same extent as for any other medical condition under the policy.

d. The provisions of this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1z Group health insurer prescription drug plans to cover certain infant formulas.

4. A group health insurer which provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a policy that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits under the policy for expenses incurred in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula.

The benefits shall be provided to the same extent as for any other prescribed items under the policy.

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1aa Policy issued under Chapter 27 of Title 17B required to cover certain out-of-network services.

4. Notwithstanding the provisions of chapter 27 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy meets the requirements of P.L.2001, c.367 (C.26:2S-6.1 et al.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1bb Group health insurer to offer coverage for domestic partner.

51. A group health insurer that provides hospital or medical expense benefits under a policy that is delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to a covered person for a covered person's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3).

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1cc Group health insurance policy, high deductible, coverage for preventive care.

8. No group health insurance policy providing hospital or medical expense benefits for groups with more than 50 persons, that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in connection with any medically necessary benefits provided in-network which represent preventive care as permitted by that federal law.

The benefits provided pursuant to this section shall be provided to the same extent as for any other medical condition under the policy, except that a deductible shall not be applied for benefits provided pursuant to this section. This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium.

§ 17B:27-46.1dd Group health insurance policy, high deductible, deductible inapplicable, certain circumstances.

9. Notwithstanding the provisions of section 3 of P.L.1995, c.316 (C.17B:27-46.1l) regarding deductibles for a high deductible health plan, a group health insurance policy providing hospital or medical expense benefits for groups with more than 50 persons, that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), and that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), shall not apply a deductible for any benefits for which a deductible is not applicable pursuant to any law enacted after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.).

This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium.

§ 17B:27-46.1ee Group health insurers, coverage for contraceptives.

4. a. A group health insurer that provides hospital or medical expense benefits shall provide coverage under every policy delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:

(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:

(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.

(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration.

(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.

(2) Voluntary male and female sterilization.

(3) Patient education and counseling on contraception.

(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:

(a) Management of side effects;

(b) Counseling for continued adherence to a prescribed regimen;

(c) Device insertion and removal;

(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and

(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.

b. The coverage provided shall include prescriptions for dispensing contraceptives for:

(1) (Deleted by amendment, P.L.2021, c.376)

(2) up to a 12-month period at one time.

c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the policy, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.

(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).

d. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.

§ 17B:27-46.1ff Group health insurance policies to provide benefits for orthotic and prosthetic appliances.

5. a. Every group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

(2) an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, if the covered person's physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports.

As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3), "licensed podiatrist" has the meaning assigned to it in R.S.45:5-1 et seq., and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18).

b. On and after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), a group health insurance policy shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the policy.

d. The provisions of this section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1gg Group health insurance policy to provide coverage for hearing aids, cochlear implant for covered persons.

6. a. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for medically necessary expenses incurred in the purchase of a hearing aid or cochlear implant for a covered person, as provided in this section.

b. A policy shall provide coverage that includes the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. An insurer may limit the benefit provided in this section to one hearing aid for each hearing-impaired ear every 24 months.

c. A group health insurance policy shall provide coverage of the cost of treatment related to cochlear implants, including procedures for the implantation of cochlear devices and costs for any parts, attachments, or accessories of the device, including replacement of obsolete external cochlear implant processors.

d. The benefits shall be provided to the same extent as for any other condition under the policy.

e. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1hh Group health insurance policy to provide installment payments to obstetrical provider for maternity services.

5. a. Every group health insurance policy that provides benefits for maternity services, and that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide for reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a covered person's pregnancy.

b. For the purposes of this section, "obstetrical provider licensed in New Jersey" means:

(1) an obstetrician/gynecologist licensed by the State Board of Medical Examiners; or

(2) a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife.

c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1ii Group health insurance policy to provide benefits for treatment of autism or other developmental disability.

5. Notwithstanding any other provision of law to the contrary, every group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

a. The insurer shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability.

b. When the insured's primary diagnosis is autism or another developmental disability, the insurer shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.

c. When the insured is under 21 years of age and the insured's primary diagnosis is autism, the insurer shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.

(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the policy, but shall not be subject to limits on the number of visits that an insured may make to a provider of behavioral interventions.

(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

(3) (a) The maximum benefit amount for an insured in any calendar year through 2011 shall be $36,000.

(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

(c) The adjusted maximum benefit amount shall apply to a policy that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

(d) Notwithstanding the provisions of this paragraph to the contrary, an insurer shall not be precluded from providing a benefit amount for an insured in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the insurer to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The insurer may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the insurer and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.

e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to an insured.

f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

g. The coverage required under this section may be subject to utilization review, including periodic review, by the insurer of the continued medical necessity of the specified therapies and interventions.

h. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1jj Group health insurance policy to provide coverage for oral anticancer medications.

5. a. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis no less favorable than the policy provides for intravenously administered or injected anticancer medications.

b. Pursuant to subsection a. of this section, coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medications.

c. A group health insurance policy shall not achieve compliance with the provisions of this section by imposing an increase in patient cost sharing, including any copayment, deductible or coinsurance, for anticancer medications, whether intravenously administered or injected or orally administered, that are covered under the policy as of the effective date of this act.

d. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1kk Group health insurance policy to provide coverage for sickle cell anemia.

4. Every group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for medical expenses incurred by a covered person for the treatment of sickle cell anemia and, if the policy provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the policy shall provide coverage for prescription drug expenses incurred by a covered person for the treatment of sickle cell anemia.

The benefits shall be provided to the same extent as for any other medical condition under the policy.

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1ll Group health insurer to provide coverage for prescription eye drops.

5. a. A group health insurer which provides hospital or medical expense benefits that include coverage for prescription eye drops, under a policy delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services, provided that:

(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and

(2) the refill requested by the insured or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.

b. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1mm Group health insurance policy, contract, coverage for synchronization of prescribed medications.

5. a. Every group health insurance policy or contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall, on at least one occasion per year for each covered person:

(1) apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a 30 days' supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person's chronic medications;

(2) provide coverage for a drug prescribed for the treatment of a chronic illness dispensed in accordance with a plan among the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and

(3) determine dispensing fees based exclusively on the total number of prescriptions dispensed; dispensing fees shall not be prorated or based on the number of the days' supply of medication prescribed or dispensed.

b. This section shall apply to all policies in which the insurer has reserved the right to change the premium.

c. This section shall not apply to prescriptions for opioid analgesics. "Opioid analgesic" means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

§ 17B:27-46.1nn Group health insurance to provide benefits for treatment of substance use disorder.

5. a. A group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide unlimited benefits for inpatient and outpatient treatment of substance use disorder at in-network facilities. The services for the treatment of substance use disorder shall be prescribed by a licensed physician, licensed psychologist, or licensed psychiatrist and provided by licensed health care professionals or licensed or certified substance use disorder providers in licensed or otherwise State-approved facilities, as required by the laws of the state in which the services are rendered.

b. The benefits for the first 180 days per plan year of inpatient and outpatient treatment of substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. The facility shall notify the insurer of both the admission and the initial treatment plan within 48 hours of the admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, an insurer shall provide necessary exceptions to its network to ensure admission in a treatment facility within 24 hours.

c. Providers of treatment for substance use disorder to persons covered under a covered insurance policy shall not require pre-payment of medical expenses during this 180 days in excess of applicable co-payment, deductible, or co-insurance under the policy.

d. The benefits for outpatient visits shall not be subject to concurrent or retrospective review of medical necessity or any other utilization management review.

e. (1) The benefits for the first 28 days of an inpatient stay during each plan year shall be provided without any retrospective review or concurrent review of medical necessity and medical necessity shall be as determined by the covered person's physician.

(2) The benefits for days 29 and thereafter of inpatient care shall be subject to concurrent review as defined in this section. A request for approval of inpatient care beyond the first 28 days shall be submitted for concurrent review before the expiration of the initial 28-day period. A request for approval of inpatient care beyond any period that is approved under concurrent review shall be submitted within the period that was previously approved. No insurer shall initiate concurrent review more frequently than at two-week intervals. If an insurer determines that continued inpatient care in a facility is no longer medically necessary, the insurer shall within 24 hours provide written notice to the covered person and the covered person's physician of its decision and the right to file an expedited internal appeal of the determination pursuant to an expedited process pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.5, as applicable. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered person and the covered person's physician. If the determination is to uphold the denial, the covered person and the covered person's physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.6, as applicable. An independent utilization review organization shall make a determination within 24 hours. If the insurer's determination is upheld and it is determined continued inpatient care is not medically necessary, the insurer shall remain responsible to provide benefits for the inpatient care through the day following the date the determination is made and the covered person shall only be responsible for any applicable co-payment, deductible and co-insurance for the stay through that date as applicable under the policy. The covered person shall not be discharged or released from the inpatient facility until all internal appeals and independent utilization review organization appeals are exhausted. For any costs incurred after the day following the date of determination until the day of discharge, the covered person shall only be responsible for any applicable cost-sharing, and any additional charges shall be paid by the facility or provider.

f. (1) The benefits for the first 28 days of intensive outpatient or partial hospitalization services shall be provided without any retrospective review of medical necessity and medical necessity shall be as determined by the covered person's physician.

(2) The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization services shall be subject to a retrospective review of the medical necessity of the services.

g. Benefits for inpatient and outpatient treatment of substance use disorder after the first 180 days per plan year shall be subject to the medical necessity determination of the insurer and may be subject to prior authorization or, retrospective review and other utilization management requirements.

h. Medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health.

i. The benefits for outpatient prescription drugs to treat substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements.

j. The first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange provided in this subsection.

k. Except as stated above, the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.

l. The benefits required by this section are to be provided to all covered persons with a diagnosis of substance use disorder. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this section.

m. The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium.

n. The Attorney General's Office shall be responsible for overseeing any violations of law that may result from P.L.2017, c.28 (C.17:48-6nn et al.), including fraud, abuse, waste, and mistreatment of covered persons. The Attorney General's Office is authorized to adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations to implement any of the provisions of P.L.2017, c.28 (C.17:48-6nn et al.).

o. The provisions of this section shall not apply to a group health insurance policy which, pursuant to a contract between the insurer and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the "Family Health Care Coverage Act," P.L.2005, c.156 (C.30:4J-8 et seq.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.

p. As used in this section:

"Concurrent review" means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and as appropriate, the discharge plans.

"Substance use disorder" is as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include substance use withdrawal.

§ 17B:27-46.1oo Group health insurance policy to provide coverage regardless of gender identity, expression.

5. a. Notwithstanding any other law or regulation to the contrary, a group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance on or after the effective date of this act, shall not contain any provision that discriminates, and the insurer shall not discriminate, on the basis of a covered person's or prospective covered person's gender identity or expression or on the basis that the covered person or prospective covered person is a transgender person.

b. The discrimination prohibited by this section shall include:

(1) denying, cancelling, limiting or refusing to issue or renew a policy on the basis of a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person;

(2) demanding or requiring a payment or premium that is based in whole or in part on a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person;

(3) designating a covered person's or prospective covered person's gender identity or expression, or the fact that a covered person or prospective covered person is a transgender person, as a preexisting condition for which coverage will be denied or limited; or

(4) denying or limiting coverage, or denying a claim, for services including but not limited to the following, due to a covered person's gender identity or expression or for the reason that the covered person is a transgender person:

(a) health care services related to gender transition if coverage is available for those services under the policy when the services are not related to gender transition, including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training; or

(b) health care services that are ordinarily or exclusively available to individuals of one sex when the denial or limitation is due only to the fact that the covered person is enrolled as belonging to the other sex or has undergone, or is in the process of undergoing, gender transition.

c. For the purposes of this section:

"Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's assigned sex at birth.

"Gender identity" means a person's internal sense of their own gender, regardless of the sex the person was assigned at birth.

"Gender transition" means the process of changing a person's outward appearance, including physical sex characteristics, to accord with the person's actual gender identity.

"Transgender person" means a person who identifies as a gender different from the sex assigned to the person at birth.

d. The provisions of this section shall apply to those group health insurance policies in which the insurer has reserved the right to change the premium.

e. Nothing in this section shall preclude the insurer from performing utilization review, including periodic review of the medical necessity of a particular service.

§ 17B:27-46.1pp Group health insurance policy to cover digital tomosynthesis of the breast.

5. a. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in conducting digital tomosynthesis to detect or screen for breast cancer in women 40 years of age and over; and for diagnostic purposes in women of any age.

b. In the case of digital tomosynthesis conducted to detect or screen for breast cancer in women 40 years of age and over, no deductible, coinsurance or other cost sharing shall be applied; and in the case of digital tomosynthesis conducted for diagnostic purposes in women of any age, the same deductibles, coinsurance, and other cost sharing as apply to similar services under the policy shall be applied.

c. This section shall apply to those group health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1qq Group health insurance policy to provide coverage for donated human breast milk.

5. a. A group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the provision of pasteurized donated human breast milk, which may include human milk fortifiers if indicated by the prescribing licensed medical practitioner, provided that:

(1) the covered person is an infant under the age of six months;

(2) the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health ; and

(3) a licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or

(4) a licensed medical practitioner has issued an order for an infant who meets any of the following conditions:

(a) a body weight below healthy levels determined by the licensed medical practitioner;

(b) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or

(c) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health.

b. The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium.

c. Nothing in this section shall preclude the insurer from performing utilization review, including periodic review of the medical necessity of a particular service.

d. The benefits shall be provided to the same extent as for any other prescribed items under the policy.

e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the insurer shall not be required to provide coverage of expenses pursuant to this section.

§ 17B:27-46.1rr Group health insurance policy to provide coverage for standard fertility preservation services.

4. a. A group health insurance policy which provides hospital or medical expense benefits for groups with more than 50 persons and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility.

For the purposes of this section:

"Iatrogenic infertility" means an impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

"May directly or indirectly cause" means a medical treatment with a likely side effect of iatrogenic infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health.

"Standard fertility preservation services" means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health. "Standard fertility preservation services" shall not include the storage of sperm or oocytes.

The benefits shall be provided to the same extent as for any other medical condition under the policy. The same copayments, deductibles, and benefit limits shall apply to the provision of standard fertility preservation services pursuant to this section as those applied to other medical or surgical benefits under the policy.

b. An insurer providing coverage under this section shall not determine the provision of standard fertility preservation services based on an insured's expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life, or other health conditions, or based on personal characteristics, including age, sex, sexual orientation, marital status, or gender identity.

c. This section shall apply to those group health insurance policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1ss Group health insurer to provide coverage for breastfeeding support.

5. a. A group health insurer policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2019, c.343 (C.17:48-6ss et al.), shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for health plan enrollees, with no cost-sharing.

b. Coverage of breastfeeding equipment shall include:

(1) Purchase of a single-user breast pump, subject to the following conditions:

(a) A policy shall cover the purchase of a double electric breast pump. If an enrollee requests a manual pump in lieu of the double electric breast pump, the health plan shall cover the purchase of a manual pump.

(b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding.

(c) A policy shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph.

(d) Coverage shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the plan enrollee.

(e) Coverage for breast pumps shall include repair or replacement if necessary.

(2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions:

(a) When recommended by a licensed health care provider, a policy shall provide coverage for a multi-user breast pump.

(b) A group health insurer may determine whether a rental or purchase is covered.

(c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump.

(d) A group health insurer may require a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump.

(3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider.

(4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the group health insurer cannot ensure an enrollee receives breastfeeding equipment within 48 hours, an enrollee may purchase the equipment and the health plan shall reimburse all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts.

(5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the group health insurer shall reimburse all out-of-pocket rental expenses incurred by an enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment.

c. Coverage of comprehensive lactation counseling and lactation consultation shall include:

(1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions:

(a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits.

(b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need.

(2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need.

(3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups.

(4) A policy shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting.

(5) A group health insurer shall not impose medical management techniques not described in this section.

d. Except as otherwise authorized pursuant to this section, a group health insurer shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided.

e. As used in this section:

"Cost-sharing" means deductible, co-insurance or co-payments, or similar charges.

"Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump.

"Lactation consultant" means an individual who is an International Board Certified Lactation Consultant.

"Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services.

Lactation care and services shall include, but not be limited to:

(1) lactation assessment through the systematic collection of subjective and objective data;

(2) analysis of data and creation of a plan of care;

(3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider;

(4) evaluation of outcomes;

(5) provision of lactation education to parents and health care providers; and

(6) the recommendation and use of assistive devices.

"Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as:

(1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding;

(2) acting as an advocate for breastfeeding as the norm for feeding infants and young children;

(3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals;

(4) using principles of adult education when teaching clients, health care providers, and others in the community; and

(5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately.

"Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is:

(1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or

(2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice. "Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication.

f. This section shall apply to those policies in which the group health insurer has reserved the right to change the premium.

§ 17B:27-46.1tt Group health insurer policy to cover preventive services.

5. a. A group health insurer policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage, without requiring any cost sharing, for the following preventive services:

(1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;

(2) immunizations that have in effect a recommendation from the Department of Health, which shall in making its recommendations consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians;

(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

(4) with respect to women, any additional preventive care and screenings not described in paragraph (1) as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

b. (1) Except as provided in paragraph (2) of this subsection, nothing in this section shall:

(a) require a policy which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or

(b) preclude a policy which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider.

(2) If a policy does not have in its network a provider who can provide an item or service described in subsection a. of this section, the policy shall cover the item or service when performed by an out-of-network provider and shall not impose cost sharing with respect to that item or service.

c. (1) A policy shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued.

(2) (a) Except as provided in subparagraph (b) of this paragraph, a policy that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year.

(b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section.

d. This section shall apply to those policies in which the insurer has reserved the right to change the premium.

e. With respect to an annual wellness visit for a covered member who is over three years of age, a carrier is required to cover only one wellness visit per plan year or calendar year, as provided for under the policy, but may not impose a waiting period for the wellness visit.

§ 17B:27-46.1uu Group health insurance policy to provide certain coverage for prescription drugs.

5. a. Notwithstanding any other provision of law to the contrary, an insurer that offers a group health insurance policy that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, shall ensure that the insurer offers at least two plans in the large group market pursuant to N.J.S.17B:27-26 et seq.

b. The provisions of the section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1vv Group health insurance policy to cover adolescent depression screenings.

5. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service.

The benefits shall be provided to the same extent as for any other condition under the policy, except that the insurer shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance.

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

§ 17B:27-46.1ww Group health insurance policy, coverage, epinephrine auto-injector device.

14. A group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide coverage for at least one epinephrine auto-injector device, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of an epinephrine auto-injector device shall not be subject to any deductible, and no copayment or coinsurance for the purchase of an epinephrine auto-injector device shall exceed $25 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

Nothing in this section shall prevent a group health insurer from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section.

§ 17B:27-46.1xx Group health insurance policy, coverage, prescription asthma inhaler.

15. A group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide benefits to a person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

Nothing in this section shall prevent a group health insurer from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section.

§ 17B:27-46.1yy Biomarker precision medical testing coverage, group health insurance policies.

5. a. Each group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes or is approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide benefits for biomarker precision medical testing, as defined by subsection g. of this section.

b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of an insured when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for an insured's disease or condition is recognized by:

(1) labeled indications for an FDA-approved or -cleared test;

(2) indicated tests for an FDA-approved drug;

(3) actions to address warnings and precautions on FDA-approved drug labels;

(4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or

(5) nationally recognized clinical practice guidelines.

c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of an insured.

d. (1) If utilization review is required, an insurer shall provide a decision pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.).

(2) The insured and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the insured shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination.

e. The benefits shall be provided to the same extent as for any other medical condition under the contract, including determinations of clinical review criteria used for utilization review of health care services along with copayment, deductible, and coinsurance provisions.

f. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

g. As used in this section:

"Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression.

"Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing.

"Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. The guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.

§ 17B:27-46.1zz Group health insurance policy, HIV preexposure prophylaxis, HIV postexposure prophylaxis.

7. a. (1) Except as provided in paragraph (2) of this subsection, no group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L.2025, c.196 (C.45:14-67.13) without requiring prior authorization or step therapy.

(2) If the federal Food and Drug Administration has authorized or approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the policy to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.

b. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the group health insurance policy to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:

(1) the service or procedure is within the scope of practice of the treating pharmacist; and

(2) the service or procedure would otherwise be covered under the policy if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.

c. A group health insurance policy shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the policy to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.

d.A group health insurance policy shall not:

(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and

(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L.2025, c.196 (C.45:14-67.13) in excess of a 90-day supply for a single patient within a given two year period.

e. Nothing in this section shall be construed to require a group health insurance policy to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.

f. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

g. As used in this section:

“HIV preexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12).

“HIV postexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12).

“Step therapy” means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits.

§ 17B:27-46.1aaa Benefits provided under group health policies.

5. a. Every group health policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2025, c.200 (C. 17:48-6bbb et al.), shall provide benefits to any named insured or other person covered thereunder for expenses incurred in obtaining medically necessary treatment for women with a diagnosis of perimenopause, menopause, and symptoms associated with perimenopause and menopause, including, but not limited to:

(1) hormonal therapies such as hormone replacement therapy and bioidentical hormone treatments;

(2) non-hormonal treatments, including medications to manage perimenopause and menopausal symptoms;

(3) behavioral health care services;

(4) pelvic floor physical therapy;

(5) bone health treatments, including screenings and medications due to hormonal changes related to perimenopause and menopause;

(6) preventative services that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force for early detection and treatment of health conditions related to perimenopause and menopause such as osteoporosis and cancer; and

(7) counseling and education regarding menopause management.

b. Every group policy shall provide clear and accessible information to insureds regarding covered perimenopause and menopause treatments.

c. The benefits shall be provided to the same extent as for any other medical condition under the policy.

d. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

e. As used in this section:

“Menopause” means the permanent end of a female’s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period.

“Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles.

§ 17B:27-46.2 Second surgical opinions; definitions

As used in this act:

a. "Elective surgical procedure" means any nonemergency surgical procedure which may be scheduled at the convenience of the patient or the surgeon without jeopardizing the patient's life or causing serious impairment to the patient's bodily functions.

b. "Second surgical opinion" means an opinion of an eligible physician based on that physician's examination of a person for the purpose of evaluating the medical advisability of that person undergoing an elective surgical procedure. The examination must be performed after another physician licensed to practice medicine and surgery has proposed to perform such surgical procedure on the person but prior to the performance of such surgical procedure.

c. "Eligible physician" means a physician licensed to practice medicine and surgery who holds the rank of Diplomate of an American Board (M.D.) or Certified Specialist (D.O.) in the surgical or medical specialty for which surgery is proposed.

§ 17B:27-46.3 Group insurance policies; provision of program on request

Any insurer issuing a group insurance policy in accordance with chapter 27 of Title 17B of the New Jersey Statutes which provides coverage of surgical operations performed on a person while confined in a hospital as an inpatient shall make available, and if requested by the group policyholder, provide a second surgical opinion program for elective surgical procedures which would require inpatient admission to a hospital for persons insured under the group policy for such surgical coverage.

§ 17B:27-46.4 Payment for second surgical opinion services

A second surgical opinion program shall provide for payment for the second surgical opinion services of an eligible physician and for essential laboratory and X-ray services incidental thereto, either as a benefit under the group policy or, at the insurer's option, by a separate arrangement with the group policyholder. The program may be limited to eligible physicians who have agreed to participate in the insurer's second surgical opinion program. If the benefits are provided by the group insurance policy, the amount shall be reasonably related to amounts payable under the group policy for covered surgical procedures.

§ 17B:27-46.5 Third surgical opinion

If a second surgical opinion does not confirm that a proposed elective surgical procedure is medically advisable, the program must cover a third surgical opinion in the same manner as the second opinion.

§ 17B:27-46.6 Reduction of benefits where no second opinion obtained

Where a second surgical opinion program is operative in connection with surgical coverage under a group insurance policy, and provides second and third surgical opinion services at no cost to the insured or patient, the group policy may, as an incentive to encourage utilization of the program when elective surgery is proposed, provide reduced benefits for the surgeon's charges for such elective surgery if it is performed without first obtaining a second or third opinion confirming that the proposed elective surgery was advisable.

§ 17B:27-46.7 Permissible benefit exclusions

A second surgical opinion program may exclude benefits while the patient is confined in a hospital as an inpatient, any surgical procedure not covered by the group insurance policy, and surgical procedures in the following categories: cosmetic surgery, dental surgery, and podiatric surgery.

§ 17B:27-46.8 Payment for opinion services of physician

If a physician who furnishes a second or third surgical opinion also performs the surgical procedure, the second surgical opinion program need not provide payment for the second or third opinion services of that physician.

§ 17B:27-46.9 Application of act

This act shall apply to all contracts in which the insurer has reserved the right to change the premium.

§ 17B:27-46.10 Group health insurance policy to cover newborn home care visitation.

9. a. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159). The policy shall:

(1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159);

(2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant;

(3) ensure that the policy does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and

(4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing:

(a) a value-based payment methodology;

(b) an invoice claim process;

(c) a capitated payment arrangement;

(d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or

(e) any other payment arrangement agreed to by the insurer and an agency or organization providing services under the program.

b. Any copayment, coinsurance, or deductible that may be required pursuant to the policy for such services shall be waived.

c. Every insurer that is subject to the provisions of this section shall submit to the Department of Banking and Insurance, in a form and manner prescribed by the department, a report on the claims submitted for services provided under the newborn home nurse visitation program.

The information contained in the report shall be shared with the Department of Children and Families and used by that department to assess the newborn home nurse visitation program pursuant to subsection a. of section 4 of P.L.2021, c.187 (C.26:2H-161).

d. (1) Except as provided in paragraphs (2) and (3) of this subsection, the contract shall specify that no deductible, coinsurance, copayment, or any other cost-sharing requirement may be imposed on the coverage required pursuant to this section.

(2) A group health insurance policy that qualifies as a high deductible health plan shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement permitted for a high deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).

(3) A group health insurance policy that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement to the extent permitted for a catastrophic plan under federal law.

e. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

§ 17B:27-47 Group health or blanket insurance--provisions as favorable; policies issued outside State

No policy of group health or blanket insurance, and no certificate thereunder shall be delivered or issued for delivery in this State if such policy or certificate contains any provision inconsistent with any of the provisions of this chapter, except that such policy may contain any provision which in the opinion of the commissioner is as favorable to policyholders or certificate holders as the provision herein required, and except that such policy issued by any insurer of this State for delivery outside of this State may contain any provision not consistent with the provisions of this chapter; provided, such policy conforms to the laws of the State or country in which it is delivered.

§ 17B:27-48 Exceptions in same type as benefits

Exceptions in the policy shall be printed in the policy and in the certificate with the same prominence as the benefits to which they apply.

§ 17B:27-49 Filing of forms

a. No group health insurance policy, or blanket insurance policy, or application, if a written application is required and is to be made a part of the policy, certificate, printed rider or endorsement for use with the policy, shall be delivered or issued for delivery in this State unless the form has been filed with the commissioner in accordance with the provisions of section 16 of P.L.1995, c.73 (C.17B:25-18.2).

b. (Deleted by amendment, P.L.1995, c.73.)

c. If a form is disapproved for filing by the commissioner during the 60-day period, it may not be delivered or issued for delivery unless it is resubmitted and approved in accordance with the provisions of subsections b., c., and d. of section 16 of P.L.1995, c.73 (C.17B:25-18.2). Such disapproval shall be subject to review in accordance with the procedure described in the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder. Any such form which is filed by the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith

d. (Deleted by amendment, P.L.1995, c.73.)

e. (Deleted by amendment, P.L.1995, c.73.)

f. This section shall not apply to documents which relate only to the manner of distribution of benefits or to the reservation of rights and benefits under such policies and which are used at the request of the individual insured or policyholder.

g. The disapproval by the commissioner of any such form may be on the ground that such form contains provisions which are unjust, unfair, inequitable, misleading, contrary to law or to the public policy of this State.

§ 17B:27-50 Reimbursement for service of physician or practicing psychologist

a. Notwithstanding any provision of a policy or contract of group health insurance, hereafter delivered or issued for delivery in this State, whenever such a policy or contract provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed practicing psychologist, a person covered under such group health policy or contract shall be entitled to reimbursement for such service whether the said service is performed by a physician or duly licensed practicing psychologist.

b. The foregoing provision shall be liberally construed in favor of reimbursement and no claim for reimbursement shall be denied by reason of:

(1) The fact that physical delivery of a policy or contract of group health insurance or any package of insurance of which group health insurance is a part, or of a contract, certificate or other evidence of insurance coverage drawn thereunder, was made outside this State, provided, the member of the group covered is, at the time of delivery or at any time thereafter to the time of reimbursement, either (a) a resident of this State, or (b) a nonresident employed in this State and the said policy or contract is related to or arose out of such employment; or

(2) The inclusion in such policy or contract of a description or designation of the person rendering the services for which reimbursement is sought as a "physician" or "psychiatrist," or other professional designation; or

(3) The fact that the psychiatric or psychologist services rendered by a licensed psychologist for which reimbursement is sought are such as might also be lawfully rendered by a physician or psychiatrist as medical care, services or treatment under the laws of this State.

c. Any person insured under any policy or contract of group health insurance or blanket insurance, whether written separately or as part of a package policy, which policy or contract is issued, delivered, amended, renewed, or ratified on or after 3 months from the effective date of this act, and, in any event, any person insured under any policy or contract of group health insurance or blanket insurance, written separately or as part of a package policy, which is in effect on or after July 1, 1974, shall be entitled to reimbursement for any service rendered by a practicing psychologist, provided, reimbursement is authorized in such policy or contract for services of the same or similar nature and scope, and further provided, the services for which reimbursement is claimed are within the lawful scope of practice of a practicing psychologist, whether the service is performed by a physician or a psychiatrist or duly licensed practicing psychologist at any time while the policy is in effect; and further provided (1) such person is a resident of this State, or, (2) the policy or contract is related to or arises out of employment and the member of the group seeking reimbursement is engaged in such employment in this State, or (3) the policy or contract, or certificate of insurance thereunder, or amendment, renewal, or notification thereof, is either issued or delivered in this State.

§ 17B:27-50.1 Severability

If any section, subsection, paragraph, sentence, clause, phrase or word contained in this act shall be declared invalid for any reason whatsoever, such invalidity shall not effect the remaining portions of this act which shall remain in full force and effect, and, to this end, the provisions of this act are hereby declared to be severable.

§ 17B:27-51 Reimbursement for optometric service

Notwithstanding any provision of a policy or contract of group health insurance, hereafter delivered or issued for delivery in this State, whenever such a policy or contract provides for reimbursement for any optometric service which is within the lawful scope of practice of a duly licensed optometrist, a person covered under such group health policy or contract shall be entitled to reimbursement for such service, whether the said service is performed by a physician or duly licensed optometrist.

§ 17B:27-51.1 Reimbursement for service of chiropractor

Notwithstanding any provision of a policy or contract of group health insurance, hereafter delivered or issued for delivery in this State, whenever such a policy or contract provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed chiropractor, a person covered under such group health policy or contract or the chiropractor rendering such service shall be entitled to reimbursement for such service when the said service is performed by a chiropractor. The foregoing provision shall be liberally construed in favor of reimbursement of chiropractors.

§ 17B:27-51.1a Group health insurance benefits for certain nursing services

2. a. Notwithstanding any provision of a policy of group health insurance, whenever such a policy provides for reimbursement for any service which is within the lawful scope of practice of a duly registered professional nurse who is not being paid a salary by a health care provider for the services so performed, a person covered under that group health insurance policy or the registered professional nurse rendering the service shall be entitled to reimbursement for the service.

b. This act shall exclude salaried services which are already reimbursed and shall not be construed to affect or impair hospital procedures for billing in-hospital nursing care. The practice of nursing shall be deemed to be within the provisions of chapter 27 of Title 17B of the New Jersey Statutes and duly registered professional nurses shall have those privileges and benefits in the scope of their practice as are afforded thereunder to licensed physicians and surgeons in the scope of their practice.

c. This section shall apply to any group health insurance policy: (1) delivered or issued for delivery in this State on or after the effective date of this act; or (2) under which the insurer reserves the right to change the premium.

§ 17B:27-51.2 Legislative findings and declarations

The Legislature hereby finds and declares that the high cost of hospital care necessitates the establishment of alternative means of caring for patients who need some professional health care, but who do not need to remain hospitalized. Home health care, therefore, is a necessary and desirable means of providing professional services to patients, consistent with the following objectives:

a. Rehabilitation of the patient in order to assist in the development of independent living capabilities;

b. Rehabilitation of the patient in order to attain reduction of physical or mental disability.

§ 17B:27-51.3 Definitions

As used in this act:

a. "Home health care" means those nursing and other home health care services rendered to a person in his place of residence, under the following conditions:

(1) On a part-time and intermittent basis, except when full-time or 24-hour services are needed on a short-term basis;

(2) If continuing hospitalization would otherwise have been required if home health care were not provided;

(3) Pursuant to a physician's order and under a plan of care established by the responsible physician in collaboration with a home health care provider, which plan shall be periodically reviewed and approved by said physician. All care plans shall be established within 14 days following the commencement of home health care.

b. "Home health care services" means any of the following services necessary for achievement of the care plan set forth for the patient:

(1) Nursing care;

(2) Physical therapy;

(3) Occupational therapy;

(4) Medical social work;

(5) Nutrition services;

(6) Speech therapy;

(7) Home health aide services;

(8) Medical appliances and equipment, drugs and medications, laboratory services and special meals, to the extent such items and services would have been covered under the policy if the covered person had been in a hospital;

(9) Any diagnostic or therapeutic service, including surgical services, performed in a hospital outpatient department, a doctor's office or any other licensed health care facility, provided such service would have been covered under the policy if performed as inpatient hospital services.

c. "Home health care provider" means a home health care agency which is certified to participate as a home health agency under Title XVIII of the Social Security Act or a proprietary agency licensed by the Commissioner of Health. At such time as home health agency licensure standards are promulgated pursuant to c. 136 and 138, P.L.1971, home health care providers shall be licensed agencies.

§ 17B:27-51.4 Home health care; requirement for coverage

Notwithstanding any provision of a policy of group health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides coverage for inpatient hospital care or skilled nursing facility care, it shall also provide coverage for home health care.

§ 17B:27-51.5 Benefits

Every policy shall provide benefits required by section 3 without a separate deductible or coinsurance provision for the home health care benefit. For the purpose of determining the benefits for home health care, each visit by a member of a home health care team shall be considered as one home health care visit. The policy may contain a limitation on the number of home health care visits, but no policy may provide for less than 60 home health care visits in any calendar year or in any continuous period of 12 months.

§ 17B:27-51.6 Direct reimbursement to home health care providers

The State Commissioner of Insurance, after consultation with the State Commissioner of Health, shall provide for a system of direct reimbursement to home health care providers for services rendered pursuant to this act.

§ 17B:27-51.7 Regulations

The State Commissioner of Insurance, after consultation with the State Commissioner of Health, is hereby empowered and directed to promulgate regulations necessary to effectuate the provisions of this act.

§ 17B:27-51.8 Policy provision for reimbursement of dental services; payment regardless of discipline of provider

Notwithstanding any provision of a policy or contract of group health insurance hereafter delivered, issued for delivery, amended, renewed or ratified in this State whenever such a policy or contract provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed dentist, the following provisions shall apply:

a. A person covered under such group health policy or contract shall be entitled to reimbursement for such service regardless of whether the service is performed by a duly licensed physician or duly licensed dentist.

b. Equal reimbursement rates shall be paid for services performed, regardless of the discipline of the provider of the service.

§ 17B:27-51.9 Application to policy or contract not limited to reimbursement of specific types of duly licensed health care professionals other than dentists

The provisions of section 1 of this act shall also apply to any policy or contract of group health insurance already delivered or issued for delivery in this State, if such policy or contract does not limit reimbursement to specific types of duly licensed health care professionals other than dentists.

§ 17B:27-51.10 Renewal date; policy with reservation of right to change premium

For the purposes of this act, a policy or contract in which the company has reserved the right to change the premium shall be considered renewed as of the date on which the premium is changed or is subject to change.

§ 17B:27-51.10a Alternative dental coverage; original coverage restricted to limited number of providers

Each employer or other organization which employs or has 25 or more employees or members during the full preceding calendar year which contributes to a group health insurance contract which restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers, shall also offer its employees or their eligible dependents or members or members' eligible dependents at the time a dental benefits plan is offered or renewed the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist.

§ 17B:27-51.10b Employer contribution

An employer or other organization shall be required to pay or contribute towards the provision of alternative coverage an amount equal to the premium or cost which it pays or contributes to the group health insurance contract for dental services which limits the number of providers of dental services.

§ 17B:27-51.10c Rules and regulations

Within 120 days of the effective date of this act, the Commissioner of the Department of Insurance shall promulgate rules and regulations necessary to effectuate the purpose of this act, including procedures for notice to covered persons, employers and other organizations of the provisions of this act.

§ 17B:27-51.11 Definitions

As used in this act:

a. "Group policy" means a group health insurance policy issued by an insurer pursuant to Title 17B of the New Jersey Statutes.

b. "Insurer" means the entity issuing a group policy or an individual policy or converted policy.

c. "Insurance" , "Insures" and "Insured" refer to coverage under a group policy on a premium-paying basis.

d. "Premium" includes any premium or other consideration payable for coverage under a group or individual policy.

e. "Medicare" means Title XVIII of the United States Social Security Act as amended or superseded.

f. "Total disability of the employee or member" exists only while the employee or member (1) is not engaged in any gainful occupation, and (2) is completely unable, due to sickness or injury or both, to engage in any and every gainful occupation for which the person is reasonably fitted by education, training or experience.

§ 17B:27-51.12 Total disability of employee or member; continuation under group policy; conditions

A group policy delivered or issued for delivery in this State which insures employees or members and their dependents for hospital, surgical or major medical insurance on an expense incurred or service basis, other than for specific diseases or for accidental injuries only, shall provide that employees or members whose insurance under the group policy would otherwise terminate because of termination of employment or membership due to total disability of the employee or member shall be entitled to continue their hospital, surgical and major medical insurance under that group policy, for themselves and their eligible dependents, subject to all of the group policy's terms and conditions applicable to those forms of insurance and subject to the following conditions:

a. Continuation shall only be available to any employee or member who has been continuously insured under the group policy during the entire 3-month period ending with such termination.

b. Continuation shall be available for any person who is covered by or eligible for Medicare, subject to any nonduplication of benefits provisions in the group policy.

c. In addition to hospital, surgical, or major medical benefits, continuation shall include all other health care expense benefits provided under the group policy, including dental, vision care, or prescription drug benefits.

d. An employee or member electing continuation shall pay to the group policyholder or his employer, on a monthly basis in advance, the amount of contribution required by the policyholder or employer, but not more than the group rate for the insurance being continued under the group policy on the due date of each payment. The employee's or member's written election for continuation, together with the first contribution required to establish contributions on a monthly basis in advance, shall be given to the policyholder or employer within 31 days of the date the employee's or member's insurance would otherwise terminate.

e. Continuation of insurance under the group policy for any person shall terminate at the first to occur of the following:

(1) Failure of the former employee or member to make timely payment of a required contribution. Termination shall occur at the end of the period for which contributions were made.

(2) The date the employee again becomes employed and eligible for benefits under another group plan providing health care expense benefits, or in the case of a qualified dependent, the date such qualified dependent becomes employed and eligible for such benefits.

(3) The date on which the group policy is terminated or, in the case of an employee, the date his employer terminates participation under the group policy, provided that

(a) The employee or member shall have the right to become covered under any new group policy contracted for by the employer, for the balance of the period that he would have remained covered under the prior group policy in accordance with this act had a termination of a group not occurred;

(b) The minimum level of benefits to be provided by the other group policy shall be the applicable level of benefits of the prior group policy reduced by any benefits payable under that prior group policy; and

(c) The prior group policy shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.

f. A notification of the continuation privilege shall be included in each certificate of coverage.

§ 17B:27-51.13 Inapplicability to policy without right of insurer to terminate without consent of insured

The provisions of this act shall not apply to any policy in which the insurer does not have the right to terminate the policy without the consent of the insured.

§ 17B:27-51.14 Insurer provide health benefits plan, aggregate benefits.

4. a. Beginning with the calendar year starting on January 1, 2020, and in each calendar year thereafter, an insurer providing a health benefits plan shall return, in the form of aggregate benefits for all large group health insurance policy forms offered by the insurer pursuant to N.J.S.17B:27-26 et seq., at least 85 percent of the aggregate premiums collected for all of the policy forms.

b. An insurer shall annually report to the Commissioner of Banking and Insurance, no later than August 1 of each year, the loss ratio calculated for all of the policy forms for the previous calendar year. In each case in which the loss ratio fails to substantially comply with the 85 percent loss ratio requirement, the insurer shall issue a dividend or credit against future premiums for all policyholders in an amount sufficient to assure that the aggregate benefits paid in the previous calendar year plus the amount of the dividends and credits shall equal 85 percent of the premiums collected. The insurer shall distribute all dividends and credits by December 31 of the year following the calendar year in which the loss ratio requirements were not satisfied. The insurer's annual report shall include the insurer's calculation of the dividends and credits applicable to all policy forms, as well as an explanation of the insurer's plan to issue dividends or credits.

c. The commissioner shall specify by regulation:

(1) any informational filings required to be submitted by insurers to the commissioner in order to determine whether insurers are in compliance with their loss ratio requirements;

(2) the instructions and format for calculating and reporting loss ratios and issuing dividends or credits;

(3) procedures for the distribution of a dividend or credit in the event of cancellation or termination by a policyholder; and

(4) the instructions and format for submitting annual reports.

§ 17B:27-52 Group life and health--package policies

Any insurer authorized to write in this State group life and group health insurance may provide such coverages in one policy or in separate policies, or in supplements or riders to such policy or policies, with or without health insurance benefits on account of families or dependents of the insured employees or members, if the provisions of any such policy, supplement or rider which treat of group life insurance, and the provisions which treat of group health insurance comply respectively with the requirements of the law of this State applicable to the respective forms of insurance.

§ 17B:27-53 Group life and health--rate reductions and application of dividends; excess over employer's cost

If a policy dividend is hereafter declared or a reduction in rate is hereafter made or continued under any group insurance policy heretofore or hereafter issued to an employer, or to a labor union, or to the trustees of a fund established in whole or in part by an employer or a labor union, the excess, if any, of the aggregate dividends or rate reductions under such policy and all other group insurance policies of the policyholder over the aggregate expenditure for insurance under such policies made from funds contributed by the policyholder, or by an employer of insured persons, or by a union or association to which insured persons belong, including expenditures made in connection with administration of such policies, shall be applied by the policyholder for the sole benefit of insured employees or members.

§ 17B:27-54 Application of provisions; definitions.

14. The provisions of sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67) shall apply to group health insurance coverage that is not subject to the provisions of P.L.1992, c.161 and c.162 (C.17B:27A-2 et seq. and 17B:27A-17 et seq.). To the extent that any provision of sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67) is inconsistent with the provisions of chapter 27 of Title 17B of the New Jersey Statutes and P.L.1973, c.337 (C.26:2J-1 et seq.), the provisions of sections 14 through 27 shall supersede those laws.

As used in sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67):

"Affiliation period" means a period which, under the terms of the group health plan offered by a health maintenance organization, begins on the enrollment date and which must expire before the health insurance becomes effective. The health maintenance organization shall not be required to provide health care services or benefits during such period and no premium shall be charged.

"Creditable coverage" means, with respect to an individual, coverage of the individual, other than coverage of excepted benefits, under any of the following: a group health plan; health insurance coverage; Part A or Part B of Title XVIII of the federal Social Security Act (42 U.S.C.s.1395 et seq.); Title XIX of the federal Social Security Act (42 U.S.C.s.1396 et seq.); other than coverage consisting solely of benefits under section 1928 of Title XIX of the federal Social Security Act (42 U.S.C.s.1396s); chapter 55 of Title 10, United States Code (10 U.S.C. s.1071 et seq.); a medical care program of the Indian Health Service of a tribal organization; a state health benefits risk pool; a health plan offered under chapter 89 of Title 5, United States Code (5 U.S.C. s.8901 et seq.); a public health plan; and a health benefits plan under section 5(e) of the "Peace Corps Act" (22 U.S.C.s.2504(e)).

"Enrollment date" means, with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for enrollment.

"Excepted benefits" means:

a. coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified by federal regulation, under which benefits for medical care are secondary or incidental to other insurance benefits;

b. when provided under a separate policy, certificate or contract of insurance or otherwise not an integral part of the group health plan: limited scope dental or vision benefits, benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof, and such other similar, limited benefits as are specified by federal regulation;

c. when offered as independent, noncoordinated benefits: hospital indemnity or other fixed indemnity insurance;

d. when offered as a separate insurance policy, certificate or contract of insurance: Medicare supplemental insurance as defined under section 1882(g)(1) of the federal Social Security Act (42 U.S.C. s.1395ss(g)(1)) and coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code (10 U.S.C.s.1071 et seq.) and similar supplemental coverage provided in addition to coverage under a group health plan.

"Group health plan" means an employee welfare benefit plan, as defined in Title I of section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C. s.1002(1)), to the extent that the plan provides medical care and including items and services paid for as medical care to employees or their dependents, as defined under the terms of the plan, directly or through insurance, reimbursement or otherwise.

"Health insurance coverage" means benefits consisting of medical care, provided directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care, under any hospital or medical expense policy or certificate or health maintenance organization contract offered by a health insurer.

"Health insurer" means an insurer licensed to sell health insurance pursuant to Title 17B of the New Jersey Statutes, a health, hospital or medical service corporation, fraternal benefit association or a health maintenance organization.

"Health status-related factor" means: health status; medical condition, including both physical and mental illness; claims experience; receipt of health care; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; and disability.

"Health maintenance organization" means a federally qualified health maintenance organization as defined in the "Health Maintenance Organization Act of 1973," Pub.L.93-222 (42 U.S.C. s.300e et seq.), an organization authorized under P.L.1973, c.337 (C.26:2J-1 et seq.), or a similar organization regulated under State law for solvency in the same manner and to the same extent as a health maintenance organization authorized to do business in this State.

"Late enrollee" means a participant or beneficiary who enrolls in a group health plan other than during: the first period during which the individual is eligible to enroll in the plan; or a special enrollment period.

"Medical care" means amounts paid: (1) for the diagnosis, care, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body; and (2) transportation primarily for and essential to medical care referred to in (1) above.

"Network plan" means a group health plan offered by a health insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. Network plan includes a health maintenance organization or health insurance company with selective contracting arrangements.

"Preexisting condition" means with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for that coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before that date.

"Waiting period" means with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan.

§ 17B:27-60 Written certification of creditable coverage under COBRA

20. a. A health insurer which offers a group health plan shall provide a written certification of creditable coverage at the time an individual ceases coverage or otherwise becomes covered under a COBRA continuation provision; at the time an individual ceases to be covered under a COBRA continuation provision; and upon request, on behalf of an individual not later than 24 months after the cessation of coverage under the plan or a COBRA continuation provision.

b. The written certification of creditable coverage shall include the period of creditable coverage of the individual under the group health plan and the coverage under any COBRA continuation provision and any waiting or affiliation period imposed with respect to the individual for coverage under the plan.

§ 17B:27-61 Affiliation period imposed by HMO

21. A health maintenance organization which offers a group health plan and which does not impose a preexisting condition exclusion, may impose an affiliation period if the period is applied uniformly without regard to any health status-related factors and the period does not exceed two months, or three months in the case of a late enrollee.

§ 17B:27-62 Permission to enroll for group coverage

22. A health insurer which offers a group health plan shall permit an employee or dependent who is eligible, but not enrolled, for coverage under the terms of the plan, to enroll for coverage if:

a. the employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent, and the employee stated in writing at such time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, if the health insurer required such a statement at that time and notified the employee of the insurer s requirements;

b. the employee s or dependent s other coverage described in subsection a. of this section was under a COBRA continuation provision and coverage under that provision was exhausted or the coverage was terminated due to loss of eligibility for coverage, including legal separation, divorce, death, termination of employment and reduction in hours of employment, or to the termination of employer contributions toward that coverage; and

c. the employee requests enrollment not later than 30 days after exhaustion of coverage under a COBRA continuation provision or termination of coverage pursuant to subsection b. of this section.

§ 17B:27-63 Dependent special enrollment period

23. If a group health plan makes coverage available with respect to a dependent of an individual who is a participant under the plan or has satisfied any waiting period and is eligible to be enrolled, and the dependent becomes a dependent of the individual through marriage, birth, adoption or placement for adoption, the group health plan shall provide for a dependent special enrollment period during which the dependent and individual, if necessary, may be enrolled.

The dependent special enrollment period shall be for a period of not less than 30 days and shall begin on the later of the date dependent coverage is made available or the date of marriage, birth, adoption or placement for adoption. If an individual enrolls a dependent during the first 30 days of the dependent special enrollment period, the coverage of the dependent shall become effective: in the case of a marriage, no later than the first day of the first month after the date the completed request for enrollment is received; in the case of a dependent s birth, as of the date of birth; and in the case of a dependent s adoption or placement for adoption, the date of the adoption or placement for adoption.

§ 17B:27-64 Rules for eligibility, health status-related factors prohibited

24. A health insurer which offers a group health plan may not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the plan based on health status-related factors in relation to the individual or a dependent of the individual.

The provisions of this section shall not be construed to require a group health plan to provide particular benefits other than those provided under the terms of its coverage or to prevent the coverage from establishing limitations or restrictions on the amount, level, extent or nature of the benefits or coverage for similarly situated individuals enrolled in the coverage.

§ 17B:27-65 Premiums, contributions regulated

25. A health insurer which offers a group health plan may not require an individual, as a condition of enrollment or continued enrollment under the plan, to pay a premium or contribution which is greater than the premium or contribution for a similarly situated enrollee in the plan on the basis of any health status-related factor in relation to the individual or to an enrollee or a dependent of the individual or enrollee. This provision shall not be construed to restrict the amount that an employer may be charged for coverage under a group health plan or to prevent a health insurer offering group health insurance coverage from establishing premium discounts or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.

§ 17B:27-66 Renewal of coverage; exceptions

26. A health insurer which offers health insurance coverage in connection with a group health plan shall renew the coverage under the plan at the option of the policy holder, except that:

a. A health insurer may discontinue the coverage only if:

(1) the policy holder has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the insurer has not received timely premium payments;

(2) the policy holder has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the health insurance coverage; and

(3) in the case of a health insurer which offers a group health plan through a network plan, there is no longer any enrollee in the plan who lives, resides or works in the service area of the insurer or in the area for which the insurer is authorized to do business; or

b. A health insurer may not renew the health insurance coverage only if:

(1) the policy holder has failed to comply with a material plan provision relating to employer contribution or group participation rules; or

(2) the insurer is ceasing to offer coverage in the market in accordance with State and federal law.

c. A health insurer may cease offering and not renew a particular type of health insurance coverage only if:

(1) the insurer provides notice to each certificate or policy holder who is provided coverage of this type, and to participants and beneficiaries covered under the coverage of the nonrenewal at least 90 days prior to the date of the nonrenewal of the coverage;

(2) the insurer offers the option to purchase all or any other health insurance coverage that the insurer offers; and

(3) in exercising the option to not renew coverage of a particular type and in offering the option to purchase all or any other health insurance coverage that the insurer offers, the insurer acts uniformly without regard to the claims experience of the certificate or policy holder or any health status-related factor relating to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for the coverage.

d. A health insurer may cease offering and not renew all health insurance coverage only if:

(1) the insurer provides notice to the Department of Banking and Insurance and each employer and participants and beneficiaries covered under the health insurance coverage, of the nonrenewal at least 180 days prior to the date of the nonrenewal;

(2) the insurer ceases offering all health insurance coverage issued or delivered for issuance in the State for groups under the provisions of sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67) and coverage under the health insurance coverage is not renewed; and

(3) the insurer may not provide for the issuance of any health insurance coverage for groups in this State under the provisions of sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67), during a five-year period beginning on the termination date of the last health insurance coverage that was not renewed.

§ 17B:27-67 Modification of coverage

27. At the time of coverage renewal, a health insurer may modify the health insurance coverage for a product offered to a group health plan.

§ 17B:27-68 Conditions for issuance, delivery of group life insurance.

1. Except as provided in section 2 of this act, no policy of group life insurance shall be delivered or issued for delivery in this State unless it meets one of the descriptions in subsections a. through h. of this section:

a. A policy issued to an employer, or to the trustees of a fund established by an employer, which employer or trustees shall be deemed the policyholder, to insure employees of the employer for the benefit of persons other than the employer, including the funding of employee benefit plans, subject to the following requirements:

(1) The employees eligible for insurance under the policy shall be all of the employees of the employer, or all of any class thereof. The policy may provide that the term "employees" shall include the employees of one or more subsidiary corporations, and the employees, individual proprietors, and partners of one or more affiliated corporations, proprietorships or partnerships if the business of the employer and of the affiliated corporations, proprietorships or partnerships is under common control. The policy may provide that the term "employees" shall include the individual proprietor or partners if the employer is an individual proprietorship or partnership. The policy may provide that the term "employees" may include retired employees, former employees and directors of a corporate employer.

(2) The premium for the policy shall be remitted by the policyholder either from the employer's funds or from funds contributed by the insured employees, or from both. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from funds contributed by the insured employees shall insure all eligible employees, except those who reject the coverage in writing.

(3) An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer.

b. A policy issued to a creditor or its parent holding company or to a trustee or agent designated by two or more creditors, which creditor, holding company, affiliate, trustee or agent shall be deemed the policyholder, to insure debtors of the creditor subject to the following requirements:

(1) The debtors eligible for insurance under the policy shall be all of the debtors of the creditor, or all of any class thereof. The policy may provide that the term "debtors" shall include:

(a) Borrowers of money or purchasers or lessees of goods, services or property for which payment is arranged through a credit transaction;

(b) The debtors of one or more subsidiary corporations; and

(c) The debtors of one or more affiliated corporations, proprietorships or partnerships if the business of the policyholder and of the affiliated corporations, proprietorships or partnerships is under common control.

(2) The premium for the policy shall be remitted by the policyholder either from the creditor's funds, or from charges collected from the insured debtors, or from both. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from the funds contributed by insured debtors specifically for their insurance shall insure all eligible debtors.

(3) An insurer may exclude any debtors as to whom evidence of individual insurability is not satisfactory to the insurer.

(4) The amount of the insurance on the life of any debtor shall at no time exceed the greater of the scheduled or actual amount of unpaid indebtedness to the creditor, except that insurance written in connection with open-end credit having a credit limit exceeding $10,000 may be in an amount not exceeding the credit limit.

(5) The insurance may be payable to the creditor or any successor to the right, title and interest of the creditor. The payment shall reduce or extinguish the unpaid indebtedness of the debtor to the extent of the payment and any excess of the insurance shall be payable to the estate of the insured.

(6) Notwithstanding the provisions of paragraphs (1) through (5) of this subsection, insurance on agricultural credit transaction commitments may be written up to the amount of the loan commitment on a non-decreasing or level term plan. Insurance on educational credit transactions commitments may be written up to the amount of the loan commitment less the amount of any repayments made on the loan.

c. A policy issued to a labor union, or similar employee organization, which shall be deemed to be the policyholder, to insure members of the union or organization for the benefit of persons other than the union or organization or any of its officials, representatives or agents, shall be subject to the following requirements:

(1) The members eligible for insurance under the policy shall be all of the members of the union or organization, or all of any class or classes thereof.

(2) The premium for the policy shall be remitted by the policyholder either from funds of the union or organization, or from funds contributed by the insured members specifically for their insurance, or from both. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from funds contributed by the insured members specifically for their insurance shall insure all eligible members, except those who reject the coverage in writing.

(3) An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer.

d. A policy issued to a trust or to the trustees of a fund established or adopted by two or more employers, or by one or more labor unions or similar employee organizations, or by one or more employers and one or more labor unions or similar employee organizations, which trust or trustees shall be deemed the policyholder, to insure employees of the employers or members of the unions or organizations for the benefit of persons other than the employers or the unions or organizations, subject to the following requirements:

(1) The persons eligible for insurance shall be all of the employees of the employers or all of the members of the unions or organizations, or all of any class thereof. The policy may provide that the term "employees" shall include the employees of one or more subsidiary corporations, and the employees, individual proprietors, and partners of one or more affiliated corporations, proprietorships or partnerships if the business of the employer and of the affiliated corporations, proprietorships or partnerships is under common control. The policy may provide that the term "employees" shall include the individual proprietor or partners if the employer is an individual proprietorship or partnership. The policy may provide that the term "employees" shall include retired employees, former employees and directors of a corporate employer. The policy may provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally connected with the trusteeship.

(2) The premium for the policy shall be remitted by the policyholder from funds contributed by the employer of the insured persons, or by the union or similar employee organizations, or by both, or from funds contributed by the insured persons or from both the insured persons and the employers or unions or similar employee organizations. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from funds contributed by the insured persons specifically for their insurance shall insure all eligible persons, except those who reject the coverage in writing.

(3) An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer.

e. (1) A policy issued to an association or to a trust or to the trustees of a fund established, created or maintained for the benefit of members of one or more associations. The association shall have at the outset a minimum of 100 persons; shall have been organized and maintained in good faith for purposes other than that of obtaining insurance; shall have been in active existence for at least two years; and shall have a constitution and by-laws which provide that the association hold regular meetings not less than annually to further purposes of the members; except for credit unions, the association, collect dues or solicit contributions from members; and the members have voting privileges and representation on the governing board and committees.

(2) The policy shall be subject to the following requirements:

(a) The policy may insure members of the association, employees thereof or employees of members, or one or more of the preceding or all of any class thereof for the benefit of persons other than the employee's employer. The policy may provide that the term "employees" may include retired employees, former employees and directors of a corporate member of the association.

(b) The premium for the policy shall be remitted by the policyholder from funds contributed by the association, or by employer members, or by both, or from funds contributed by the covered persons or from both the covered persons and the associations, or employer members.

(c) Except as provided in subparagraph (d) of this paragraph, a policy on which no part of the premium is to be derived from funds contributed by the covered persons specifically for the insurance shall insure all eligible persons, except those who reject the coverage in writing.

(d) An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer.

f. A policy issued to a credit union or to a trustee or agent designated by two or more credit unions, which credit union, trustee or agent shall be deemed the policyholder, to insure members of the credit union for the benefit of persons other than the credit union, trustee or agent, or any of their officials, subject to the following requirements:

(1) The members eligible for insurance shall be all of the members of the credit union, or all of any class thereof.

(2) The premium for the policy shall be remitted by the policyholder from the credit union's funds and, except as provided in paragraph (3) of this section, shall insure all eligible members.

(3) An insurer may exclude or limit the coverage on any member as to whom evidence of individual insurability is not satisfactory to the insurer.

g. A policy issued to a bank, savings and loan association, or other regulated financial institution or to a trustee or agent designated by two or more such financial institutions, or to a regulated issuer of a credit card, charge card or payment card used to buy goods or services, which shall be deemed policyholders, to insure the depositors, account holders or card holders of such policyholders. Such insurance shall be for the benefit of persons other than the policyholders or any of their officials. The insurance shall be subject to the following requirements:

(1) Those eligible for insurance shall be all of the depositors, account holders or card holders of the policyholder, or all of any class or classes thereof.

(2) The premium for the policy shall be remitted by the policyholder from funds contributed by the policyholder, or contributed by the insured persons, or contributed by both. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from funds contributed by the insured persons, shall insure all eligible persons, except those who reject the coverage in writing.

(3) An insurer may exclude or limit the coverage on any member as to whom evidence of individual insurability is not satisfactory to the insurer.

h. A policy issued to a duly incorporated State Policemen's Benevolent Association or Fraternal Order of Police, which association or order shall be deemed the policyholder, to insure members of the association or order for the benefit of persons other than the association, order or any of its officials, subject to the following requirements:

(1) The persons eligible for insurance under the policy shall be all of the members of the association or order or all of any class thereof determined by conditions pertaining to their employment, or the membership in the association, order or both.

(2) The premium for the policy shall be remitted by the policyholder wholly from the association's or order's funds. No policy may be issued on which any part of the premium is to be derived from funds contributed by the insured members specifically for their insurance. The policy must insure all eligible members, or all except any as to whom evidence of individual insurability is not satisfactory to the insurer.

(3) The policy must cover at least 10 members at date of issue.

(4) The amounts of insurance under the policy must be based upon some plan precluding individual selection either by the members or the association or order.

§ 17B:27-69 Conditions for issuance, delivery of group life insurance to groups not included in C.17B:27-68.

2. a. Group life insurance offered to a resident of this State under a group life insurance policy issued to a group other than one described in section 1 of this act shall be subject to the requirements of this section.

b. A group life insurance policy shall not be delivered or issued for delivery in this State unless the commissioner finds that:

(1) The issuance of the group policy is not contrary to the best interest of the public;

(2) The issuance of the group policy would result in economies of acquisition or administration; and

(3) The benefits are reasonable in relation to the premiums charged.

c. Group life insurance coverage may not be offered in this State by an insurer under a policy issued in another state unless this State or another state having requirements substantially similar to those included in paragraphs (1), (2) and (3) of subsection b. of this section has made a determination that those requirements have been met.

d. The premium for the policy shall be remitted by the policyholder either from the policyholder's funds or from funds contributed by the covered persons, or from both.

e. An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer.

§ 17B:27-70 Written notice to prospective insureds of noncompliance with C.17B:27-68; definitions.

3. a. With respect to a program of insurance which, if issued on a group basis, does not meet the requirements of section 1 of this act, the insurer shall cause to be distributed to prospective insureds a written notice that compensation shall or may be paid, if compensation of any kind shall or may be paid to:

(1) A policyholder or sponsoring or endorsing entity in the case of a group policy; or

(2) A sponsoring or endorsing entity in the case of individual, blanket or franchise policies marketed by means of direct response solicitation.

b. The notice shall be distributed:

(1) Whether compensation is direct or indirect; and

(2) Whether the compensation is paid to or retained by the policyholder or sponsoring or endorsing entity, or paid to or retained by a third party at the direction of the policyholder or sponsoring or endorsing entity, or an entity affiliated therewith by way of ownership, contract or employment.

c. The notice required by this section shall be placed on or accompany an application or enrollment form provided to prospective insureds.

d. For the purposes of this section:

(1) "Direct response solicitation" means a solicitation through a sponsoring or endorsing entity through the mails, telephone or other mass communications media; and

(2) "Sponsoring or endorsing entity" means an organization that has arranged for the offering of a program of insurance in a manner that communicates that eligibility for participation in the program is dependent upon affiliation with the organization or that it encourages participation in the program.

§ 17B:27-71 Extension to dependents of group life insurance policy.

4. Except for a policy issued under subsection b. of section 1 of this act, a group life insurance policy may be extended to insure the employees or members against loss due to the death of their spouses, domestic partners and dependent children, and any other persons dependent upon the insured employees or members, or any class thereof, subject to the following:

a. The premium for the insurance shall be remitted by the policyholder either from funds contributed by the employer, union, association or other person to whom the policy has been issued, or from funds contributed by the covered persons, or from both. Except as provided in subsection b. of section 1 of this act, a policy on which no part of the premium for the spouse's, domestic partner's, dependent child's and other dependent's coverage is to be derived from funds contributed by the covered persons shall insure all eligible employees or members with respect to their spouses, domestic partners, dependent children and other dependents, or any class thereof.

b. An insurer may exclude or limit the coverage on any spouse, domestic partner, dependent child or any other person dependent upon the insured employee or member as to whom evidence of individual insurability is not satisfactory to the insurer.

c. The amounts of insurance for any covered spouse, domestic partner, dependent child or any other person dependent upon the insured employee or member under the policy may not exceed 100% of the amount of insurance for which the employee or member is insured.

§ 17B:27-72 Required provisions for delivery, issuance of group life insurance policy.

5. a. No policy of group life insurance shall be delivered or issued for delivery in this State unless it contains in substance the following provisions, or provisions which in the opinion of the Commissioner of Banking and Insurance are more favorable to the persons insured, or at least as favorable to the persons insured and more favorable to the policyholder. However, subsections g. through l. of this section shall not apply to policies insuring the lives of debtors; the standard provisions required for individual life insurance policies shall not apply to group life insurance policies; and if the group life insurance policy is on a plan of insurance other than the term plan, it shall contain a nonforfeiture provision which, in the opinion of the commissioner, is equitable to the insured persons and to the policyholder. Nothing herein shall be construed to require that group life insurance policies contain the same nonforfeiture provisions as are required for individual life insurance policies.

b. The policy shall contain a provision that the policyholder is entitled to a grace period of 31 days for the payment of any premium due except the first, during which grace period the death benefit coverage shall continue in force, unless the policyholder gives the insurer written notice of discontinuance in advance of the date of discontinuance and in accordance with the terms of the policy. The policy may provide that the policyholder shall be liable to the insurer for the payment of a pro rata premium for the time the policy was in force during the grace period.

c. The policy shall contain a provision that the validity of the policy shall not be contested except for nonpayment of premiums after it has been in force for two years from its date of issue; and that no statement made by any person insured under the policy relating to the person's insurability shall be used in contesting the validity of the insurance with respect to which the statement was made after the insurance has been in force prior to the contest for a period of two years during the person's lifetime or unless it is contained in a written instrument signed by the person.

d. The policy shall contain a provision that a copy of the application of the policyholder, if any, shall be attached to the policy when issued, that all statements made by the policyholder or by the persons insured shall be deemed representations and not warranties, and that no statement made by any person insured shall be used in any contest unless a copy of the instrument containing the statement is or has been furnished to the person or, in the event of death or incapacity of the insured person, to the insured person's beneficiary or personal representative.

e. The policy shall contain a provision setting forth the conditions, if any, under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer as a condition to part or all of his coverage.

f. The policy shall contain a provision specifying an equitable adjustment of premiums or benefits, or both, to be made in the event the age of a person insured has been misstated. The provision shall contain a clear statement of the method of adjustment to be made.

g. The policy shall contain a provision that any sum becoming due by reason of the death of the person insured shall be payable to the beneficiary designated by the person insured, except that, where the policy contains conditions pertaining to family status, the beneficiary may be the family member specified by the policy terms, subject to the provisions of the policy in the event there is no designated beneficiary, as to all or any part of the sum, living at the death of the person insured, and subject to any right reserved by the insurer in the policy and set forth in the certificate to pay at its option a part of the sum not exceeding $2,000 to any person appearing to the insurer to be equitably entitled to it by reason of having incurred funeral or other expenses incident to the last illness or death of the person insured.

h. The policy shall contain a provision that the insurer will issue to the policyholder, for delivery to each person insured, a certificate setting forth a statement as to the insurance protection to which the person is entitled, to whom the insurance benefits are payable, a statement as to any dependent's coverage included in the certificate, and the rights and conditions set forth in subsections i., j., k., and l. of this subsection.

i. The policy shall contain a provision that, if the insurance, or any portion of it, on a person covered under the policy or on the dependent of a person covered, ceases because of termination of employment or of membership in the class eligible for coverage under the policy or change to a class eligible for a smaller amount of insurance, the person shall be entitled to have issued to him by the insurer, without evidence of insurability, an individual policy of life insurance without disability or other supplementary benefits, provided application for the individual policy shall be made, and the first premium paid to the insurer, within 31 days after termination and provided further that:

(1) The individual policy shall, at the option of the person, be on any one of the forms then customarily issued by the insurer at the age and for the amount applied for, except that the group policy may exclude the option to elect term insurance;

(2) The individual policy shall be in an amount not in excess of the amount of life insurance that ceases because of termination, less the amount of any life insurance for which the person becomes eligible under the same or any other group policy within 31 days after termination, provided that any amount of insurance that shall have matured on or before the date of termination as an endowment payable to the person insured, whether in one sum or in installments or in the form of an annuity, shall not, for the purposes of this provision, be included in the amount that is considered to cease because of termination; and

(3) The premium on the individual policy shall be at the insurer's then customary rate applicable to the form and amount of the individual policy, to the class of risk to which the person then belongs, and to the individual age attained on the effective date of the individual policy. Subject to the conditions established in paragraphs (1) and (2) of this subsection, the conversion privilege shall be available:

(a) To a surviving dependent, if any, at the death of the employee or member, with respect to the coverage under the group policy that terminates by reason of the death; and

(b) To the dependent of the employee or member upon termination of coverage of the dependent, while the employee or member remains insured under the group policy, by reason of the dependent ceasing to be a qualified family member under the group policy.

j. The policy shall contain a provision that if the group policy terminates or is amended so as to terminate the insurance of any class of insured persons, every person insured thereunder at the date of termination whose insurance terminates, including the insured dependent of a covered person, and who has been so insured under a group policy for at least five years prior to the termination date, shall be entitled to have issued by the insurer an individual policy of life insurance, subject to the same conditions and limitations as are provided by subsection i. of this section, except that the group policy may provide that the amount of the individual policy shall not exceed the smaller of:

(1) The amount of the person's life insurance protection ceasing because of the termination or amendment of the group policy, less the amount of any life insurance for which the person is or becomes eligible under a group policy issued or reinstated by the same or another insurer within 31 days after termination; or

(2) $10,000.

k. The policy shall contain a provision that, if a person insured under the group policy, or the insured dependent of a covered person, dies during the period within which the individual would have been entitled to have an individual policy issued in accordance with subsection i. or j. of this section and before the individual policy shall have become effective, the amount of life insurance which he would have been entitled to have issued under the individual policy shall be payable as a claim under the group policy, whether or not application for the individual policy or the payment of the first premium therefor had been made.

l. Where active employment is a condition of insurance, the policy shall contain a provision that an insured may continue coverage during the insured's total disability by timely payment to the policyholder of that portion, if any, of the premium that would have been required from the insured had total disability not occurred. The continuation shall be on a premium paying basis for a period of six months from the date on which the total disability started, but not beyond the earlier of:

(1) Approval by the insurer of continuation of the coverage under any disability provision which the group insurance policy may contain; or

(2) The discontinuance of the group insurance policy.

m. In the case of a policy insuring the lives of debtors, the policy shall contain a provision that the insurer shall furnish to the policyholder for delivery to each debtor insured under the policy a certificate of insurance describing the coverage and specifying that the death benefit shall first be applied to reduce or extinguish the indebtedness.

n. In participating policies, there shall be a provision that the policy shall participate in the divisible surplus of the insurer as determined by the insurer and that the insurer shall determine annually the extent of such participation, if any; and that the policyholder shall have the right to any dividend arising from the participation paid in cash unless another dividend option contained in the policy has been elected.

o. In the case of a policy which provides that each insured debtor whose protection under the group insurance policy terminates by reason of absolute assignment by the creditor of the insured debtor's indebtedness for the discharge of which the debtor had agreed upon installment payments over a period of more than 10 years, there shall be a provision that each insured debtor shall be entitled to have issued to him by the insurer, without evidence of insurability, upon application made to the insurer and upon the payment of the premium applicable to the class of risk to which he belongs and to the form and amount of the policy at his then attained age within 31 days after that assignment of the indebtedness, an individual policy of life insurance; provided, the individual policy of life insurance so issued shall be in any one of the level premium forms customarily issued by the insurer, except term insurance, in an amount equal to the amount of his protection terminated under the group insurance policy because of the assignment, less the amount of insurance for which the insured debtor may become eligible and qualify under any group insurance policy in effect with the assignee at the date of the assignment or issued to the assignee within that period of 31 days; and provided further, that in the event that the assignment of the indebtedness shall have been made by the creditor at the request of the insured debtor, the insurer may require satisfactory evidence of the debtor's insurability before making the individual policy of life insurance effective. If the insured debtor dies during the period within which he would have been entitled to have an individual policy issued to him in accordance with this provision and before such an individual policy shall have become effective, the amount of life insurance which he would have been entitled to have issued to him under that individual policy shall be payable as a claim under the group policy, whether or not application for the individual policy or the payment of the first premium therefor has been made.

§ 17B:27-73 Issuance, delivery of individual policy of life insurance.

6. If an individual insured under a group insurance policy hereafter delivered or issued for delivery in this State becomes entitled under the terms of the policy to have an individual policy of life insurance issued without evidence of insurability, subject to making application and payment of the first premium within the period specified in the policy, and if the individual is not given notice of the existence of the right at least 15 days prior to the expiration date of the period, then the individual shall have an additional period within which to exercise the right, but nothing herein contained shall be construed to continue any insurance beyond the period provided in the policy. This additional period shall expire 15 days after the individual is given notice but in no event shall the additional period extend beyond 60 days after the expiration date of the period provided in the policy. Written notice presented to the individual or mailed by the policyholder to the last known address of the individual or mailed by the insurer to the last known address of the individual as furnished by the policyholder shall constitute notice for the purpose of this section.

§ 17B:27-74 Filing of form required for delivery, issuance of group life insurance.

7. a. No group life insurance policy, or application, if a written application is required and is to be made a part of the policy, certificate, printed rider or endorsement for use with the policy, shall be delivered or issued for delivery in this State unless the form has been filed with the Commissioner of Banking and Insurance for approval in accordance with the provisions of section 16 of P.L.1995, c.73 (C.17B:25-18.2).

b. If a form is disapproved for filing by the commissioner during the 60-day period provided in section 16 of P.L.1995, c.73 (C.17B:25-18.2), it may not be delivered or issued for delivery unless it is resubmitted and approved in accordance with the provisions of subsections b., c., and d., of section 16 of P.L.1995, c.73 (C.17B:25-18.2). Such disapproval shall be subject to review in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

c. Any form which is filed by the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), becomes final in accordance therewith.

d. This section shall not apply to documents which relate only to the manner of distribution of benefits or to the reservation of rights and benefits under group life insurance policies and which are used at the request of the individual insured or policyholder.

e. The disapproval by the commissioner of any form may be on the grounds that the form contains provisions which are unjust, unfair, inequitable, misleading, or contrary to law or to the public policy of this State.

§ 17B:27-75 Payment of benefits.

8. a. Notwithstanding any policy provision to the contrary, benefits under a group life insurance policy subject to this act shall become payable by reason of the death of the insured within 60 days after the receipt of due proof of death and, at the insurer's option, proof of the interest of the claimant.

b. If a claim or a portion of a claim for benefits under a policy requires additional investigation or is denied by the insurer, the claimant shall be notified in writing no later than 45 days following receipt by the insurer of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer under the terms of the policy, that the claim, or a portion thereof, is subject to additional investigation or denied, and the reason the claim is being investigated or denied. Notwithstanding the provisions of this subsection b. to the contrary, the notice to the claimant for any claim which the insurer concludes, based upon its investigation and which conclusion is reasonably based upon the contents of the insurer's claim file, constitutes probable cause for fraud shall not be required to contain the specific reasons for the investigation. A conclusion of fraud that is not reasonably based upon the contents of the insurer's claim file shall be a violation of section 1 of P.L.1975, c.101 (C.17B:30-13.1), notwithstanding that the violation did not occur with such frequency as to indicate a general business practice. Any uncontested portion of a claim shall be paid no later than 60 days following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer under the terms of the policy.

c. The insurer, upon receipt of any document or information requested relating to a claim or portion of a claim under investigation, shall pay the benefits for which the claim is made, or deny the claim no later than 90 days following the receipt of the document or information.

d. Payment of a claim or a portion thereof that is not under investigation by the insurer shall be overdue if not remitted to the claimant by the insurer on or before 60 days following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer pursuant to the policy. Payment of a claim, or a portion of a claim under investigation, or denied, that becomes eligible for payment shall be overdue if not remitted to the claimant by the insurer on or before 90 days following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer. Overdue payments shall bear an annual rate of interest equal to the average rate of return of the State of New Jersey Cash Management Fund, established pursuant to section 1 of P.L.1977, c.281 (C.52:18A-90.4), for the preceding fiscal year, rounded to the nearest one-half percent.

Chapter 27A

§ 17B:27A-1 Filing of paid hospital expense claims; definitions

18. a. Every carrier issuing health benefits plans in this State shall file its paid hospital expense claims paid by January 30, 1993 and by January 30, 1994, respectively, in accordance with the following:

(1) A carrier issuing individual health benefits plans shall file with the board created pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.) and with the Commissioner of Insurance the aggregate hospital expense claims paid for the calendar year 1992 which are attributable to its policies or contracts for individual health benefits plans.

(2) A carrier issuing small employer or small group health benefits plans shall file with the board created pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) and with the Commissioner of Insurance the aggregate hospital expense claims paid for the calendar year 1992 which are attributable to its policies or contracts for small employer or small group health benefits plans.

(3) A carrier issuing group health benefits plans other than small employer or small group health benefits plans shall file with the Commissioner of Insurance the aggregate hospital expense claims paid for the calendar year 1992 which are attributable to its policies or contracts for group health benefits plans.

b. (1) In formulating policy or contract rates for calendar year 1993, a carrier shall take into account any modifications in exposure for hospital expenses which may be brought about by the changes in billing procedures established pursuant to the provisions of P.L.1992, c.160 (C.26:2H-18.51 et al.), and shall modify its premiums accordingly as is appropriate to reflect those modifications.

(2) No later than March 1, 1994, the board created pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.), the board created pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), and the Commissioner of Insurance shall determine if any premium modifications made in accordance with this subsection accurately reflect any differential in claims paid for hospital expenses between calendar years 1992 and 1993 which are attributable to the changes in hospital billing procedures pursuant to the provisions of P.L.1992, c.160 (C.26:2H-18.51 et al.), as opposed to any differential in expenses which may be caused by changes in utilization, cost, and morbidity normally used in trending. To the extent that further modifications may need to be made in the premium level as a result of the changes in loss experience reflected by any extraordinary differential between the claims paid in 1992 and 1993, the boards and the Commissioner of Insurance shall require that rates be modified accordingly.

c. For the purposes of this section:

(1) "Carrier" means an insurance company, health service corporation or health maintenance organization authorized to issue health benefits plans in this State;

(2) "Health benefits plans" means a hospital and medical expense insurance policy; health service corporation contract; or health maintenance organization subscriber contract delivered or issued for delivery in this State;

(3) "Hospital expenses" means any charges billed by, and payable directly by, a carrier to a hospital.

§ 17B:27A-2 Definitions.

1. As used in sections 1 through 15, inclusive, of this act:

"Board" means the board of directors of the program.

"Carrier" means any entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital or health service corporation, or any other entity providing a plan of health insurance, health benefits or health services. For purposes of this act, carriers that are affiliated companies shall be treated as one carrier.

"Church plan" has the same meaning given that term under Title I, section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C. s.1002 (33)).

"Commissioner" means the Commissioner of Banking and Insurance.

"Community rating" means a rating system in which the premium for all persons covered by a contract is the same, based on the experience of all persons covered by that contract, without regard to age, sex, health status, occupation and geographical location.

"Creditable coverage" means, with respect to an individual, coverage of the individual under any of the following: a group health plan; a group or individual health benefits plan; Part A or Part B of Title XVIII of the federal Social Security Act (42 U.S.C. s.1395 et seq.); Title XIX of the federal Social Security Act (42 U.S.C. s.1396 et seq.), other than coverage consisting solely of benefits under section 1928 of Title XIX of the federal Social Security Act (42 U.S.C.s.1396s); Chapter 55 of Title 10, United States Code (10 U.S.C. s.1071 et seq.); a medical care program of the Indian Health Service or of a tribal organization; a state health benefits risk pool; a health plan offered under chapter 89 of Title 5, United States Code (5 U.S.C. s.8901 et seq.); a public health plan as defined by federal regulation; and a health benefits plan under section 5(e) of the "Peace Corps Act" (22 U.S.C. s.2504(e)); or coverage under any other type of plan as set forth by the commissioner by regulation.

Creditable coverage shall not include coverage consisting solely of the following: coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit only insurance; coverage for on-site medical clinics; coverage, as specified in federal regulation, under which benefits for medical care are secondary or incidental to the insurance benefits; and other coverage expressly excluded from the definition of health benefits plan.

"Department" means the Department of Banking and Insurance.

"Dependent" means the spouse, domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3), civil union partner as defined in section 2 of P.L.2006, c.103 (C.37:1-29), or child of an eligible person, subject to applicable terms of the individual health benefits plan.

"Eligible person" means a person who is a resident who is not eligible to be covered under a group health benefits plan, group health plan, governmental plan, church plan, or Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C.s.1395 et seq.).

"Federally defined eligible individual" means an eligible person: (1) for whom, as of the date on which the individual seeks coverage under P.L.1992, c.161 (C.17B:27A-2 et al.), the aggregate of the periods of creditable coverage is 18 or more months; (2) whose most recent prior creditable coverage was under a group health plan, governmental plan, church plan, or health insurance coverage offered in connection with any such plan; (3) who is not eligible for coverage under a group health plan, Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C.s.1395 et seq.), or a State plan under Title XIX of the Social Security Act (42 U.S.C.s.1396 et seq.) or any successor program, and who does not have another health benefits plan, or hospital or medical service plan; (4) with respect to whom the most recent coverage within the period of aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud; (5) who, if offered the option of continuation coverage under the COBRA continuation provision or a similar State program, elected that coverage; and (6) who has elected continuation coverage described in (5) above and has exhausted that continuation coverage.

"Financially impaired" means a carrier which, after the effective date of this act, is not insolvent, but is deemed by the commissioner to be potentially unable to fulfill its contractual obligations, or a carrier which is placed under an order of rehabilitation or conservation by a court of competent jurisdiction.

"Governmental plan" has the meaning given that term under Title I, section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C.s.1002(32)) and any governmental plan established or maintained for its employees by the Government of the United States or by any agency or instrumentality of that government.

"Group health benefits plan" means a health benefits plan for groups of two or more persons.

"Group health plan" means an employee welfare benefit plan, as defined in Title I, section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C. s.1002 (1)), to the extent that the plan provides medical care, and including items and services paid for as medical care to employees or their dependents directly or through insurance, reimbursement, or otherwise.

"Health benefits plan" means a hospital and medical expense insurance policy; health service corporation contract; hospital service corporation contract; medical service corporation contract; health maintenance organization subscriber contract; or other plan for medical care delivered or issued for delivery in this State. For purposes of this act, health benefits plan shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; stop loss or excess risk insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefits plan shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in federal regulations. Health benefits plan shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. Health benefits plan shall not include the following if it is offered as a separate policy, certificate or contract of insurance: Medicare supplemental health insurance as defined under section 1882(g)(1) of the federal Social Security Act (42 U.S.C.s.1395ss(g)(1)); and coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code (10 U.S.C. s.1071 et seq.); and similar supplemental coverage provided to coverage under a group health plan.

"Health status-related factor" means any of the following factors: health status; medical condition, including both physical and mental illness; claims experience; receipt of health care; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; and disability.

"Individual health benefits plan" means: a. a health benefits plan for eligible persons and their dependents; and b. a certificate issued to an eligible person which evidences coverage under a policy or contract issued to a trust or association, regardless of the situs of delivery of the policy or contract, if the eligible person pays the premium and is not being covered under the policy or contract pursuant to continuation of benefits provisions applicable under federal or State law.

Individual health benefits plan shall not include a certificate issued under a policy or contract issued to a trust, or to the trustees of a fund, which trust or fund is an employee welfare benefit plan, to the extent the "Employee Retirement Income Security Act of 1974" (29 U.S.C. s.1001 et seq.) preempts the application of P.L.1992, c.161 (C.17B:27A-2 et al.) to that plan.

"Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).

"Medical care" means amounts paid: (1) for the diagnosis, care, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body; and (2) transportation primarily for and essential to medical care referred to in (1) above.

"Member" means a carrier that issues or has in force health benefits plans in New Jersey. Member shall not include a carrier whose combined average Medicare, Medicaid, and NJ FamilyCare enrollment represents more than 75% of its average total enrollment for all health benefits plans or whose combined Medicare, Medicaid, and NJ FamilyCare net earned premium for the two-year calculation period represents more than 75% of its total net earned premium for the two-year calculation period.

"Modified community rating" means a rating system in which the premium for all persons covered under a policy or contract for a specific health benefits plan and a specific date of issue of that plan is the same without regard to sex, health status, occupation, geographical location or any other factor or characteristic of covered persons, other than age.

The rating system shall provide that the premium rate charged by the carrier for the highest rated individual or class of individuals shall not be greater than 350% of the premium rate charged for the lowest rated individual or class of individuals purchasing the same individual health benefits plan. The rate differential among the premium rates charged to individuals covered under the same individual health benefits plans shall be based on the actual or expected experience of persons covered under that plan; provided, however, that the rate differential may also be based upon age. The factors upon which the rate differential is applied shall be consistent with regulations promulgated by the commissioner, which shall include age classifications established, at a minimum, in five-year increments. There may be a reasonable differential among the premium rates charged for different family structure rating tiers within an individual health benefits plan or for different health benefits plans offered by the carrier.

"Net earned premium" means the premiums earned in this State on health benefits plans, less return premiums thereon and dividends paid or credited to policy or contract holders on the health benefits plan business. Net earned premium shall include the aggregate premiums earned on the carrier's insured group and individual business and health maintenance organization business, including premiums from any Medicare, Medicaid, or NJ FamilyCare contracts with the State or federal government, but shall not include premiums earned from contracts funded pursuant to the "Federal Employee Health Benefits Act of 1959," 5 U.S.C. ss.8901-8914, any excess risk or stop loss insurance coverage issued by a carrier in connection with any self insured health benefits plan, or Medicare supplement policies or contracts.

"NJ FamilyCare" means the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.).

"Non-group person life year" means coverage of a person for 12 months by an individual health benefits plan or conversion policy or contract subject to P.L.1992, c.161 (C.17B:27A-2 et al.), Medicare cost or risk contract or Medicaid contract.

"Open enrollment" means the offering of an individual health benefits plan to any eligible person on a guaranteed issue basis, pursuant to procedures established by the board.

"Plan of operation" means the plan of operation of the program adopted by the board pursuant to this act.

"Plan sponsor" shall have the meaning given that term under Title I, section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C. s.1002 (16)(B)).

"Preexisting condition" means a condition that, during a specified period of not more than six months immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment, or for which medical advice, diagnosis, care or treatment was recommended or received as to that condition or as to a pregnancy existing on the effective date of coverage.

"Program" means the New Jersey Individual Health Coverage Program established pursuant to this act.

"Resident" means a person whose primary residence is in New Jersey and who is present in New Jersey for at least six months of the calendar year, or, in the case of a person who has moved to New Jersey less than six months before applying for individual health coverage, who intends to be present in New Jersey for at least six months of the calendar year.

"Two-year calculation period" means a two calendar year period, the first of which shall begin January 1, 1997 and end December 31, 1998.

§ 17B:27A-2.1 Regulations.

36. The Commissioner of Banking and Insurance shall, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), adopt regulations necessary to implement sections 9 through 25 and sections 29 through 34 of this act.

§ 17B:27A-2.2 Effective date.

37. Sections 1 through 8, 26 through 28, 36 and this section of this act shall take effect immediately and sections 9 through 25 and 29 through 35 of this act shall take effect on the 180th day after enactment, except that the 80 percent minimum loss ratio requirements in sections 16, 19, and 24 of this act shall take effect on January 1 next following the date of enactment. Sections 9 through 25 and 29 through 35 shall apply to all contracts and policies that are delivered, issued, executed or renewed or approved for issuance or renewal in this State on or after the effective date provided herein, but the Commissioner of Banking and Insurance may take such anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.

§ 17B:27A-3 Individual health benefits plans, applicability of act.

2. a. An individual health benefits plan issued on or after the effective date of this section of P.L.2008, c.38 shall be subject to the rating provisions established in P.L.2008, c.38; except that for the four years next following the effective date of this section, in the case of a person who is 55 years of age or older who purchases a health benefits plan on or after that effective date, the annual rate increase for that person shall be limited to the lower of 15% or the medical trend assumption used by the carrier to project claims.

In the case of an individual health benefits plan issued to a covered person prior to the effective date of P.L.2008, c.38 and renewed thereafter, for the four years next following that effective date, the annual rate increase filed for the plan shall be limited to the lower of 15% or the medical trend assumption used by the carrier to project claims.

b. (1) An individual health benefits plan issued on an open enrollment, modified community rated basis or community rated basis prior to August 1, 1993 shall not be subject to sections 3 through 8, inclusive, of P.L.1992, c.161 (C.17B:27A-4 through 17B:27A-9), unless otherwise specified therein.

(2) An individual health benefits plan issued other than on an open enrollment basis prior to August 1, 1993 shall not be subject to the provisions of this act, except that the plan shall be liable for assessments made pursuant to section 11 of P.L.1992, c.161 (C.17B:27A-12).

(3) A group conversion contract or policy issued prior to August 1, 1993 that is not issued on a modified community rated basis or community rated basis, shall not be subject to the provisions of this act, except that the contract or policy shall be liable for assessments made pursuant to section 11 of P.L.1992, c.161 (C.17B:27A-12).

(4) Notwithstanding any other provision of law to the contrary, an individual health benefits plan issued by a hospital service corporation or medical service corporation prior to the effective date of P.L.1997, c.146 (C.17B:27-54 et al.) shall not be subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et al.), except that the plan shall guarantee renewal pursuant to subsection b. of section 5 of P.L.1992, c.161 (C.17B:27A-6).

(5) Notwithstanding any other provision of law to the contrary, an individual health benefits plan issued by a hospital service corporation or medical service corporation to an eligible person or federally defined eligible individual after the effective date of P.L.1997, c.146 (C.17B:27-54 et al.) shall comply with the provisions of subsections c. and d. of section 2, subsection b. of section 3, section 5, subsection b. of section 6, and subsections c., d., and e. of section 8 of P.L.1992, c.161 (C.17B:27A-3, C.17B:27A-4, 17B:27A-6, 17B:27A-7, and 17B:27A-9), but shall not be subject to the remaining provisions of P.L.1992, c. 161.

c. After August 1, 1993, an individual who is eligible to participate in a group health benefits plan that provides coverage for hospital or medical expenses shall not be covered by an individual health benefits plan which provides benefits for hospital and medical expenses that are the same or similar to coverage provided in the group health benefits plan, except that an individual who is eligible to participate in a group health benefits plan but is currently covered by an individual health benefits plan may continue to be covered by that plan until the first anniversary date of the group health benefits plan occurring on or after January 1, 1994.

d. Except as otherwise provided in subsection c. of this section, after August 1, 1993, a person who is covered by an individual health benefits plan who is a participant in, or is eligible to participate in, a group health benefits plan that provides the same or similar coverage as the individual health benefits plan, and a person, including an employer or insurance producer, who causes another person to be covered by an individual health benefits plan which person is a participant in, or who is eligible to participate in a group health benefits plan that provides the same or similar coverage as the individual health benefits plan, shall be subject to a fine by the commissioner in an amount not less than twice the annual premium paid for the individual health benefits plan, together with any other penalties permitted by law.

e. (Deleted by amendment, P.L.1997, c.146).

§ 17B:27A-4 Offering of individual health benefits required by issuer of small employer health benefits plans.

3. a. Every carrier that offers individual health benefits plans shall make a good faith effort to market the individual health benefits plans. The department may impose fines against any carrier that violates the provisions of this subsection.

b. A carrier shall offer to an eligible person a choice of at least three individual health benefits plans established by the board pursuant to section 6 of P.L.1992, c.161 (C.17B:27A-7).

c. (1) (Deleted by amendment, P.L.2019, c.359).

(2) (Deleted by amendment, P.L.2019, c.359).

(3) (Deleted by amendment, P.L.2019, c.359).

(4) (Deleted by amendment, P.L.2019, c.359).

(5) The provisions of section 13 of P.L.1985, c.236 (C.17:48E-13), N.J.S.17B:26-1, and section 8 of P.L.1973, c.337 (C.26:2J-8) with respect to the filing of policy forms shall not apply to health plans issued on or after the effective date of P.L.1992, c.161 (C.17B:27A-2 et al.).

(6) The provisions of section 27 of P.L.1985, c.236 (C.17:48E-27) and section 7 of P.L.1988, c.71 (C.17:48E-27.1) with respect to rate filings shall not apply to individual health plans issued on or after the effective date of P.L.1992, c.161 (C.17B:27A-2 et al.).

d. Every group conversion contract or policy issued after the effective date of P.L.1992, c.161 (C.17B:27A-2 et al.) shall be issued pursuant to this section; except that this requirement shall not apply to any group conversion contract or policy in which a portion of the premium is chargeable to, or subsidized by, the group policy from which the conversion is made.

e. (Deleted by amendment, P.L.2008, c.38).

f. (Deleted by amendment, P.L.2019, c.359).

§ 17B:27A-4.1 Individual policy, contract for hospital, medical expense benefits, coverage of subscriber's child.

7. a. A policy or contract which provides hospital or medical expense benefits under which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A policy or contract shall not deny coverage for a policy or contract holder's child on the grounds that:

(1) The child was born out of wedlock;

(2) The child is not claimed as a dependent on the policy or contract holder's federal tax return;

(3) The child does not reside with the policy or contract holder or in the carrier's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the policy or contract with respect to the use of specified providers;

(4) The child is married;

(5) The child has or adopts a child; or

(6) The child starts or leaves school.

b. If a child has coverage through a policy or contract of a noncustodial parent, the carrier shall:

(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child's noncustodial parent's coverage;

(2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and

(3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.

c. When a parent who is the policy or contract holder is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the carrier shall:

(1) Permit the parent to enroll his child as a dependent, without regard to any open enrollment restrictions;

(2) Permit the child's other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the policy or contract if the parent who is the policy or contract holder fails to enroll the child; and

(3) Not terminate coverage of the child unless the parent who is the policy or contract holder provides the carrier with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage.

§ 17B:27A-4.2 Requirements applicable to State Medicaid

8. A carrier shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other policy or contract holder.

§ 17B:27A-4.3 Eligibility for enrollment in individual health benefits plan

4. Notwithstanding any other provision of law to the contrary, a carrier shall not consider a person's eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the equivalent statute in another state, when determining the person's eligibility for enrollment in, or the provision of benefits under, an individual health benefits plan delivered, issued or executed in this State.

§ 17B:27A-5 Laws not applicable to managed care health benefits plans.

4. The following provisions shall not apply to managed care health benefits plans issued pursuant to section 3 of this act:

Sections 12, 32 through 35, inclusive, of P.L.1985, c.236 (C.17:48E-12 and C.17:48E-32 through C.17:48E-35, inclusive); section 2 of P.L.1987, c.62 (C.17:48E-35.1); sections 3, 4 and 6 of P.L.1991, c.279 (C.17:48E-35.4, 17B:26-2.1e and 26:2J-4.4); section 1 of P.L.1977, c.118 (C.17B:26-2.1); section 1 of P.L.1983, c.53 (C.17B:26-2.1a); section 1 of P.L.1987 c.64 (C.17B:26-2.1c); P.L.1979, c.328 (C.17B:26-2.2 et seq.); and sections 1 and 2 of P.L.1979, c.161 (C.17B:26-44.1 and C.17B:26-44.2).

§ 17B:27A-6 Individual health benefits plans, requirements.

5. An individual health benefits plan issued pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4) is subject to the following provisions:

a. The health benefits plan shall guarantee coverage for an eligible person and his dependents on a modified community rated basis.

b. A health benefits plan shall be renewable with respect to an eligible person and his dependents at the option of the policy or contract holder. A carrier may terminate a health benefits plan under the following circumstances:

(1) the policy or contract holder has failed to pay premiums in accordance with the terms of the policy or contract or the carrier has not received timely premium payments;

(2) the policy or contract holder has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.

c. A carrier may not renew a health benefits plan only under the following circumstances:

(1) termination of eligibility of the policy or contract holder if the person is no longer a resident or becomes eligible for a group health benefits plan, group health plan, governmental plan or church plan;

(2) cancellation or amendment by the board of the specific individual health benefits plan;

(3) approval by the commissioner of a request by the individual carrier to not renew a particular type of health benefits plan, in accordance with rules adopted by the commissioner. After receiving approval by the commissioner, a carrier may not renew a type of health benefits plan only if the carrier: (a) provides notice to each covered individual provided coverage of this type of the nonrenewal at least 90 days prior to the date of the nonrenewal of the coverage; (b) offers to each individual provided coverage of this type the option to purchase any other individual health benefits plan currently being offered by the carrier; and (c) in exercising the option to not renew coverage of this type and in offering coverage as required under (b) above, the carrier acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for coverage;

(4) approval by the commissioner of a request by the individual carrier to cease doing business in the individual health benefits market. A carrier may not renew all individual health benefits plans only if the carrier: (a) first receives approval from the commissioner; and (b) provides notice to each individual of the nonrenewal at least 180 days prior to the date of the expiration of such coverage. The commissioner may impose a five-year prohibition on the issuance of any health benefits plan in the individual or small employer markets if the commissioner determines the prohibition would be beneficial to the small employer and individual health benefits markets; and

(5) In the case of a health benefits plan made available by a health maintenance organization carrier, the carrier shall not be required to renew coverage to an eligible individual who no longer resides, lives, or works in the service area, or in an area for which the carrier is authorized to do business, but only if coverage is terminated under this paragraph uniformly without regard to any health status-related factor of covered individuals.

§ 17B:27A-6.1 Individual Health Coverage Program, open enrollment period established.

1. Notwithstanding the provisions of any other law, rule or regulation to the contrary, the board of the New Jersey Individual Health Coverage Program established pursuant to section 9 of P.L.1992, c.161 (C.17B:27A-10) shall establish, by regulation, an annual open enrollment period during which time individuals are permitted to enroll in an individual health benefits plan and individuals who already have coverage may replace current coverage. During any plan year in which the State is on the federally-facilitated exchange, the annual open enrollment period shall conform to federal requirements, unless the State is permitted to offer a longer open enrollment period. During any plan year in which the State operates a State-based exchange, the open enrollment period shall be set by New Jersey's State-based exchange and shall not be less than 90 days.

§ 17B:27A-7 Approval of policy and contract forms, benefit levels.

6. The commissioner shall approve the policy and contract forms and benefit levels to be made available by all carriers for the health benefits plans required to be issued pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4), and shall adopt such modifications to one or more plans as the board determines are necessary to make available a "high deductible health plan" or plans consistent with section 301 of Title III of the "Health Insurance Portability and Accountability Act of 1996," Pub.L.104-191 (26 U.S.C. s.220), regarding tax-deductible medical savings accounts, within 60 days after the enactment of P.L.1997, c.414 (C.54A:3-4 et al.). The commissioner shall provide the board with an informational filing of the policy and contract forms and benefit levels it approves.

a. The individual health benefits plans established by the board may include cost containment measures such as, but not limited to: utilization review of health care services, including review of medical necessity of hospital and physician services; case management benefit alternatives; selective contracting with hospitals, physicians, and other health care providers; reasonable benefit differentials applicable to participating and nonparticipating providers; and other managed care provisions.

b. An individual health benefits plan offered pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4) shall not contain a preexisting condition limitation of any period and shall not include a preexisting condition as a factor in calculating the premium.

c. In addition to the standard individual health benefits plans provided for in section 3 of P.L.1992, c.161 (C.17B:27A-4), the board may develop up to five rider packages. Premium rates for the rider packages shall be determined in accordance with section 8 of P.L.1992, c.161 (C.17B:27A-9).

d. After the board's establishment of the individual health benefits plans required pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4), and notwithstanding any law to the contrary, a carrier shall file the policy or contract forms with the commissioner and certify to the commissioner that the health benefits plans to be used by the carrier are in substantial compliance with the provisions in the corresponding approved plans. The certification shall be signed by the chief executive officer of the carrier. Upon receipt by the commissioner of the certification, the certified plans may be used until the commissioner, after notice and hearing, disapproves their continued use.

e. Effective immediately for an individual health benefits plan issued on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) and effective on the first 12-month anniversary date of an individual health benefits plan in effect on the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), the individual health benefits plans required pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4), including any plan offered by a federally qualified health maintenance organization, shall contain benefits for expenses incurred in the following:

(1) Screening by blood lead measurement for lead poisoning for children, including confirmatory blood lead testing as specified by the Department of Health pursuant to section 7 of P.L.1995, c.316 (C.26:2-137.1); and medical evaluation and any necessary medical follow-up and treatment for lead poisoned children.

(2) All childhood immunizations as recommended by the Department of Health, which shall consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians. A carrier shall notify its insureds, in writing, of any change in the health care services provided with respect to childhood immunizations and any related changes in premium. Such notification shall be in a form and manner to be determined by the Commissioner of Banking and Insurance.

(3) Screening for newborn hearing loss by appropriate electrophysiologic screening measures and periodic monitoring of infants for delayed onset hearing loss, pursuant to P.L.2001, c.373 (C.26:2-103.1 et al.). Payment for this screening service shall be separate and distinct from payment for routine new baby care in the form of a newborn hearing screening fee as negotiated with the provider and facility.

The benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, except that a deductible shall not be applied for benefits provided pursuant to this subsection; however, with respect to a health benefits plan that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), a deductible shall not be applied for any benefits provided pursuant to this subsection that represent preventive care as permitted by that federal law, and shall not be applied as provided pursuant to section 14 of P.L.2005, c.248 (C.17B:27A-7.11). This subsection shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

f. Effective immediately for a health benefits plan issued on or after the effective date of P.L.2001, c.361 (C.17:48-6z et al.) and effective on the first 12-month anniversary date of a health benefits plan in effect on the effective date of P.L.2001, c.361 (C.17:48-6z et al.), the health benefits plans required pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4) that provide benefits for expenses incurred in the purchase of prescription drugs shall provide benefits for expenses incurred in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula.

The benefits shall be provided to the same extent as for any other prescribed items under the health benefits plan.

This subsection shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

g. Effective immediately for an individual health benefits plan issued on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) and effective on the first 12-month anniversary date of an individual health benefits plan in effect on the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), the health benefits plans required pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4) that qualify as high deductible health plans for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), including any plan offered by a federally qualified health maintenance organization, shall contain benefits for expenses incurred in connection with any medically necessary benefits provided in-network which represent preventive care as permitted by that federal law.

The benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, except that a deductible shall not be applied for benefits provided pursuant to this subsection. This subsection shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.1 Coverage for birth and natal care; individual health policy

5. a. Every policy that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide benefits for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

b. Notwithstanding the provisions of subsection a. of this section, a policy that provides coverage for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child.

c. Every insurer shall provide notice to policyholders regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the policyholder; (2) the yearly informational packet sent to the policyholder; or (3) January 1, 1996.

§ 17B:27A-7.2 Coverage for minimum inpatient care following mastectomy by individual health benefits plan

6. a. Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide benefits for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The health benefits plan shall not require a health care provider to obtain authorization from the carrier for prescribing 72 or 48 hours as appropriate, of inpatient care as provided for in this section.

The provisions of this section shall not be construed to: require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the carrier under the health benefits plan.

The benefits shall be provided to the same extent as for any other sickness under the health benefits plan.

The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

b. The New Jersey Individual Health Coverage Program Board shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

§ 17B:27A-7.3 Applicability of Health Care Quality Act

24. Notwithstanding the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy or contract meets the requirements of P.L.1997, c.192 (C.26:2S-1 et al.) and regulations adopted thereto. The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.4 Coverage for treatment of inherited metabolic diseases by individual health benefits plan.

6. No individual health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the health benefits plan provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.

The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.5 Individual health benefits plan to provide coverage for mental health conditions, substance use disorders; collaborative care model.

6. a. (1) Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide benefits for mental health conditions and substance use disorders under the same terms and conditions as provided for any other sickness under the health benefits plan and shall meet the requirements of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. s.18031(j), and any amendments to, and federal guidance or regulations issued under that act, including 45 C.F.R. Parts 146 and 147 and 45 C.F.R. s.156.115(a)(3).

Coverage provided pursuant to this section shall include benefits delivered through the psychiatric Collaborative Care Model.

(2) As used in this section:

"Mental health condition" means a condition defined to be consistent with generally recognized independent standards of current medical practice referenced in the current version of the Diagnostic and Statistical Manual of Mental Disorders.

"Psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method wherein a primary care provider and a care manager collaborate with a psychiatric consultant to provide care to a patient. "Psychiatric Collaborative Care Model" shall include those benefits that are billed using the following list of Current Procedural Terminology (CPT) codes, which list shall be updated by the Commissioner of Banking and Insurance whenever the codes are altered or supplemented:

(a) 99492 - Initial psychiatric collaborative care management;

(b) 99493 - Subsequent psychiatric collaborative care management; and

(c) 99494 - Initial or subsequent psychiatric collaborative care management, additional time.

"Same terms and conditions" means that the plan cannot apply more restrictive non-quantitative limitations, such as utilization review and other criteria or more quantitative limitations such as copayments, deductibles, aggregate or annual limits or benefit limits to mental health condition and substance use disorder benefits than those applied to substantially all other medical or surgical benefits.

"Substance use disorder" means a disorder defined to be consistent with generally recognized independent standards of current medical practice referenced in the most current version of the Diagnostic and Statistical Manual of Mental Disorders.

b. (Deleted by amendment, P.L.2019, c.58)

c. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

d. Nothing in this section shall reduce the requirement for a plan to provide benefits pursuant to section 6 of P.L.2017, c.28 (C.17B:27A-7.21).

§ 17B:27A-7.6 Coverage for hemophilia services by individual health policy

6. Notwithstanding the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the policy or contract meets the requirements of sections 1 and 2 of P.L.2000, c.121 (C.26:2S-10.1 and C.26:2S-10.2) and the regulations adopted thereto. The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.7 Individual health benefits plan to provide coverage for colorectal cancer screening.

6. a. Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recently published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person.

b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force.

c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

d. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.8 Policy, contract issued under C.17B:27A-2 et seq. required to cover certain out-of-network services.

6. Notwithstanding the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy or contract meets the requirements of P.L.2001, c.367 (C.26:2S-6.1 et al.). The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.9 Individual health benefits plan to offer coverage for domestic partner.

53. Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State on or after the effective date of P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to a covered person for a covered person's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3).

The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.10 Individual health benefits plan, mammogram examination benefits.

7. a. Every individual health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in conducting:

(1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and

(2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the carrier of the medical necessity of the additional screening and diagnostic testing.

b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

c. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.11 Individual health benefits plan, high deductible, deductible inapplicable, certain circumstances.

14. Notwithstanding the provisions of subsection e. of section 6 of P.L.1992, c.161 (C.17B:27A-7) regarding deductibles for a high deductible health plan, a health benefits plan offered pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C.s.223), shall not apply a deductible for any benefits for which a deductible is not applicable pursuant to any law enacted after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.). This section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.12 Individual health benefits plan, coverage for contraceptives.

7. a. An individual health benefits plan required pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4) shall provide coverage for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:

(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:

(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.

(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration.

(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.

(2) Voluntary male and female sterilization.

(3) Patient education and counseling on contraception.

(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:

(a) Management of side effects;

(b) Counseling for continued adherence to a prescribed regimen;

(c) Device insertion and removal;

(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and

(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.

b. The coverage provided shall include prescriptions for dispensing contraceptives for:

(1) (Deleted by amendment, P.L.2021, c.376)

(2) up to a 12-month period at one time.

c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the health benefits plan, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.

(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).

d. This section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.

§ 17B:27A-7.13 Individual health benefits plans to provide benefits for orthotic and prosthetic appliances.

6. a. Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

(2) an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, if the covered person's physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports.

As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3), "licensed podiatrist" has the meaning assigned to it in R.S.45:5-1 et seq., and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18).

b. On and after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), an individual health benefits plan shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

d. The provisions of this section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.14 Individual health benefits plan to provide coverage for hearing aids, cochlear implant for covered persons.

7. a. An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.), on or after the effective date of this act, shall provide coverage for medically necessary expenses incurred in the purchase of a hearing aid or cochlear implant for a covered person, as provided in this section.

b. A health benefits plan shall provide coverage that includes the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. A carrier may limit the benefit provided in this section to one hearing aid for each hearing-impaired ear every 24 months.

c. An individual health benefits plan shall provide coverage of the cost of treatment related to cochlear implants, including procedures for the implantation of cochlear devices and costs for any parts, attachments, or accessories of the device, including replacement of obsolete external cochlear implant processors.

d. The benefits shall be provided to the same extent as for any other condition under the health benefits plan.

e. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.15 Individual health benefits plan to provide installment payments to obstetrical provider for maternity services.

6. a. Every individual health benefits plan that provides benefits for maternity services, and that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide for reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a covered person's pregnancy.

b. For the purposes of this section, "obstetrical provider licensed in New Jersey" means:

(1) an obstetrician/gynecologist licensed by the State Board of Medical Examiners; or

(2) a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife.

c. This section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.16 Individual health benefits plan to provide benefits for treatment of autism or other developmental disability.

6. Notwithstanding any other provision of law to the contrary, an individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, renewed, or approved for issuance or renewal in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

a. The carrier shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability.

b. When the covered person's primary diagnosis is autism or another developmental disability, the carrier shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.

c. When the covered person is under 21 years of age and the covered person's primary diagnosis is autism, the carrier shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.

(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

(c) The adjusted maximum benefit amount shall apply to a health benefits plan that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

(d) Notwithstanding the provisions of this paragraph to the contrary, a carrier shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The carrier may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the carrier and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.

e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.

f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

g. The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.

h. The provisions of this section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.17 Individual health benefits plan to provide coverage for oral anticancer medication.

6. a. An individual health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), on or after the effective date of this act, shall provide coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis no less favorable than the plan provides for intravenously administered or injected anticancer medications.

b. Pursuant to subsection a. of this section, coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medications.

c. An individual health benefits plan shall not achieve compliance with the provisions of this section by imposing an increase in patient cost sharing, including any copayment, deductible or coinsurance, for anticancer medications, whether intravenously administered or injected or orally administered, that are covered under the plan as of the effective date of this act.

d. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.18 Individual health benefits plan to provide coverage for sickle cell anemia.

7. Every individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide coverage for medical expenses incurred by a covered person for the treatment of sickle cell anemia and, if the plan provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the plan shall provide coverage for prescription drug expenses incurred by a covered person for the treatment of sickle cell anemia.

The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

This section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.19 Individual health benefits plan to provide coverage for prescription eye drops.

6. a. An individual health benefits plan which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services, provided that:

(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and

(2) the refill requested by the covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.

b. The provisions of this section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.20 Individual health benefits plan, coverage for synchronization of prescribed medications.

7. a. Every individual health benefits plan delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State on or after the effective date of this act, which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall, on at least one occasion per year for each covered person:

(1) apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a 30 days' supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person's chronic medications;

(2) provide coverage for a drug prescribed for the treatment of a chronic illness dispensed in accordance with a plan among the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and

(3) determine dispensing fees based exclusively on the total number of prescriptions dispensed; dispensing fees shall not be prorated or based on the number of the days' supply of medication prescribed or dispensed.

b. This section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

c. This section shall not apply to prescriptions for opioid analgesics. "Opioid analgesic" means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

§ 17B:27A-7.21 Individual health benefits plan to provide benefits for treatment of substance use disorder.

6. a. An individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide unlimited benefits for inpatient and outpatient treatment of substance use disorder at in-network facilities. The services for the treatment of substance use disorder shall be prescribed by a licensed physician, licensed psychologist, or licensed psychiatrist and provided by licensed health care professionals or licensed or certified substance use disorder providers in licensed or otherwise State-approved facilities, as required by the laws of the state in which the services are rendered.

b. The benefits for the first 180 days per plan year of inpatient and outpatient treatment of substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. The facility shall notify the carrier of both the admission and the initial treatment plan within 48 hours of the admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, a carrier shall provide necessary exceptions to their network to ensure admission in a treatment facility within 24 hours.

c. Providers of treatment for substance use disorder to persons covered under a covered health benefits plan shall not require pre-payment of medical expenses during this 180 days in excess of applicable co-payment, deductible, or co-insurance under the plan.

d. The benefits for outpatient visits shall not be subject to concurrent or retrospective review of medical necessity or any other utilization management review.

e. (1) The benefits for the first 28 days of an inpatient stay during each plan year shall be provided without any retrospective review or concurrent review of medical necessity and medical necessity shall be as determined by the covered person's physician.

(2) The benefits for days 29 and thereafter of inpatient care shall be subject to concurrent review as defined in this section. A request for approval of inpatient care beyond the first 28 days shall be submitted for concurrent review before the expiration of the initial 28-day period. A request for approval of inpatient care beyond any period that is approved under concurrent review shall be submitted within the period that was previously approved. No carrier shall initiate concurrent review more frequently than at two-week intervals. If a carrier determines that continued inpatient care in a facility is no longer medically necessary, the carrier shall within 24 hours provide written notice to the covered person and the covered person's physician of its decision and the right to file an expedited internal appeal of the determination pursuant to an expedited process pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.5, as applicable. The carrier shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered person and the covered person's physician. If the determination is to uphold the denial, the covered person and the covered person's physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.6, as applicable. An independent utilization review organization shall make a determination within 24 hours. If the carrier's determination is upheld and it is determined continued inpatient care is not medically necessary, the carrier shall remain responsible to provide benefits for the inpatient care through the day following the date the determination is made and the covered person shall only be responsible for any applicable co-payment, deductible and co-insurance for the stay through that date as applicable under the policy. The covered person shall not be discharged or released from the inpatient facility until all internal appeals and independent utilization review organization appeals are exhausted. For any costs incurred after the day following the date of determination until the day of discharge, the covered person shall only be responsible for any applicable cost-sharing, and any additional charges shall be paid by the facility or provider.

f. (1) The benefits for the first 28 days of intensive outpatient or partial hospitalization services shall be provided without any retrospective review of medical necessity and medical necessity shall be as determined by the covered person's physician.

(2) The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization services shall be subject to a retrospective review of the medical necessity of the services.

g. Benefits for inpatient and outpatient treatment of substance use disorder after the first 180 days per plan year shall be subject to the medical necessity determination of the carrier and may be subject to prior authorization or, retrospective review and other utilization management requirements.

h. Medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health.

i. The benefits for outpatient prescription drugs to treat substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements.

j. The first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange provided in this subsection.

k. Except as stated above, the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the health benefits plan.

l. The benefits required by this section are to be provided to all covered persons with a diagnosis of substance use disorder. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this section.

m. The provisions of this section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

n. The Attorney General's Office shall be responsible for overseeing any violations of law that may result from P.L.2017, c.28 (C.17:48-6nn et al.), including fraud, abuse, waste, and mistreatment of covered persons. The Attorney General's Office is authorized to adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations to implement any of the provisions of P.L.2017, c.28 (C.17:48-6nn et al.).

o. The provisions of this section shall not apply to an individual health benefits plan which, pursuant to a contract between the carrier and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the "Family Health Care Coverage Act," P.L.2005, c.156 (C.30:4J-8 et seq.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.

p. As used in this section:

"Concurrent review" means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and as appropriate, the discharge plans.

"Substance use disorder" is as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include substance use withdrawal.

§ 17B:27A-7.22 Individual health benefits plan to provide coverage regardless of gender identity, expression.

6. a. Notwithstanding any other law or regulation to the contrary, an individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance on or after the effective date of this act, shall not contain any provision that discriminates, and the carrier shall not discriminate, on the basis of a covered person's or prospective covered person's gender identity or expression or on the basis that the covered person or prospective covered person is a transgender person.

b. The discrimination prohibited by this section shall include:

(1) denying, cancelling, limiting or refusing to issue or renew a contract on the basis of a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person;

(2) demanding or requiring a payment or premium that is based in whole or in part on a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person;

(3) designating a covered person's or prospective covered person's gender identity or expression, or the fact that a covered person or prospective covered person is a transgender person, as a preexisting condition for which coverage will be denied or limited; or

(4) denying or limiting coverage, or denying a claim, for services including but not limited to the following, due to a covered person's gender identity or expression or for the reason that the covered person is a transgender person:

(a) health care services related to gender transition if coverage is available for those services under the contract when the services are not related to gender transition, including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training; or

(b) health care services that are ordinarily or exclusively available to individuals of one sex when the denial or limitation is due only to the fact that the covered person is enrolled as belonging to the other sex or has undergone, or is in the process of undergoing, gender transition.

c. For the purposes of this section:

"Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's assigned sex at birth.

"Gender identity" means a person's internal sense of their own gender, regardless of the sex the person was assigned at birth.

"Gender transition" means the process of changing a person's outward appearance, including physical sex characteristics, to accord with the person's actual gender identity.

"Transgender person" means a person who identifies as a gender different from the sex assigned to the person at birth.

d. The provisions of this section shall apply to all those health benefits plans in which the carrier has reserved the right to change the premium.

e. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service.

§ 17B:27A-7.23 Individual health benefits plan to cover digital tomosynthesis of the breast.

6. a. An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in conducting digital tomosynthesis to detect or screen for breast cancer in women 40 years of age and over; and for diagnostic purposes in women of any age.

b. In the case of digital tomosynthesis conducted to detect or screen for breast cancer in women 40 years of age and over, no deductible, coinsurance or other cost sharing shall be applied; and in the case of digital tomosynthesis conducted for diagnostic purposes in women of any age, the same deductibles, coinsurance, and other cost sharing as apply to similar services under the health benefits plan shall be applied.

c. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.24 Individual health benefits plan to provide coverage for donated human breast milk.

6. a. An individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the provision of pasteurized donated human breast milk, which may include human milk fortifiers if indicated by the prescribing licensed medical practitioner, provided that:

(1) the covered person is an infant under the age of six months;

(2) the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health ; and

(3) a licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or

(4) a licensed medical practitioner has issued an order for an infant who meets any of the following conditions:

(a) a body weight below healthy levels determined by the licensed medical practitioner;

(b) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or

(c) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health.

b. The provisions of this section shall apply to those individual health benefits plans in which the carrier has reserved the right to change the premium.

c. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service.

d. The benefits shall be provided to the same extent as for any other prescribed items under the plan.

e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the carrier shall not be required to provide coverage of expenses pursuant to this section.

§ 17B:27A-7.25 Individual health benefits plan to provide coverage for breastfeeding support.

6. a. An individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2019, c.343 (C.17:48-6ss et al.), shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for health plan enrollees, with no cost-sharing.

b. Coverage of breastfeeding equipment shall include:

(1) Purchase of a single-user breast pump, subject to the following conditions:

(a) A plan shall cover the purchase of a double electric breast pump. If an enrollee requests a manual pump in lieu of the double electric breast pump, the health plan shall cover the purchase of a manual pump.

(b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding.

(c) A plan shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph.

(d) Coverage shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the plan enrollee.

(e) Coverage for breast pumps shall include repair or replacement if necessary.

(2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions:

(a) When recommended by a licensed health care provider, a plan shall provide coverage for a multi-user breast pump.

(b) An individual health benefits plan may determine whether a rental or purchase is covered.

(c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump.

(d) An individual health benefits plan may require a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump.

(3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider.

(4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the individual health benefits plan cannot ensure an enrollee receives breastfeeding equipment within 48 hours, an enrollee may purchase the equipment and the health plan shall reimburse all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts.

(5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the individual health benefits plan shall reimburse all out-of-pocket rental expenses incurred by an enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment.

c. Coverage of comprehensive lactation counseling and lactation consultation shall include:

(1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions:

(a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits.

(b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need.

(2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need.

(3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups.

(4) A plan shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting.

(5) An individual health benefits plan shall not impose medical management techniques not described in this section.

d. Except as otherwise authorized pursuant to this section, an individual health benefits plan shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided.

e. As used in this section:

"Cost-sharing" means deductible, co-insurance or co-payments, or similar charges.

"Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump.

"Lactation consultant" means an individual who is an International Board Certified Lactation Consultant.

"Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services.

Lactation care and services shall include, but not be limited to:

(1) lactation assessment through the systematic collection of subjective and objective data;

(2) analysis of data and creation of a plan of care;

(3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider;

(4) evaluation of outcomes;

(5) provision of lactation education to parents and health care providers; and

(6) the recommendation and use of assistive devices.

"Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as:

(1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding;

(2) acting as an advocate for breastfeeding as the norm for feeding infants and young children;

(3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals;

(4) using principles of adult education when teaching clients, health care providers, and others in the community; and

(5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately.

"Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is:

(1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or

(2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice.

"Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication.

f. This section shall apply to those plans in which the individual health benefits plan has reserved the right to change the premium.

§ 17B:27A-7.26 Individual health benefits plan to meet essential health benefits requirements.

1. a. An individual health benefits plan subject to P.L.1992, c.161 (C.17B:27A-2 et seq.) shall provide coverage under every plan delivered, issued, executed or renewed in this State, on or after the effective date of this act, that meets the essential health benefits requirements provided by this section.

b. Pursuant to section 3 of P.L.2019, c.354 (C.17B:27A-60), the commissioner shall define essential health benefits to include at least the following general categories and the items and services covered within the categories:

(1) ambulatory patient services;

(2) emergency services;

(3) hospitalization;

(4) maternity and newborn care;

(5) mental health and substance use disorder services, including behavioral health treatment;

(6) prescription drugs;

(7) rehabilitative and habilitative services and devices;

(8) laboratory services;

(9) preventive and wellness services and chronic disease management; and

(10) pediatric services, including oral and vision care.

c. An individual health benefits plan shall provide for a level of coverage that is designed to provide benefits that are actuarially equivalent to:

(1) 60 percent of the full actuarial value of the benefits provided under the plan;

(2) 70 percent of the full actuarial value of the benefits provided under the plan; or

(3) 80 percent of the full actuarial value of the benefits provided under the plan.

d. The level of coverage of a plan shall be determined on the basis that the essential health benefits described in subsection b. of this section are provided to a standard population, and without regard to the actual population to which the plan may provide benefits.

e. The commissioner shall develop guidelines to provide for a de minimis variation in the actuarial calculations used in determining the level of coverage of a plan to account for differences in actuarial estimates.

§ 17B:27A-7.27 Individual health benefits plan to cover preventive services.

6. a. An individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage, without requiring any cost sharing, for the following preventive services:

(1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;

(2) immunizations that have in effect a recommendation from the Department of Health, which shall in making its recommendations consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians;

(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

(4) with respect to women, any additional preventive care and screenings not described in paragraph (1) as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

b. (1) Except as provided in paragraph (2) of this subsection, nothing in this section shall:

(a) require a plan which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or

(b) preclude a plan which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider.

(2) If a plan does not have in its network a provider who can provide an item or service described in subsection a. of this section, the plan shall cover the item or service when performed by an out-of-network provider and shall not impose cost sharing with respect to that item or service.

c. (1) A plan shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued.

(2) (a) Except as provided in subparagraph (b) of this paragraph, a plan that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year.

(b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section.

d. This section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

e. With respect to an annual wellness visit for a covered member who is over three years of age, a carrier is required to cover only one wellness visit per plan year or calendar year, as provided for under the health benefits plan contract, but may not impose a waiting period for the wellness visit.

§ 17B:27A-7.28 Individual health benefits plan to provide coverage for certain prescription drugs.

6. a. Notwithstanding any other provision of law to the contrary, a carrier that offers an individual health benefits plan that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), shall ensure that: at least 25 percent of all plans, or at least one plan if the carrier offers less than four plans, offered by the carrier in each rating area and in each of the bronze, silver, gold, and platinum levels of coverage, in the individual market pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), shall conform with the following:

(1) (a) a health benefits plan that provides a silver, gold, or platinum level of coverage, as defined in 45 C.F.R. s.156.140, shall limit a covered person's cost-sharing, including any copayment or coinsurance, for prescription drugs, including specialty drugs, to no more than $150 per month for each prescription drug for up to a 30-day supply of any single drug;

(b) a health benefits plan that provides a bronze level of coverage, as defined in 45 C.F.R. s.156.140, shall ensure that any required covered person's cost-sharing, including any copayment or coinsurance, does not exceed $250 per month for each prescription drug for up to a 30-day supply of any single drug;

(c) a health benefits plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall be exempt from the requirements of subparagraphs (a) and (b) of this paragraph;

(2) except as provided in paragraph (3) of this subsection, the limits described in paragraph (1) of this subsection shall apply at any point in the benefit design, including before and after any applicable deductible is reached; and

(3) for prescription drug benefits offered in conjunction with a high-deductible health plan, the plan shall not provide prescription drug benefits until the expenditures applicable to the deductible under the plan have met the amount of the minimum annual deductibles in effect for self-only and family coverage under section 223(c)(2)(A)(i) of the federal Internal Revenue Code (26 U.S.C. s.223(c)(2)(A)(i)) for self-only and family coverage, respectively. Once the foregoing expenditure amount has been met under the plan, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in paragraph (1) of this subsection.

b. The provisions of this section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.29 Individual health benefits plan to cover adolescent depression screenings.

6. An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), on or after the effective date of this act, shall provide coverage for expenses incurred in screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service.

The benefits shall be provided to the same extent as for any other condition under the health benefits plan, except that the carrier shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance.

This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.30 Individual health benefits plan to cover newborn home nurse visitation.

10. a. Every individual health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159). The plan shall:

(1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159);

(2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant;

(3) ensure that the plan does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and

(4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing:

(a) a value-based payment methodology;

(b) an invoice claim process;

(c) a capitated payment arrangement;

(d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or

(e) any other payment arrangement agreed to by the carrier and an agency or organization providing services under the program.

b. Any copayment, coinsurance, or deductible that may be required pursuant to the health benefits plan for such services shall be waived.

c. Every carrier that is subject to the provisions of this section shall submit to the Department of Banking and Insurance, in a form and manner prescribed by the department, a report on the claims submitted for services provided under the newborn home nurse visitation program.

The information contained in the report shall be shared with the Department of Children and Families and used by that department to assess the newborn home nurse visitation program pursuant to subsection a. of section 4 of P.L.2021, c.187 (C.26:2H-161).

d. (1) Except as provided in paragraphs (2) and (3) of this subsection, the contract shall specify that no deductible, coinsurance, copayment, or any other cost-sharing requirement may be imposed on the coverage required pursuant to this section.

(2) An individual health benefits plan that qualifies as a high deductible health plan shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement permitted for a high deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).

(3) An individual health benefits plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement to the extent permitted for a catastrophic plan under federal law.

e. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.31 Individual health benefits plan, coverage, insulin for diabetes treatment.

19. An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide coverage to an enrollee or other person covered thereunder for insulin for the treatment of diabetes, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

The benefits shall be provided to the same extent as for any other condition under the health benefits plan.

This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-7.32 Individual health benefits plan, coverage, epinephrine auto-injector device.

20. An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide coverage for at least one epinephrine auto-injector device, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of an epinephrine auto-injector device shall not be subject to any deductible, and no copayment or coinsurance for the purchase of an epinephrine auto-injector device shall exceed $25 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

Nothing in this section shall prevent a carrier from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section.

§ 17B:27A-7.33 Individual health benefits plan, coverage, prescription asthma inhaler.

21. An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide benefits to an enrollee or other person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

Nothing in this section shall prevent a carrier from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section.

§ 17B:27A-7.34 Biomarker precision medical testing coverage, individual health benefits plans.

6. a. Each individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or is approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide benefits for biomarker precision medical testing, as defined by subsection g. of this section.

b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of a covered person when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for a covered person's disease or condition is recognized by:

(1) labeled indications for an FDA-approved or -cleared test;

(2) indicated tests for an FDA-approved drug;

(3) actions to address warnings and precautions on FDA-approved drug labels;

(4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or

(5) nationally recognized clinical practice guidelines.

c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of a covered person.

d. (1) If utilization review is required, a carrier shall provide a decision pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.).

(2) The covered person and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the covered person shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination.

e. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan, including determinations of clinical review criteria used for utilization review of health care services along with copayment, deductible, and coinsurance provisions.

f. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

g. As used in this section:

"Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression.

"Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing.

"Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. The guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.

§ 17B:27A-7.35 Individual health benefits plan, HIV preexposure prophylaxis, HIV postexposure prophylaxis.

8. a. (1) Except as provided in paragraph (2) of this subsection, every individual health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L.2025, c.196 (C.45:14-67.13) without requiring prior authorization or step therapy.

(2) If the federal Food and Drug Administration has authorized or approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the plan to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.

b. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the individual health benefits plan to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:

(1) the service or procedure is within the scope of practice of the treating pharmacist; and

(2) the service or procedure would otherwise be covered under the plan if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.

c. An individual health benefits plan shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the plan to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.

d.An individual health benefits plan shall not:

(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and

(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L.2025, c.196 (C.45:14-67.13) in excess of a 90-day supply for a single patient within a given two year period.

e. Nothing in this section shall be construed to require an individual health benefit plan to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.

f. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

g. As used in this section:

“HIV preexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12).

“HIV postexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12).

“Step therapy” means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits.

§ 17B:27A-7.36 Benefits provided under individual health benefits plans.

7. a. Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2025, c.200 (C. 17:48-6bbb et al.), shall provide benefits to any person covered thereunder for expenses incurred in obtaining medically necessary treatment for women with a diagnosis of perimenopause, menopause, and symptoms associated with perimenopause and menopause, including, but not limited to:

(1) hormonal therapies such as hormone replacement therapy and bioidentical hormone treatments;

(2) non-hormonal treatments, including medications to manage menopausal symptoms;

(3) behavioral health care services;

(4) pelvic floor physical therapy;

(5) bone health treatments, including screenings and medications due to hormonal changes related to perimenopause and menopause;

(6) preventative services that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force for early detection and treatment of health conditions related to perimenopause and menopause such as osteoporosis and cancer; and

(7) counseling and education regarding menopause management.

b. An individual health benefits plan shall provide clear and accessible information to a covered person regarding covered perimenopause and menopause treatments.

c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

d. The provisions of this section shall apply to all enrollee agreements in which the insurer has reserved the right to change the premium.

e. As used in this section:

“Menopause” means the permanent end of a female’s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period.

“Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles.

§ 17B:27A-8 Offering of certain coverage not required

7. a. A health maintenance organization shall not be required to offer coverage to or accept an applicant pursuant to this act if:

(1) the eligible individual does not live, reside, or work within the health maintenance organization's approved service area; and

(2) the carrier has demonstrated to the commissioner that the carrier will not have the capacity to deliver services adequately to additional eligible persons because of its obligations to existing group contract holders and enrollees and individual enrollees and it applies this paragraph uniformly to individuals without regard to any health status-related factor of such individuals and without regard to whether the individuals are eligible persons. Upon denying individual health benefits coverage pursuant to this paragraph, a carrier may not offer such coverage in the individual market for a period of 180 days after the date the coverage is denied. If the health maintenance organization does not have the capacity in its facilities for additional individual enrollees, it also shall not offer coverage to or accept any new group enrollees.

b. A carrier shall not be required to offer coverage or accept applications pursuant to this act if the commissioner determines that the carrier does not have the financial reserves necessary to underwrite additional coverage. Upon denying individual health benefits coverage pursuant to this subsection, a carrier may not offer such coverage in the individual market for a period of 180 days after the date the coverage is denied or until the carrier has demonstrated to the commissioner that the carrier has sufficient financial reserves to underwrite additional coverage, whichever is later.

§ 17B:27A-9 Determination of rates.

8. a. (Deleted by amendment, P.L.2008, c.38).

b. The board shall make application on behalf of all carriers for any other subsidies, discounts, or funds that may be provided for under State or federal law or regulation. A carrier may include subsidies or funds granted to the board to reduce its premium rates for individual health benefits plans subject to P.L.1992, c.161 (C.17B:27A-2 et al.).

c. A carrier shall not issue individual health benefits plans on a new contract or policy form pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.) until an informational filing of a full schedule of rates which applies to the contract or policy form has been filed with the commissioner. The commissioner shall provide a copy of the informational filing to the Attorney General and the board.

d. A carrier desiring to increase or decrease premiums for any contract or policy form may implement that increase or decrease upon making an informational filing with the commissioner of that increase or decrease, along with the actuarial assumptions and methods used by the carrier in establishing that increase or decrease. The commissioner may disapprove any informational filing on a finding that it is incomplete and not in substantial compliance with P.L.1992, c.161 (C.17B:27A-2 et al.), or that the rates are inadequate or unfairly discriminatory.

e. (1) Rates shall be formulated on contracts or policies required pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4) so that the anticipated minimum loss ratio for a contract or policy form shall not be less than 80% of the premium calculated based on a three-year rolling average. The carrier shall submit with its rate filing supporting data, as determined by the commissioner, and a certification by a member of the American Academy of Actuaries, or other individuals in a format acceptable to the commissioner, that the carrier is in compliance with the provisions of this subsection.

(2) Each calendar year, a carrier shall return, in the form of aggregate benefits for all of the policy or contract forms offered by the carrier pursuant to subsection a. of section 3 of P.L.1992, c.161 (C.17:B:27A-4), at least 80% of the aggregate premiums collected for all of the policy or contract forms during that calendar year. Carriers shall annually report, no later than August 1 of each year, the loss ratio calculated pursuant to this section for all of the policy or contract forms for the previous calendar year. The loss ratio for the previous year shall be calculated based on a three-year rolling average. In each case in which the loss ratio fails to comply with the 80% loss ratio requirement, the carrier shall issue a dividend or credit against future premiums for all policy or contract holders, as applicable, in an amount sufficient to assure that the aggregate benefits paid in the previous calendar year plus the amount of the dividends and credits, calculated based on a three-year rolling average, equal 80% of the aggregate premiums collected for the policy or contract forms in the previous calendar year calculated based on a three-year rolling average. All dividends and credits shall be distributed by December 31 of the year following the calendar year in which the loss ratio requirements were not satisfied. The annual report required by this subsection shall include a carrier's calculation of the dividends and credits applicable to all policy or contract forms, as well as an explanation of the carrier's plan to issue dividends or credits. The instructions and format for calculating and reporting loss ratios and issuing dividends or credits shall be specified by the commissioner by regulation. Those regulations shall include provisions:

(a) for the distribution of a dividend or credit in the event of cancellation or termination by a policyholder; and

(b) requiring a carrier's minimum loss ratio to be calculated by aggregating the data for a three-year period which includes the data for the previous calendar year whose minimum loss ratio is being calculated, including three months of runout through the first quarter of the subsequent year; and the data for the two years immediately preceding the year for which the minimum loss ratio is being calculated.

f. (Deleted by amendment, P.L.2008, c.38).

§ 17B:27A-10 New Jersey Individual Health Coverage Program; board of directors.

9. a. There is created the New Jersey Individual Health Coverage Program. All carriers subject to the provisions of this act shall be members of the program.

b. Within 30 days of the effective date of this act, the commissioner shall give notice to all members of the time and place for the initial organizational meeting, which shall take place within 60 days of the effective date. The board shall consist of nine representatives. The commissioner or his designee shall serve as an ex officio member on the board. Four members of the board shall be appointed by the Governor, with the advice and consent of the Senate: one of whom shall be a representative of an employer, appointed upon the recommendation of a business trade association, who is a person with experience in the management or administration of an employee health benefit plan; one of whom shall be a representative of organized labor, appointed upon the recommendation of the A.F.L.-C.I.O., who is a person with experience in the management or administration of an employee health benefit plan; and two of whom shall be consumers of a health benefits plan who are reflective of the population in the State. Four board members who represent carriers shall be elected by the members, subject to the approval of the commissioner, as follows: to the extent there is one licensed in this State that is willing to have a representative serve on the board, a representative from each of the following entities shall be elected:

(1) a health service corporation or a domestic stock insurer which converted from a health service corporation pursuant to the provisions of P.L.2001, c.131 (C.17:48E-49 et al.) and is primarily engaged in the business of issuing health benefit plans in this State;

(2) a health maintenance organization;

(3) an insurer authorized to write health insurance in this State subject to Subtitle 3 of Title 17B of the New Jersey Statutes; and

(4) a foreign health insurance company authorized to do business in this State.

In approving the selection of the carrier representatives of the board, the commissioner shall assure that all members of the program are fairly represented.

Initially, two of the Governor's appointees and two of the carrier representatives shall serve for a term of three years; one of the Governor's appointees and one of the carrier representatives shall serve for a term of two years; and one of the Governor's appointees and one of the carrier representatives shall serve for a term of one year. Thereafter, all board members shall serve for a term of three years. Vacancies shall be filled in the same manner as the original appointments.

c. If the initial carrier representatives to the board are not elected at the organizational meeting, the commissioner shall appoint those members to the initial board within 15 days of the organizational meeting.

d. Within 90 days after the appointment of the initial board, the board shall submit to the commissioner a plan of operation and thereafter, any amendments to the plan necessary or suitable to assure the fair, reasonable, and equitable administration of the program. The commissioner may disapprove the plan of operation, if the commissioner determines that it is not suitable to assure the fair, reasonable, and equitable administration of the program, and that it does not provide for the sharing of program losses on an equitable and proportionate basis in accordance with the provisions of section 11 of this act. The plan of operation or amendments thereto shall become effective unless disapproved in writing by the commissioner within 45 days of receipt by the commissioner.

e. If the board fails to submit a suitable plan of operation within 90 days after its appointment, the commissioner shall adopt a temporary plan of operation pursuant to section 9 of P.L.1993, c.164 (C.17B:27A-16.2). The commissioner shall amend or rescind a temporary plan adopted under this subsection, at the time a plan of operation is submitted by the board.

f. The plan of operation shall establish procedures for:

(1) the handling and accounting of assets and moneys of the program, and an annual fiscal reporting to the commissioner;

(2) collecting assessments from members to provide for sharing program losses in accordance with the provisions of section 11 of this act and administrative expenses incurred or estimated to be incurred during the period for which the assessment is made;

(3) approving the coverage, benefit levels, and contract forms for individual health benefits plans in accordance with the provisions of section 3 of this act;

(4) the imposition of an interest penalty for late payment of an assessment pursuant to section 11 of this act; and

(5) any additional matters at the discretion of the board.

g. The board shall appoint an insurance producer licensed to sell health insurance pursuant to P.L.1987, c.293 (C.17:22A-1 et seq.) to advise the board on issues related to sales of individual health benefits plans issued pursuant to this act.

§ 17B:27A-10.1 Short title.

1. This act shall be known and may be cited as the "New Jersey Health Insurance Premium Security Act."

§ 17B:27A-10.2 Purpose of act.

2. It is the intent of the Legislature to stabilize or reduce premiums in the individual health insurance market by providing reinsurance payments to health insurance carriers with respect to claims for eligible individuals. The Commissioner of Banking and Insurance, and the board of directors of the New Jersey Individual Health Coverage Program, are authorized to apply for, accept and receive federal funds to implement and sustain market stabilization programs. Preliminary planning, analysis, and implementation to effectuate the purposes of this act shall continue under the direction of the commissioner and the board.

§ 17B:27A-10.3 Definitions relative to health insurance premiums.

3. For the purposes of this act:

"Affiliated carrier" means the same as defined in N.J.A.C.11:20-1.2.

"Affordable Care Act" or "PPACA" means the federal Patient Protection and Affordable Care Act, Pub.L.111-148, as amended by the federal "Health Care and Education Reconciliation Act of 2010," Pub.L.111-152, and any federal rules and regulations adopted pursuant thereto.

"Attachment point" means an amount as provided in subsection h. of section 4 of this act.

"Benefit year" means the calendar year for which an eligible carrier provides coverage through an individual health benefits plan.

"Board" means the board of directors of the New Jersey Individual Health Coverage Program established pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.).

"Carrier" means any entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefits plan, including a sickness and accident insurance company, a health maintenance organization, a hospital, medical or health service corporation, or any other entity providing a health benefits plan. For purposes of this act, carriers that are affiliated carriers shall be treated as one carrier.

"Paid claim" means a claim by a covered person for payment of benefits under a health benefits plan for which the financial obligation for the payment of the claim under the contract rests upon and has been paid by the carrier, excluding claims adjustment expenses.

"Coinsurance rate" means the rate as provided in subsection i. of section 4 of this act.

"Commissioner" means the Commissioner of Banking and Insurance.

"Department" means the Department of Banking and Insurance.

"Eligible carrier" means a carrier that offers individual health benefits plans in the State.

"Fund" means the New Jersey Health Insurance Premium Security Fund created pursuant to section 10 of this act.

"Health benefits plan" means the same as that term is defined in section 1 of P.L.1992, c.161 (C.17B:27A-2).

"Payment parameters" means the attachment point, reinsurance cap, and coinsurance rate for the plan.

"Plan" means the Health Insurance Premium Security Plan established pursuant to section 4 of this act.

"Reinsurance cap" means the threshold amount as provided in subsection j. of section 4 of this act.

"Reinsurance payment" means an amount paid by the board to an eligible carrier under the plan.

§ 17B:27A-10.4 Health Insurance Premium Security Plan.

4. a. There is hereby established, and the board in consultation with the commissioner shall administer, the Health Insurance Premium Security Plan.

b. The board or commissioner may apply for any available federal funding for the plan. All funds received pursuant to an application for federal funding, assessed by the board pursuant to this act, or otherwise dedicated to the fund shall be remitted to the State Treasurer and deposited in the fund.

c. The commissioner, in consultation with the board, shall collect data from carriers necessary to determine the reinsurance payment parameters and shall share this data with the board.

d. For each applicable benefit year, the board shall notify carriers, the commissioner, and the State Treasurer of the reinsurance payments to be made for the applicable benefit year no later than June 30 of the year following the applicable benefit year.

e. On a quarterly basis during the applicable benefit year, the board shall provide each eligible carrier and the commissioner with the calculation of total reinsurance payment requests.

f. By November 1 of the year following the applicable benefit year, the State Treasurer shall disburse all applicable reinsurance payments to an eligible carrier.

g. The board, subject to the disapproval of the commissioner pursuant to section 5 of this act, shall design and adjust the payment parameters to ensure the payment parameters:

(1) will stabilize or reduce premium rates in the individual market by achieving between a 10% and 20% reduction in what indicated premium rates would be for the applicable benefit year without the plan;

(2) will encourage increased participation in the individual market;

(3) mitigate the impact high-risk individuals have on premium rates in the individual market;

(4) take into account any federal funding available for the plan;

(5) take into account the total amount available to fund the plan; and

(6) encourage cost savings mechanisms related to the management of health care services.

h. The attachment point for the plan is the threshold amount for paid claims by an eligible carrier for an enrolled individual's covered benefits in a benefit year, beyond which the paid claims are eligible for reinsurance payments. The attachment point shall be set by the board, but shall not exceed the reinsurance cap.

i. The coinsurance rate for the plan is the rate at which the board will reimburse an eligible carrier for paid claims for an enrolled individual's covered benefits in a benefit year above the attachment point and below the reinsurance cap. The coinsurance rate shall be set by the board.

j. The reinsurance cap is the amount for paid claims of an eligible carrier for an enrolled individual's covered benefits, above which the paid claims for benefits are no longer eligible for reinsurance payments. The reinsurance cap shall be set by the board.

§ 17B:27A-10.5 Payment parameters.

5. The board shall propose to the commissioner the payment parameters for the next benefit year by April 30 of the year before the applicable benefit year. The commissioner shall have 15 days to review the payment parameters. If the commissioner takes no affirmative action to disapprove the payment parameters within that time the proposed payment parameters are final and effective.

§ 17B:27A-10.6 Calculation of reinsurance payment.

6. a. Each reinsurance payment shall be calculated with respect to an eligible carrier's paid claims for an individual enrollee's covered benefits in the applicable benefit year. If the paid claims do not exceed the attachment point, a reinsurance payment shall not be made. If the paid claims exceed the attachment point, the reinsurance payment shall be calculated as the product of the coinsurance rate and the lesser of:

(1) the paid claims minus the attachment point; or

(2) the reinsurance cap minus the attachment point.

b. The board shall ensure that reinsurance payments made to eligible carriers do not exceed the total amount paid by the eligible carrier for any eligible claim. "Total amount paid" means the amount paid by the eligible carrier based upon the allowed amount less any deductible, coinsurance, or co-payment, as of the time the data are submitted or made accessible under section 7 of this act.

§ 17B:27A-10.7 Requests for reinsurance payments.

7. a. An eligible carrier shall submit a request to the board for reinsurance payments when the eligible carrier's total amount paid for an enrollee meets the criteria for reinsurance payments.

b. An eligible carrier shall make requests for reinsurance payments in accordance with any requirements established by the board.

c. An eligible carrier shall calculate the premium amount the carrier would have charged for the applicable benefit year if the plan was not in effect and submit this information as part of its rate filing.

d. An eligible carrier shall maintain documents and records, whether paper, electronic, or in other media, sufficient to substantiate the requests for reinsurance payments made pursuant to this section for a period of at least six years. An eligible carrier shall also make those documents and records available upon request from the commissioner for purposes of verification, investigation, audit, or other review of reinsurance payment requests.

e. (1) At least once every five years the board shall engage an independent audit firm to audit eligible carriers that receive reinsurance payments to assess compliance with the requirements of this act. The eligible carrier shall cooperate with an audit. If an audit results in a proposed finding of material weakness or significant deficiency with respect to compliance with any requirement of this act or overpayment of reinsurance payments in the audited benefit years, the eligible carrier may respond to the draft audit report within 30 days of the draft audit report's issuance.

(2) Within 30 days of the issuance of the final audit report, if the final audit results in a finding of material weakness or significant deficiency with respect to compliance with any requirement of this act or overpayment of reinsurance payments in the audited benefit years, the eligible carrier shall:

(a) provide a written corrective action plan to the board for approval, that includes recoupment of any reinsurance overpayments;

(b) upon board approval, implement the corrective action plan described; and

(c) provide the board with documentation of the corrective actions taken.

§ 17B:27A-10.8 Accounting for each benefit year.

8. The board shall keep an accounting for each benefit year, including but not limited to, the following:

a. funds appropriated for reinsurance payments and administrative and operational expenses;

b. requests for reinsurance payments received from eligible carriers;

c. reinsurance payments made to eligible carriers; and

d. administrative and operational expenses incurred for the plan.

§ 17B:27A-10.9 Application for waiver of ACA.

9. The commissioner shall apply to the United States Secretary of Health and Human Services under 42 U.S.C. s.18052 for a waiver of applicable provisions of the Affordable Care Act with respect to health insurance coverage in the State for a plan year beginning on or after January 1, 2019, to effectuate the provisions of this act. If the waiver is approved, the commissioner may accept the waiver so long as the commissioner determines that implementation of the plan:

a. will be beneficial to policyholders; and

b. is expected to stabilize or reduce premiums in the individual health insurance market through a reduction in what indicated premium rates would be without the plan.

If the commissioner accepts the waiver, the commissioner and the board shall implement the plan to meet the waiver requirements in a manner consistent with federal and State law, as approved by the United States Secretary of Health and Human Services, and consistent with the provisions of this act. The commissioner may contract for actuarial services as necessary to implement the waiver application required pursuant to this section.

§ 17B:27A-10.10 New Jersey Health Insurance Premium Security Fund.

10. a. The New Jersey Health Insurance Premium Security Fund is hereby created in the State Treasury for the purposes of this act. This fund shall be the repository for monies collected pursuant to this act and other monies received as grants in support of this act, or monies otherwise appropriated or directed to be remitted to the fund. The establishment of this fund, the funding sources contained herein, and the plan shall be contingent upon approval from the United States Secretary of Health and Human Services and the United States Secretary of the Treasury of a State Innovation Waiver application pursuant to section 1332 of the Affordable Care Act (42 U.S.C. s.18052) and the commissioner's acceptance of any approval as provided in section 9 of this act.

b. All interest earned on the moneys that have been deposited into the fund shall be retained in the fund and used for purposes consistent with the fund.

c. The fund shall be funded to levels based upon actuarial analysis to stabilize or reduce premiums rates in the individual market achieving between a 10% and 20% reduction in what indicated rates would be for the applicable benefit year without the plan and to cover all necessary administrative costs of the reinsurance provided by the plan.

d. The fund shall be fully funded in accordance with this section by:

(1) All funds collected by the State pursuant to P.L.2018, c.31 (C.54A:11-1 et seq.);

(2) Federal payments received as a result of any waiver of requirements granted or other arrangements agreed to by the United States Secretary of Health and Human Services or other appropriate federal officials; and

(3) For the purpose of providing the funds necessary to carry out the provisions of this act, and in amounts sufficient to ensure funding levels as required by this act after the monies received pursuant to paragraphs (1) and (2) of this subsection, there shall be appropriated annually out of the General Fund of the State an amount as the board, in consultation with the commissioner, determines necessary to fully fund the plan to accomplish the objectives of this act. The board, in consultation with the commissioner, shall calculate the amount necessary to cover the submitted reinsurance requests taking into account all federal waiver payments and other monies in the fund. The board shall issue an order memorializing those amounts and requesting the Legislature to appropriate that amount to the fund.

e. Moneys in the fund shall only be used for the purposes established in this act.

§ 17B:27A-10.11 Annual report.

11. a. The board shall present an annual report to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), which contains a summary of the operations of the Health Insurance Premium Security Plan and the impact of the plan on health insurance premiums. The report shall be made available to the public upon request and by posting on the department's website.

b. (1) The board shall engage and cooperate with an independent certified public accountant to perform an audit for each benefit year of the plan, in accordance with generally accepted auditing standards. The audit shall at a minimum:

(a) assess compliance with the requirements of this act; and

(b) identify any material weaknesses or significant deficiencies and address manners in which to correct any such material weaknesses or deficiencies.

(2) The board, after receiving the completed audit, shall:

(a) provide the commissioner the results of the audit excluding any proprietary information;

(b) identify to the commissioner any material weakness or significant deficiency identified in the audit and address in writing to the commissioner how the board recommends to correct any such material weakness or significant deficiency in compliance with this subsection; and

(c) make available to the public a summary of the results of the audit by posting the summary on the department website and making the summary otherwise available, including any material weakness or significant deficiency and how the board intends to correct the material weakness or significant deficiency.

c. Documents, materials or other information that are in the possession or control of the commissioner or the board and that are obtained by or disclosed to the commissioner, the board, or any other person in the course of an examination or investigation made pursuant to this act shall be confidential by law and privileged and shall not be subject to disclosure or dissemination under P.L.1963, c.71 (C.47:1A-1 et seq.), or any other act. However, the commissioner is authorized to use the documents, materials or other information in the furtherance of any regulatory or legal action brought as a part of the commissioner's official duties. The commissioner shall not otherwise make the documents, materials or other information public without the prior written consent of the carrier.

§ 17B:27A-10.12 Violations, penalties.

12. If a carrier violates any provision of this act, the commissioner may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $1,000 nor more than $10,000 for each day the carrier is in violation of this act. The penalty may be recovered in a summary proceeding pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.).

§ 17B:27A-10.13 Rules, regulations.

13. The board, pursuant to section 8 of P.L.1993, c.164 (C.17B:27A-16.1), and the commissioner, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and in consultation with each other, shall each adopt such rules and regulations as may be necessary to effectuate the purposes of this act.

§ 17B:27A-10.14 Study, Department of Banking and Insurance, New Jersey Individual Health Coverage Program, New Jersey Small Employer Health Benefits Program; report, Governor, Legislature.

1. a. The Department of Banking and Insurance shall conduct a study of:

(1) the potential impact on the New Jersey Individual Health Coverage Program and the New Jersey Small Employer Health Benefits Program of pursuing an amendment to the waiver of applicable provisions of the Affordable Care Act granted by the United States Secretary of Health and Human Services, pursuant to 42 U.S.C. s.18052, in order to merge the individual and small group markets and the availability and impact of extending reinsurance to small businesses purchasing health insurance through the pooled market;

(2) the costs and benefits of creating a small employer health insurance subsidy, and other affordability measures as deemed appropriate by the commissioner, and sustainable funding sources for that subsidy and those measures. The examination shall consider the size of an effective and meaningful subsidy, an analysis of available sustainable funding sources, including an examination of the establishment of an assessment on other lines of insurance, the size of any such assessment, and how best to administer both the subsidy and a potential assessment. The department shall examine similar subsidies and assessments in other states, including the New Mexico health care affordability fund and health insurance premium surtax;

(3) the actuarial impact of increasing the age rating ratio in the New Jersey Small Employer Health Benefits Program from 2:1 to various ranges up to 3:1. The department shall specifically examine the impact of any increase of the age rating ratio on consumers and overall premiums in the small group market, as well as any impact on market viability, competitiveness, enrollment, and any other factors that the department finds necessary. The study shall examine and illustrate the impact of the implementation schedule of any age rating ratio changes. Additionally, the study shall examine the effect of geographic region ratings on premiums and whether it would be in the best interests of the small group market's viability and employers and employees to retain or eliminate this factor. The study shall include recommendations to the Legislature to support the health of the small group market and its eligible enrollees; and

(4) other policies that could contribute to stabilizing the small employer health insurance market.

b. The department shall make a report of the study's findings and recommendations and provide a copy of the report to the public through the Internet website of the department. The department shall also provide the report to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), no later than one year following the effective date of this act.

c. The commissioner is authorized to request directly from any other department or agency of State government information or data that may be needed to carry out the requirements of this section; and such department or agency is authorized and shall furnish the requested information or data.

d. The commissioner may request from any carrier participating in the Small Employer Health Benefits Program and Individual Health Coverage Program data necessary to conduct the study pursuant to this section, and carriers shall provide the requested data.

e. The commissioner may engage the services of experts and consultants to assist with the preparation of the study required under this section.

f. There is appropriated from the General Fund to the Department of Banking and Insurance $500,000 to effectuate the purposes of this act.

§ 17B:27A-11 Powers, authority of program, board.

10. The program shall have the general powers and authority granted under the laws of New Jersey to insurance companies, health service corporations and health maintenance organizations licensed or approved to transact business in this State, except that the program shall not have the power to issue health benefits plans directly to either groups or individuals.

The board shall have the specific authority to:

a. assess members their proportionate share of program losses and administrative expenses in accordance with the provisions of section 11 of this act, and make advance interim assessments, as may be reasonable and necessary for organizational and reasonable operating expenses and estimated losses. An interim assessment shall be credited as an offset against any regular assessment due following the close of the fiscal year;

b. establish rules, conditions, and procedures pertaining to the sharing of program losses and administrative expenses among the members of the program;

c. (Deleted by amendment, P.L.2008, c.38).

d. define the provisions of individual health benefits plans in accordance with the requirements of this act;

e. enter into contracts which are necessary or proper to carry out the provisions and purposes of this act;

f. establish a procedure for the joint distribution of information on individual health benefits plans issued pursuant to section 3 of this act;

g. establish, at the board's discretion, standards for the application of a means test for individual health benefits plans issued pursuant to section 3 of this act;

h. establish, at the board's discretion, reasonable guidelines for the purchase of new individual health benefits plans by persons who already are enrolled in or insured by another individual health benefits plan;

i. establish minimum requirements for performance standards for carriers that are reimbursed for losses submitted to the program and provide for performance audits from time to time;

j. sue or be sued, including taking any legal actions necessary or proper for recovery of an assessment for, on behalf of, or against the program or a member;

k. appoint from among its members appropriate legal, actuarial, and other committees as necessary to provide technical and other assistance in the operation of the program, in policy and other contract design, and any other function within the authority of the program;

l. borrow money to effect the purposes of the program. Any notes or other evidence of indebtedness of the program not in default shall be legal investments for carriers and may be carried as admitted assets; and

m. contract for an independent actuary and any other professional services the board deems necessary to carry out its duties under P.L.1992, c.161 (C.17B:27A-2 et al.).

§ 17B:27A-12 Procedures for equitable sharing of program losses.

11. The board shall establish procedures for the equitable sharing of program losses among all members in accordance with their total market share as follows:

a. (1) By March 1, 1999, and following the close of each two-year calculation period thereafter, or on a different date established by the board:

(a) every carrier issuing health benefits plans in this State shall file with the board its net earned premium for the preceding two-year calculation period; and

(b) every carrier issuing individual health benefits plans in the State shall file with the board the net earned premium on health benefits plans issued pursuant to paragraph (1) of subsection b. of section 2 and section 3 of this act and the claims paid. If the claims paid for all health benefits plans during the two-year calculation period exceed 115% of the net earned premium and any investment income thereon for the two-year calculation period, the amount of the excess shall be the net paid loss for the carrier that shall be reimbursable under this act.

(2) Every member shall be liable for an assessment to reimburse carriers issuing individual health benefits plans in this State which sustain net paid losses during the two-year calculation period, unless the member has received an exemption from the board pursuant to subsection d. of this section and has written a minimum number of non-group person life years as provided for in that subsection. The assessment of each member shall be in the proportion that the net earned premium of the member for the two-year calculation period preceding the assessment bears to the net earned premium of all members for the two-year calculation period preceding the assessment. Notwithstanding the provisions of this subsection to the contrary, a medical service corporation or a hospital service corporation shall not be liable for an assessment to reimburse carriers which sustain net paid losses.

(3) A member that is financially impaired may seek from the commissioner a deferment in whole or in part from any assessment issued by the board. The commissioner may defer, in whole or in part, the assessment of the member if, in the opinion of the commissioner, the payment of the assessment would endanger the ability of the member to fulfill its contractual obligations. If an assessment against a member is deferred in whole or in part, the amount by which the assessment is deferred may be assessed against the other members in a manner consistent with the basis for assessment set forth in this section. The member receiving the deferment shall remain liable to the program for the amount deferred.

b. The participation in the program as a member, the establishment of rates, forms or procedures, or any other joint or collective action required by this act shall not be the basis of any legal action, criminal or civil liability, or penalty against the program, a member of the board or a member of the program either jointly or separately except as otherwise provided in this act.

c. Payment of an assessment made under this section shall be a condition of issuing health benefits plans in the State for a carrier. Failure to pay the assessment shall be grounds for forfeiture of a carrier's authorization to issue health benefits plans of any kind in the State, as well as any other penalties permitted by law.

d. (1) Notwithstanding the provisions of this act to the contrary, a carrier may apply to the board, by a date established by the board, for an exemption from the assessment and reimbursement for losses provided for in this section. A carrier which applies for an exemption shall agree to cover a minimum number of non-group person life years on an open enrollment community rated basis, under a managed care or indemnity plan, as specified in this subsection, provided that any indemnity plan so issued conforms with sections 2 through 7, inclusive, of P.L.1992, c.161 (C.17B:27A-3 through 17B:27A-8). For the purposes of this subsection, non-group persons include individually enrolled persons, conversion policies issued pursuant to this act, Medicare cost and risk lives and Medicaid recipients; except that in determining whether the carrier meets the minimum number of non-group person life years required to be covered pursuant to this subsection, the number of Medicaid recipients and Medicare cost and risk lives shall not exceed 50% of the total. Pursuant to regulations adopted by the board, the carrier shall determine the number of non-group person life years it has covered by adding the number of non-group persons covered on the last day of each calendar quarter of the two-year calculation period, taking into account the limitations on counting Medicaid recipients and Medicare cost and risk lives, and dividing the total by eight.

(2) Notwithstanding the provisions of paragraph (1) of this subsection to the contrary, a health maintenance organization qualified pursuant to the "Health Maintenance Organization Act of 1973," Pub.L.93-222 (42 U.S.C. s.300e et seq.) and tax exempt pursuant to paragraph (3) of subsection (c) of section 501 of the federal Internal Revenue Code of 1986, 26 U.S.C. s.501, may include up to one third Medicaid recipients and up to one third Medicare recipients in determining whether it meets its minimum number of non-group person life years.

(3) The minimum number of non-group person life years required to be covered, as determined by the board, shall equal the total number of non-group person life years of community rated, individually enrolled or insured persons, including Medicare cost and risk lives and enrolled Medicaid lives, of all carriers subject to this act for the two-year calculation period, multiplied by the proportion that that carrier's net earned premium bears to the net earned premium of all carriers for that two-year calculation period, including those carriers that are exempt from the assessment.

(4) On or before March 1 of the first year of each two-year calculation period, every carrier seeking an exemption pursuant to this subsection shall file with the board a statement of its net earned premium for the two-year calculation period. The board shall determine each carrier's minimum number of non-group person life years in accordance with this subsection.

(5) On or before March 1 of each year immediately following the close of a two-year calculation period, every carrier that was granted an exemption for the preceding two-year calculation period shall file with the board the number of non-group person life years, by category, covered for the two-year calculation period.

To the extent that the carrier has failed to cover the minimum number of non-group person life years established by the board, the carrier shall be assessed by the board on a pro rata basis for any differential between the minimum number established by the board and the actual number covered by the carrier.

(6) A carrier that applies for the exemption shall be deemed to be in compliance with the requirements of this subsection if it has covered 100% of the minimum number of non-group person life years required.

(7) Any carrier that writes both managed care and indemnity business that is granted an exemption pursuant to this subsection may satisfy its obligation to cover a minimum number of non-group person life years by issuing either managed care or indemnity business, or both.

e. (Deleted by amendment, P.L.1997, c.146).

f. The loss assessment for the 2007-2008 two-year calculation period shall be the last loss assessment authorized under this section, and no further loss assessments shall be calculated or collected; provided, however, that nothing in this subsection shall relieve a carrier of its obligations for loss assessments authorized under this section prior to the effective date of this section of P.L.2008, c.38.

§ 17B:27A-12.1 Exemption from liability, certain, for HMO formed by UMDNJ.

2. Notwithstanding the provisions of any statute to the contrary, a health maintenance organization established by the University of Medicine and Dentistry of New Jersey pursuant to the provisions of P.L.1992, c.84 shall be exempt from liability for the assessment provided for in section 11 of P.L.1992, c.161 (C.17B:27A-12) for the 1999-2000 two-year calculation period.

§ 17B:27A-13 Statement of net paid losses

12. a. No later than March 1, 1993, any carrier issuing individual health benefits plans in the State shall file with the board a statement of any net paid losses for the calendar year ending December 31, 1992, as calculated pursuant to subsection a. of section 11 of this act, along with any supporting information required by the board.

b. The losses filed pursuant to subsection a. of this section shall be reimbursed in an amount up to $10,000,000 or 50% of the paid losses, whichever amount is less, to the carrier filing the losses. The assessment shall be made as a separate assessment from those required pursuant to section 11 of this act, but shall be assessed in the same manner and at the same time as the first assessment made after the effective date of this act as provided for in section 11 of this act, except that the carrier filing for the reimbursement shall not be subject to an assessment pursuant to this section.

§ 17B:27A-14 Determination of disproportionate share of substandard risks

13. The board shall determine whether any carrier has a disproportionate share of substandard risks insured or enrolled under its individual health benefits plans and shall make recommendations to the Governor and the Legislature for remedial action to minimize the losses sustained by the carrier as a result of insuring these risks.

§ 17B:27A-15 Sale of health benefits plan

14. A health benefits plan issued pursuant to section 3 of this act may be sold through an insurance producer licensed pursuant to P.L.1987, c.293 (C.17:22A-1 et seq.).

§ 17B:27A-16 Submission of rate filings by health maintenance organization not required

15. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a health maintenance organization shall not be required to submit any rate filings with the commissioner for an individual health benefits plan that is subject to the provisions of this act, but shall be subject to the minimum loss ratio provisions of section 8 of this act.

§ 17B:27A-16.1 Board actions subject to provisions of section; "action" defined; procedure

8. Effective January 1, 1994, all actions adopted by the board shall be subject to the provisions of this section, notwithstanding the provisions of P.L.1968, c.410 (C.52:14B-1 et seq.) to the contrary.

a. For the purposes of this section, "action" includes, but is not limited to:

(1) the establishment and modification of health benefits plans;

(2) procedures and standards for the: (a) assessment of members and the apportionment thereof; (b) filing of policy forms; (c) making of rate filings; (d) evaluation of material submitted by carriers with respect to loss ratios; and (e) establishment of refunds to policy or contract holders; and

(3) the promulgation or modification of policy forms.

"Action" shall not include the hearing and resolution of contested cases, personnel matters and applications for withdrawal or exemptions.

b. Prior to the adoption of an action of the board, the board shall publish notice of its intended action in three newspapers of general circulation in this State, and may publish the notice of intended action in any trade or professional publication which it deems necessary. The notice of intended action shall include procedures for obtaining a detailed description of the intended action and the time, place and manner by which interested persons may present their views. The board shall provide the notice of intended action and a detailed description of the intended action by mail, or otherwise, to affected trade and professional associations, carriers subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et al.) and such other interested persons or organizations which may request notification. The board shall forward the notice of intended action and the detailed description of the intended action concurrently to the Office of Administrative Law for publication in the New Jersey Register.

The board shall not charge any fee for placement upon the mailing list of associations, carriers or other persons to be notified, but the board may charge a fee to an association, carrier or other person requesting a copy of the text of the intended action, which fee shall not be in excess of the actual cost of reproducing and mailing the copy.

A copy of the text of the intended action shall be available in the Department of Insurance in accordance with the provisions of P.L.1963, c.73 (C.47:1A-1 et seq.).

c. The board shall hold a public hearing on the establishment and modification of health benefits plans, and the board may hold a public hearing on any other intended action. Notice of a hearing shall be given in the notice of intended action provided for in subsection b. of this section.

d. Whether or not a public hearing is held, the board shall afford all interested persons an opportunity to comment in writing on the intended action. Written comments shall be submitted to the board within the time established by the board in the notice of intended action, which time shall not be less than 20 calendar days from the date of notice.

The board shall give due consideration to all comments received. Within a reasonable period of time following submission of the comments pursuant to this subsection, the board shall prepare for public distribution a report listing all parties who provided written submissions concerning the intended action, summarizing the content of the submissions and providing the board's response to the data, views and arguments contained in the submissions. A copy of the report shall be filed with the Office of Administrative Law for publication in the New Jersey Register.

e. The board may adopt the intended action immediately following the expiration of the public comment period provided in subsection d. of this section, or the hearing provided for in subsection c. of this section, whichever date is later. The final action adopted by the board shall be submitted for publication in the New Jersey Register to the Office of Administrative Law, and shall be effective on the date of the submission or such later date as the board may establish.

f. Actions filed with the Office of Administrative Law pursuant to this section shall be filed subject to the provisions of subsections (a), (c), (d) and (e) of section 5 of P.L.1968, c.410 (C.52:14B-5).

g. Nothing in this section shall be construed to prohibit the board from adopting any action pursuant to the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

h. Nothing in this section shall be construed to prohibit the commissioner from adopting any rule or regulation pursuant to the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), or from taking any other action required or authorized by P.L.1992, c.161 (C.17B:27A-2 et al.).

§ 17B:27A-16.2 Adoption of temporary plan of operation

9. a. The commissioner shall, under the procedures provided pursuant to section 7 of P.L.1993, c.164, adopt a temporary plan of operation prepared pursuant to section 9 of P.L.1992, c.161 (C.17B:27A-10), pending submission or approval of a plan of operation prepared by the board pursuant to that section 9.

b. Subsequent amendments to the plan of operation shall be reviewed and approved by the commissioner pursuant to the procedures provided in sections 7 and 8 of P.L.1993, c.164 (C.17B:27A-16.1), as applicable.

§ 17B:27A-16.3 Purchase of other insurance coverage not required

10. A carrier shall not require an eligible person to purchase any other insurance coverage, including, but not limited to, life insurance, accident insurance or disability insurance, as a condition of or in conjunction with the purchase of a health benefits plan pursuant to P.L.1992, c.161 (C.17B:27A-2 et al.).

§ 17B:27A-16.4 Adoption of standard claim form

11. The board, in conjunction with the board of the New Jersey Small Employer Health Benefits Program established pursuant to section 12 of P.L.1992, c.162 (C.17B:27A-28), shall adopt one standard claim form.

In order to provide a standard system of payment for medical services, all claim forms for a claimant's use under an individual health benefits plan issued or delivered in this State shall conform to the form adopted by the board.

§ 17B:27A-16.5 Hospital, medical insurance policy renewals; filing of rates.

5. A domestic mutual insurer which has converted from a health service corporation pursuant to the provisions of sections 2 through 4 of P.L.1995, c.196 (C.17:48E-46 through C.17:48E-48) shall not renew individual hospital or medical insurance policies or health service contracts originally issued prior to November 30, 1992, until it has made an informational filing with the commissioner. The rates shall be formulated so that the anticipated minimum loss ratio for such policy or contract form shall not be less than 80% of the premium. Such domestic mutual insurer shall submit with its rate filing supporting data and a certification that the insurer is in compliance with the anticipated loss ratio requirement. The content and form of the supporting data and certification required pursuant to subsection e. of section 8 of P.L.1992, c.161 (C.17B:27A-9) shall satisfy the requirements of this section. Any other insurer may irrevocably elect to become subject to the provisions of this section by written notice to the commissioner in a format specified by the commissioner.

§ 17B:27A-17 Definitions relative to small employer health benefits plans.

1. As used in this act:

"Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a small employer carrier is in compliance with the provisions of section 9 of P.L.1992, c.162 (C.17B:27A-25), based upon examination, including a review of the appropriate records and actuarial assumptions and methods used by the small employer carrier in establishing premium rates for applicable health benefits plans.

"Anticipated loss ratio" means the ratio of the present value of the expected benefits, not including dividends, to the present value of the expected premiums, not reduced by dividends, over the entire period for which rates are computed to provide coverage. For purposes of this ratio, the present values must incorporate realistic rates of interest which are determined before federal taxes but after investment expenses.

"Board" means the board of directors of the program.

"Carrier" means any entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurance company authorized to issue health insurance, a health maintenance organization, a hospital service corporation, medical service corporation and health service corporation, or any other entity providing a plan of health insurance, health benefits or health services. The term "carrier" shall not include a joint insurance fund established pursuant to State law. For purposes of this act, carriers that are affiliated companies shall be treated as one carrier, except that any insurance company, health service corporation, hospital service corporation, or medical service corporation that is an affiliate of a health maintenance organization located in New Jersey or any health maintenance organization located in New Jersey that is affiliated with an insurance company, health service corporation, hospital service corporation, or medical service corporation shall treat the health maintenance organization as a separate carrier.

"Church plan" has the same meaning given that term under Title I, section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C.s.1002(33)).

"Commissioner" means the Commissioner of Banking and Insurance.

"Community rating" or "community rated" means a rating methodology in which the premium charged by a carrier for all persons covered by a policy or contract form is the same based upon the experience of the entire pool of risks covered by that policy or contract form without regard to age, gender, health status, residence or occupation.

"Creditable coverage" means, with respect to an individual, coverage of the individual under any of the following: a group health plan; a group or individual health benefits plan; Part A or part B of Title XVIII of the federal Social Security Act (42 U.S.C. s.1395 et seq.); Title XIX of the federal Social Security Act (42 U.S.C. s.1396 et seq.), other than coverage consisting solely of benefits under section 1928 of Title XIX of the federal Social Security Act (42 U.S.C.s.1396s); chapter 55 of Title 10, United States Code (10 U.S.C. s.1071 et seq.); a medical care program of the Indian Health Service or of a tribal organization; a state health benefits risk pool; a health plan offered under chapter 89 of Title 5, United States Code (5 U.S.C. s.8901 et seq.); a public health plan as defined by federal regulation; a health benefits plan under section 5(e) of the "Peace Corps Act" (22 U.S.C. s.2504(e)); or coverage under any other type of plan as set forth by the commissioner by regulation.

Creditable coverage shall not include coverage consisting solely of the following: coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit only insurance; coverage for on-site medical clinics; coverage, as specified in federal regulation, under which benefits for medical care are secondary or incidental to the insurance benefits; and other coverage expressly excluded from the definition of health benefits plan.

"Department" means the Department of Banking and Insurance.

"Dependent" means the spouse, domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3), civil union partner as defined in section 2 of P.L.2006, c.103 (C.37:1-29), or child of an eligible employee, subject to applicable terms of the health benefits plan covering the employee.

"Eligible employee" means a full-time employee who works a normal work week of 25 or more hours. The term includes a sole proprietor, a partner of a partnership, or an independent contractor, if the sole proprietor, partner, or independent contractor is included as an employee under a health benefits plan of a small employer, but does not include employees who work less than 25 hours a week, work on a temporary or substitute basis or are participating in an employee welfare arrangement established pursuant to a collective bargaining agreement.

"Enrollment date" means, with respect to a person covered under a health benefits plan, the date of enrollment of the person in the health benefits plan or, if earlier, the first day of the waiting period for such enrollment.

"Financially impaired" means a carrier which, after the effective date of this act, is not insolvent, but is deemed by the commissioner to be potentially unable to fulfill its contractual obligations or a carrier which is placed under an order of rehabilitation or conservation by a court of competent jurisdiction.

"Governmental plan" has the meaning given that term under Title I, section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C.s.1002(32)) and any governmental plan established or maintained for its employees by the Government of the United States or by any agency or instrumentality of that government.

"Group health plan" means an employee welfare benefit plan, as defined in Title I of section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C. s.1002(1)), to the extent that the plan provides medical care and including items and services paid for as medical care to employees or their dependents directly or through insurance, reimbursement or otherwise.

"Health benefits plan" means any hospital and medical expense insurance policy or certificate; health, hospital, or medical service corporation contract or certificate; or health maintenance organization subscriber contract or certificate delivered or issued for delivery in this State by any carrier to a small employer group pursuant to section 3 of P.L.1992, c.162 (C.17B:27A-19). For purposes of this act, "health benefits plan" shall not include one or more, or any combination of, the following: coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefits plan shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in federal regulations. Health benefits plan shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. Health benefits plan shall not include the following if it is offered as a separate policy, certificate or contract of insurance: Medicare supplemental health insurance as defined under section 1882(g)(1) of the federal Social Security Act (42 U.S.C.s.1395ss(g)(1)); and coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code (10 U.S.C. s.1071 et seq.); and similar supplemental coverage provided to coverage under a group health plan.

"Health status-related factor" means any of the following factors: health status; medical condition, including both physical and mental illness; claims experience; receipt of health care; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; and disability.

"Late enrollee" means an eligible employee or dependent who requests enrollment in a health benefits plan of a small employer following the initial minimum 30-day enrollment period provided under the terms of the health benefits plan. An eligible employee or dependent shall not be considered a late enrollee if the individual: a. was covered under another employer's health benefits plan at the time he was eligible to enroll and stated at the time of the initial enrollment that coverage under that other employer's health benefits plan was the reason for declining enrollment, but only if the plan sponsor or carrier required such a statement at that time and provided the employee with notice of that requirement and the consequences of that requirement at that time; b. has lost coverage under that other employer's health benefits plan as a result of termination of employment or eligibility, reduction in the number of hours of employment, involuntary termination, the termination of the other plan's coverage, death of a spouse, or divorce or legal separation; and c. requests enrollment within 90 days after termination of coverage provided under another employer's health benefits plan. An eligible employee or dependent also shall not be considered a late enrollee if the individual is employed by an employer which offers multiple health benefits plans and the individual elects a different plan during an open enrollment period; the individual had coverage under a COBRA continuation provision and the coverage under that provision was exhausted and the employee requests enrollment not later than 30 days after the date of exhaustion of COBRA coverage; or if a court of competent jurisdiction has ordered coverage to be provided for a spouse or minor child under a covered employee's health benefits plan and request for enrollment is made within 30 days after issuance of that court order.

"Medical care" means amounts paid: (1) for the diagnosis, care, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body; and (2) transportation primarily for and essential to medical care referred to in (1) above.

"Member" means all carriers issuing health benefits plans in this State on or after the effective date of this act.

"Multiple employer arrangement" means an arrangement established or maintained to provide health benefits to employees and their dependents of two or more employers, under an insured plan purchased from a carrier in which the carrier assumes all or a substantial portion of the risk, as determined by the commissioner, and shall include, but is not limited to, a multiple employer welfare arrangement, or MEWA, multiple employer trust or other form of benefit trust.

"Plan of operation" means the plan of operation of the program including articles, bylaws and operating rules approved pursuant to section 14 of P.L.1992, c.162 (C.17B:27A-30).

"Plan sponsor" has the meaning given that term under Title I of section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C.s.1002(16)(B)).

"Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for that coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date. Genetic information shall not be treated as a preexisting condition in the absence of a diagnosis of the condition related to that information.

"Program" means the New Jersey Small Employer Health Benefits Program established pursuant to section 12 of P.L.1992, c.162 (C.17B:27A-28).

"Small employer" means, in connection with a group health plan with respect to a calendar year and a plan year, any person, firm, corporation, partnership, or political subdivision that is actively engaged in business that employed an average of at least two but not more than 50 eligible employees on business days during the preceding calendar year and who employs at least two employees on the first day of the plan year, and the majority of the employees are employed in New Jersey. All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 (26 U.S.C.s.414) shall be treated as one employer. Subsequent to the issuance of a health benefits plan to a small employer and for the purpose of determining continued eligibility, the size of a small employer shall be determined annually. Except as otherwise specifically provided, provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) that apply to a small employer shall continue to apply at least until the plan anniversary following the date the small employer no longer meets the requirements of this definition. In the case of an employer that was not in existence during the preceding calendar year, the determination of whether the employer is a small or large employer shall be based on the average number of employees that it is reasonably expected that the employer will employ on business days in the current calendar year. Any reference in P.L.1992, c.162 (C.17B:27A-17 et seq.) to an employer shall include a reference to any predecessor of such employer.

"Small employer carrier" means any carrier that offers health benefits plans covering eligible employees of one or more small employers.

"Small employer health benefits plan" means a health benefits plan for small employers approved by the commissioner pursuant to section 17 of P.L.1992, c.162 (C.17B:27A-33).

"Stop loss" or "excess risk insurance" means an insurance policy designed to reimburse a self-funded arrangement of one or more small employers for catastrophic, excess or unexpected expenses, wherein neither the employees nor other individuals are third party beneficiaries under the insurance policy. In order to be considered stop loss or excess risk insurance for the purposes of P.L.1992, c.162 (C.17B:27A-17 et seq.), the policy shall establish a per person attachment point or retention or aggregate attachment point or retention, or both, which meet the following requirements:

a. If the policy establishes a per person attachment point or retention, that specific attachment point or retention shall not be less than $20,000 per covered person per plan year; and

b. If the policy establishes an aggregate attachment point or retention, that aggregate attachment point or retention shall not be less than 125% of expected claims per plan year.

"Supplemental limited benefit insurance" means insurance that is provided in addition to a health benefits plan on an indemnity non-expense incurred basis.

§ 17B:27A-18 Providers of health benefits, services subject to provisions of act

2. Every health insurer, health service corporation, medical service corporation, hospital service corporation, and health maintenance organization licensed or authorized to provide health benefits or services in this State which offers health insurance policies or coverages to small employers shall be subject to the provisions of this act. Carriers shall offer coverage to all eligible employees of small employers and their dependents and shall not exclude any employee or eligible dependent on the basis of a health status-related factor.

§ 17B:27A-18.1 Provision of benefits to subscriber's child under small employer policy, contract.

9. a. A policy or contract which provides hospital or medical expense benefits under which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A policy or contract shall not deny coverage for a covered employee's child on the grounds that:

(1) The child was born out of wedlock;

(2) The child is not claimed as a dependent on the covered employee's federal tax return;

(3) The child does not reside with the covered employee or in the carrier's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the policy or contract with respect to the use of specified providers;

(4) The child is married;

(5) The child has or adopts a child; or

(6) The child starts or leaves school.

b. If a child has coverage through a policy or contract of a noncustodial parent, the carrier shall:

(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child's noncustodial parent's coverage;

(2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and

(3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.

c. When a parent who is the covered employee is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the carrier shall:

(1) Permit the parent to enroll his child as a dependent, without regard to any open enrollment restrictions;

(2) Permit the child's other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the policy or contract if the parent who is the covered employee fails to enroll the child; and

(3) Not terminate coverage of the child unless the parent who is the covered employee provides the carrier with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage.

§ 17B:27A-18.2 Requirements applicable to State Medicaid

10. A carrier shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other covered employee.

§ 17B:27A-19 Health benefits plans offered to small employers; exceptions.

3. a. Except as provided in subsection f. of this section, every small employer carrier shall, as a condition of transacting business in this State, offer to every small employer at least three of the health benefit plans established by the board, as provided in this section. The board shall establish a standard policy form for each of the plans, which except as otherwise provided in subsection j. of this section, shall be the only plans offered to small groups on or after January 1, 1994. One policy form shall contain the benefits provided for in sections 55, 57, and 59 of P.L.1991, c. 187 (C.17:48E-22.2, 17B:26B-2 and 26:2J-4.3). In the case of indemnity carriers, one policy form shall be established which contains benefits and cost-sharing levels which are equivalent to the health benefits plans of health maintenance organizations pursuant to the "Health Maintenance Organization Act of 1973," Pub.L.93-222 (42 U.S.C. s.300e et seq.). The remaining policy forms shall contain basic hospital and medical-surgical benefits, including, but not limited to:

(1) Basic inpatient and outpatient hospital care;

(2) Basic and extended medical-surgical benefits;

(3) Diagnostic tests, including X-rays;

(4) Maternity benefits, including prenatal and postnatal care; and

(5) Preventive medicine, including periodic physical examinations and inoculations.

At least three of the forms shall provide for major medical benefits in varying lifetime aggregates, one of which shall provide at least $1,000,000 in lifetime aggregate benefits. The policy forms provided pursuant to this section shall contain benefits representing progressively greater actuarial values.

Notwithstanding the provisions of this subsection to the contrary, the board also may establish additional policy forms by which a small employer carrier, other than a health maintenance organization, may provide indemnity benefits or health maintenance organization enrollees by direct contract with the enrollees' small employer through a dual arrangement with the health maintenance organization. The dual arrangement shall be filed with the commissioner for approval. The additional policy forms shall be consistent with the general requirements of P.L.1992, c.162 (C.17B:27A-17 et seq.).

b. Initially, a carrier shall offer a plan within 90 days of the approval of such plan by the commissioner. Thereafter, the plans shall be available to all small employers on a continuing basis. Every small employer which elects to be covered under any health benefits plan who pays the premium therefor and who satisfies the participation requirements of the plan shall be issued a policy or contract by the carrier.

c. The carrier may establish a premium payment plan which provides installment payments and which may contain reasonable provisions to ensure payment security, provided that provisions to ensure payment security are uniformly applied.

d. In addition to the standard policies described in subsection a. of this section, the board may develop up to five rider packages. Any such package which a carrier chooses to offer shall be issued to a small employer who pays the premium therefor, and shall be subject to rating methodology set forth in section 9 of P.L.1992, c.162 (C.17B:27A-25).

e. (Deleted by amendment, P.L.2008, c.38).

f. Notwithstanding the provisions of this section to the contrary, a health maintenance organization which is a qualified health maintenance organization pursuant to the "Health Maintenance Organization Act of 1973," Pub.L.93-222 (42 U.S.C. s.300e et seq.) shall be permitted to offer health benefits plans formulated by the board and approved by the commissioner which are in accordance with the provisions of that law in lieu of the five plans required pursuant to this section.

Notwithstanding the provisions of this section to the contrary, a health maintenance organization which is approved pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall be permitted to offer health benefits plans formulated by the board and approved by the commissioner which are in accordance with the provisions of that law in lieu of the plans required pursuant to this section, except that the plans shall provide the same level of benefits as required for a federally qualified health maintenance organization, including any requirements concerning copayments by enrollees.

g. A carrier shall not be required to own or control a health maintenance organization or otherwise affiliate with a health maintenance organization in order to comply with the provisions of this section, but the carrier shall be required to offer at least three of the benefits plans which are formulated by the board and approved by the commissioner, including one plan which contains benefits and cost sharing levels that are equivalent to those required for health maintenance organizations.

h. Notwithstanding the provisions of subsection a. of this section to the contrary, the board may modify the benefits provided for in sections 55, 57, and 59 of P.L.1991, c.187 (C.17:48E-22.2, 17B:26B-2 and 26:2J-4.3).

i. (1) In addition to the rider packages provided for in subsection d. of this section, every carrier may offer, in connection with the health benefits plans required to be offered by this section, any number of riders which may revise the coverage offered by the plans in any way, provided, however, that any form of such rider or amendment thereof which decreases benefits or decreases the actuarial value of a plan shall be filed for informational purposes with the board and for approval by the commissioner before such rider may be sold. Any rider or amendment thereof which adds benefits or increases the actuarial value of a plan shall be filed with the board for informational purposes before such rider may be sold. The added premium or reduction in premium for each rider, as applicable, shall be listed separately from the premium for the standard plan.

The commissioner shall disapprove any rider filed pursuant to this subsection that is unjust, unfair, inequitable, unreasonably discriminatory, misleading, or contrary to law or the public policy of this State. The commissioner shall not approve any rider which reduces benefits below those required by sections 55, 57, and 59 of P.L.1991, c.187 (C.17:48E-22.2, 17B:26B-2 and 26:2J-4.3) and required to be sold pursuant to this section. The commissioner's determination shall be in writing and shall be appealable.

(2) The benefit riders provided for in paragraph (1) of this subsection shall be subject to the provisions of section 2, subsection b. of section 3, and sections 5, 7, 8, 9, and 11 of P.L.1992, c.162 (C.17B:27A-18, 17B:27A-19, 17B:27A-22, 17B:27A-23, 17B:27A-24, 17B:27A-25, and 17B:27A-27).

j. (1) Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, a health benefits plan issued by or through a carrier, association, or multiple employer arrangement prior to January 1, 1994 or, if the requirements of subparagraph (c) of paragraph (6) of this subsection are met, issued by or through an out-of-State trust prior to January 1, 1994, at the option of a small employer policy or contract holder, may be renewed or continued after February 28, 1994, or in the case of such a health benefits plan whose anniversary date occurred between March 1, 1994 and the effective date of P.L.1994, c.11 (C.17B:27A-19.1 et al.), may be reinstated within 60 days of that anniversary date and renewed or continued if, beginning on the first 12-month anniversary date occurring on or after the sixtieth day after the board adopts regulations concerning the implementation of the rating factors permitted by section 9 of P.L.1992, c.162 (C.17B:27A-25) and, regardless of the situs of delivery of the health benefits plan, the health benefits plan renewed, continued, or reinstated pursuant to this subsection complies with the provisions of section 2, subsection b. of section 3, and sections 6, 7, 8, 9, and 11 of P.L.1992, c.162 (C.17B:27A-18, 17B:27A-19, 17B:27A-22, 17B:27A-23, 17B:27A-24, 17B:27A-25 and 17B:27A-27) and section 7 of P.L.1995, c.340 (C17B:27A-19.3).

Nothing in this subsection shall be construed to require an association, multiple employer arrangement, or out-of-State trust to provide health benefits coverage to small employers that are not contemplated by the organizational documents, bylaws, or other regulations governing the purpose and operation of the association, multiple employer arrangement, or out-of-State trust. Notwithstanding the foregoing provision to the contrary, an association, multiple employer arrangement, or out-of-State trust that offers health benefits coverage to its members' employees and dependents:

(a) shall offer coverage to all eligible employees and their dependents within the membership of the association, multiple employer arrangement, or out-of-State trust;

(b) shall not use actual or expected health status in determining its membership; and

(c) shall make available to its small employer members at least one of the standard benefits plans, as determined by the commissioner, in addition to any health benefits plan permitted to be renewed or continued pursuant to this subsection.

(2) Notwithstanding the provisions of this subsection to the contrary, a carrier or out-of-State trust which writes the health benefits plans required pursuant to subsection a. of this section shall be required to offer those plans to any small employer, association, or multiple employer arrangement.

(3) (a) A carrier, association, multiple employer arrangement, or out-of-State trust may withdraw a health benefits plan marketed to small employers that was in effect on December 31, 1993 with the approval of the commissioner. The commissioner shall approve a request to withdraw a plan, consistent with regulations adopted by the commissioner, only on the grounds that retention of the plan would cause an unreasonable financial burden to the issuing carrier, taking into account the rating provisions of section 9 of P.L.1992, c.162 (C.17B:27A-25) and section 7 of P.L.1995, c.340 (C.17B:27A-19.3).

(b) A carrier which has renewed, continued, or reinstated a health benefits plan pursuant to this subsection that has not been newly issued to a new small employer group since January 1, 1994, may, upon approval of the commissioner, continue to establish its rates for that plan based on the loss experience of that plan if the carrier does not issue that health benefits plan to any new small employer groups.

(4) (Deleted by amendment, P.L.1995, c.340).

(5) A health benefits plan that otherwise conforms to the requirements of this subsection shall be deemed to be in compliance with this subsection, notwithstanding any change in the plan's deductible or copayment.

(6) (a) Except as otherwise provided in subparagraphs (b) and (c) of this paragraph, a health benefits plan renewed, continued, or reinstated pursuant to this subsection shall be filed with the commissioner for informational purposes within 30 days after its renewal date. No later than 60 days after the board adopts regulations concerning the implementation of the rating factors permitted by section 9 of P.L.1992, c.162 (C.17B:27A-25) the filing shall be amended to show any modifications in the plan that are necessary to comply with the provisions of this subsection. The commissioner shall monitor compliance of any such plan with the requirements of this subsection, except that the board shall enforce the loss ratio requirements.

(b) A health benefits plan filed with the commissioner pursuant to subparagraph (a) of this paragraph may be amended as to its benefit structure if the amendment does not reduce the actuarial value and benefits coverage of the health benefits plan below that of the lowest standard health benefits plan established by the board pursuant to subsection a. of this section. The amendment shall be filed with the commissioner for approval pursuant to the terms of sections 4, 8, 12, and 25 of P.L.1995, c.73 (C.17:48-8.2, 17:48A-9.2, 17:48E-13.2 and 26:2J-43), N.J.S.17B:26-1, and N.J.S.17B:27-49, as applicable, and shall comply with the provisions of sections 2 and 9 of P.L.1992, c.162 (C.17B:27A-18 and 17B:27A-25) and section 7 of P.L.1995, c.340 (C.17B:27A-19.3).

(c) A health benefits plan issued by a carrier through an out-of-State trust shall be permitted to be renewed or continued pursuant to paragraph (1) of this subsection upon approval by the commissioner and only if the benefits offered under the plan are at least equal to the actuarial value and benefits coverage of the lowest standard health benefits plan established by the board pursuant to subsection a. of this section. For the purposes of meeting the requirements of this subparagraph, carriers shall be required to file with the commissioner the health benefits plans issued through an out-of-State trust no later than 180 days after the date of enactment of P.L.1995, c.340. A health benefits plan issued by a carrier through an out-of-State trust that is not filed with the commissioner pursuant to this subparagraph, shall not be permitted to be continued or renewed after the 180-day period.

(7) Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, an association, multiple employer arrangement, or out-of-State trust may offer a health benefits plan authorized to be renewed, continued, or reinstated pursuant to this subsection to small employer groups that are otherwise eligible pursuant to paragraph (1) of subsection j. of this section during the period for which such health benefits plan is otherwise authorized to be renewed, continued, or reinstated.

(8) Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, a carrier, association, multiple employer arrangement, or out-of-State trust may offer coverage under a health benefits plan authorized to be renewed, continued, or reinstated pursuant to this subsection to new employees of small employer groups covered by the health benefits plan in accordance with the provisions of paragraph (1) of this subsection.

(9) Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) or P.L.1992, c.161 (C.17B:27A-2 et al.) to the contrary, any individual, who is eligible for small employer coverage under a policy issued, renewed, continued, or reinstated pursuant to this subsection, but who would be subject to a preexisting condition exclusion under the small employer health benefits plan, or who is a member of a small employer group who has been denied coverage under the small employer group health benefits plan for health reasons, may elect to purchase or continue coverage under an individual health benefits plan until such time as the group health benefits plan covering the small employer group of which the individual is a member complies with the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.).

(10) In a case in which an association made available a health benefits plan on or before March 1, 1994 and subsequently changed the issuing carrier between March 1, 1994 and the effective date of P.L.1995, c.340, the new issuing carrier shall be deemed to have been eligible to continue and renew the plan pursuant to paragraph (1) of this subsection.

(11) In a case in which an association, multiple employer arrangement, or out-of-State trust made available a health benefits plan on or before March 1, 1994 and subsequently changes the issuing carrier for that plan after the effective date of P.L.1995, c.340, the new issuing carrier shall file the health benefits plan with the commissioner for approval in order to be deemed eligible to continue and renew that plan pursuant to paragraph (1) of this subsection.

(12) In a case in which a small employer purchased a health benefits plan directly from a carrier on or before March 1, 1994 and subsequently changes the issuing carrier for that plan after the effective date of P.L.1995, c.340, the new issuing carrier shall file the health benefits plan with the commissioner for approval in order to be deemed eligible to continue and renew that plan pursuant to paragraph (1) of this subsection.

Notwithstanding the provisions of subparagraph (b) of paragraph (6) of this subsection to the contrary, a small employer who changes its health benefits plan's issuing carrier pursuant to the provisions of this paragraph, shall not, upon changing carriers, modify the benefit structure of that health benefits plan within six months of the date the issuing carrier was changed.

k. Effective immediately for a health benefits plan issued on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) and effective on the first 12-month anniversary date of a health benefits plan in effect on the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), the health benefits plans required pursuant to this section, including any plans offered by a State-approved or federally qualified health maintenance organization, shall contain benefits for expenses incurred in the following:

(1) Screening by blood lead measurement for lead poisoning for children, including confirmatory blood lead testing as specified by the Department of Health pursuant to section 7 of P.L.1995, c.316 (C.26:2-137.1); and medical evaluation and any necessary medical follow-up and treatment for lead poisoned children.

(2) All childhood immunizations as recommended by the Department of Health, which shall consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians. A carrier shall notify its insureds, in writing, of any change in the health care services provided with respect to childhood immunizations and any related changes in premium. Such notification shall be in a form and manner to be determined by the Commissioner of Banking and Insurance.

(3) Screening for newborn hearing loss by appropriate electrophysiologic screening measures and periodic monitoring of infants for delayed onset hearing loss, pursuant to P.L.2001, c.373 (C.26:2-103.1 et al.). Payment for this screening service shall be separate and distinct from payment for routine new baby care in the form of a newborn hearing screening fee as negotiated with the provider and facility.

The benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, except that a deductible shall not be applied for benefits provided pursuant to this subsection; however, with respect to a small employer health benefits plan that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), a deductible shall not be applied for any benefits that represent preventive care as permitted by that federal law, and shall not be applied as provided pursuant to section 16 of P.L.2005, c.248 (C.17B:27A-19.14). This subsection shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

l. The board shall consider including benefits for speech-language pathology and audiology services, as rendered by speech-language pathologists and audiologists within the scope of their practices, in at least one of the standard policies and in at least one of the five riders to be developed under this section.

m. Effective immediately for a health benefits plan issued on or after the effective date of P.L.2001, c.361 (C.17:48-6z et al.) and effective on the first 12-month anniversary date of a health benefits plan in effect on the effective date of P.L.2001, c.361 (C.17:48-6z et al.), the health benefits plans required pursuant to this section that provide benefits for expenses incurred in the purchase of prescription drugs shall provide benefits for expenses incurred in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula.

The benefits shall be provided to the same extent as for any other prescribed items under the health benefits plan.

This subsection shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

n. Effective immediately for a health benefits plan issued on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) and effective on the first 12-month anniversary date of a small employer health benefits plan in effect on the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), the health benefits plans required pursuant to this section that qualify as high deductible health plans for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), including any plans offered by a State-approved or federally qualified health maintenance organization, shall contain benefits for expenses incurred in connection with any medically necessary benefits provided in-network that represent preventive care as permitted by that federal law.

The benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, except that no deductible shall be applied for benefits provided pursuant to this subsection. This subsection shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19a Small employer carrier, offering of high deductible plan.

17. A small employer carrier, as a condition of transacting business in this State, may offer, on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), a health benefits plan pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), if that health benefits plan is offered to an eligible small employer that:

a. is a policy or contract holder prior to and on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) which does not qualify as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223);

b. is not a policy or contract holder on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) which does not qualify as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223) for a period of five years; or

c. was not a policy or contract holder under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) prior to the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.).

§ 17B:27A-19.1 Hospital confinement, other supplemental limited benefit insurance plans; requirements

10. a. A carrier shall not deliver or issue for delivery a hospital confinement or other supplemental limited benefit insurance plan unless the applicant for such coverage signs a statement on the application form that confirms that the applicant is already covered under a health benefits plan contract or policy. The application form shall be filed with the board on an informational basis.

b. A hospital confinement plan or other supplemental limited benefit insurance plan issued to a small employer or other group health benefits plan provider or to individual employees of a small employer or other group health benefits provider:

(1) shall be subject to the same rating requirements that apply to health benefits plans issued pursuant to paragraph (2) of subsection a. of section 9 of P.L.1992, c.162 (C.17B:27A-25), except that a hospital confinement plan and supplemental limited benefit insurance plan shall be subject to the commissioner's exclusive review and regulation with regard to loss ratios, medical underwriting and eligibility requirements, and form approval; and

(2) may include preexisting condition exclusions.

c. A health benefits plan shall not coordinate benefits against any hospital confinement or other supplemental limited benefit insurance plan.

§ 17B:27A-19.2 Coverage for birth and natal care; small employer health policy.

6. a. Every policy that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide benefits for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

b. Notwithstanding the provisions of subsection a. of this section, a policy that provides coverage for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child.

c. Every insurer shall provide notice to policyholders regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the policyholder; (2) the yearly informational packet sent to the policyholder; or (3) January 1, 1996.

§ 17B:27A-19.3 Regulations governing rating methodology, calculation of loss ratios

7. The commissioner, in consultation with the board, shall establish regulations governing the applicable rating methodology and manner in which loss ratios shall be calculated for health benefits plans permitted to be renewed or continued pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19). In establishing these regulations, the commissioner may consider, but shall not be limited to, the impact of allowing these health benefits plans to continue to be rated separately from the standard health benefits plans established pursuant to subsection a. of section 3 of P.L.1992, c.162 (C.17B:27A-19) and on their own claims experience. If the commissioner determines that the continuation of separate rating pools adversely affects the small employer insurance market and serves to counter the public policy goals which led to the enactment of P.L.1992, c.162 (C.17B:27A-17 et seq.), the commissioner shall develop a methodology which creates a linkage between the standard health benefits plans established pursuant to subsection a. of section 3 of P.L.1992, c.162 (C.17B:27A-19) and the plans permitted to be continued or renewed pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19) for the purpose of rating and loss ratio calculation.

Regulations established under the provisions of this section shall detail all additional obligations of carriers continuing or renewing health benefits plans pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19) which are necessary to meet the general requirements of P.L.1992, c.162 (C.17B:27A-17 et seq.).

The regulations shall be adopted pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) no later than 180 days following the effective date of this act. Until such time as the regulations are adopted, the health benefits plans shall continue to be rated and subject to the loss ratio calculations in accordance with applicable law in effect on the effective date of P.L.1995, c.340.

§ 17B:27A-19.4 Coverage for minimum inpatient care following mastectomy by small employer health benefits plan

7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide benefits for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The health benefits plan shall not require a health care provider to obtain authorization from the carrier for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

The provisions of this section shall not be construed to: require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate: or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the carrier under the health benefits plan.

The benefits shall be provided to the same extent as for any other sickness under the health benefits plan.

The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

b. The New Jersey Small Employer Health Benefits Program Board shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

§ 17B:27A-19.5 Applicability of Health Care Quality Act

23. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy or contract meets the requirements of P.L.1997, c.192 (C.26:2S-1 et al.) and regulations adopted thereto. The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.6 Coverage for treatment of inherited metabolic diseases by small employer health benefits plan.

7. No small employer health benefits plan subject to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the health benefits plan provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.

The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.7 Small employer health benefits plan to provide coverage for mental health conditions, substance use disorders; collaborative care model.

7. a. (1) Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide benefits for mental health conditions and substance use disorders under the same terms and conditions as provided for any other sickness under the health benefits plan and shall meet the requirements of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. s.18031(j), and any amendments to, and federal guidance or regulations issued under that act, including 45 C.F.R. Parts 146 and 147 and 45 C.F.R. s.156.115(a)(3).

Coverage provided pursuant to this section shall include benefits delivered through the psychiatric Collaborative Care Model.

(2) As used in this section:

"Mental health condition" means a condition defined to be consistent with generally recognized independent standards of current medical practice referenced in the current version of the Diagnostic and Statistical Manual of Mental Disorders.

"Psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method wherein a primary care provider and a care manager collaborate with a psychiatric consultant to provide care to a patient. "Psychiatric Collaborative Care Model" shall include those benefits that are billed using the following list of Current Procedural Terminology (CPT) codes, which list shall be updated by the Commissioner of Banking and Insurance whenever the codes are altered or supplemented:

(a) 99492 - Initial psychiatric collaborative care management;

(b) 99493 - Subsequent psychiatric collaborative care management; and

(c) 99494 - Initial or subsequent psychiatric collaborative care management, additional time.

"Same terms and conditions" means that the plan cannot apply more restrictive non-quantitative limitations, such as utilization review and other criteria or more quantitative limitations such as copayments, deductibles, aggregate or annual limits or benefit limits to mental health condition and substance use disorder benefits than those applied to substantially all other medical or surgical benefits.

"Substance use disorder" means a disorder defined to be consistent with generally recognized independent standards of current medical practice referenced in the most current version of the Diagnostic and Statistical Manual of Mental Disorders.

b. (Deleted by amendment, P.L.2019, c.58)

c. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

d. Nothing in this section shall reduce the requirement for a plan to provide benefits pursuant to section 7 of P.L.2017, c.28 (C.17B:27A-19.25).

§ 17B:27A-19.8 Coverage for hemophilia services by small employer plan

5. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the policy or contract meets the requirements of sections 1 and 2 of P.L.2000, c.121 (C.26:2S-10.1 and C.26:2S-10.2) and the regulations adopted thereto. The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.9 Small employer health benefits plan to provide coverage for colorectal cancer screening.

7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recently published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person.

b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force.

c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

d. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.10 Policy, contract issued under C.17B:27A-17 et seq. required to cover certain out-of-network services.

5. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy or contract meets the requirements of P.L.2001, c.367 (C.26:2S-6.1 et al.). The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.11 Carrier offering plans pursuant to C.17B:27A-17 et seq. may offer additional plan with certain limited benefits.

5. In addition to the standard health benefits plans offered by a carrier on the effective date of this act, a carrier that writes small employer health benefits plans pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) may also offer one or more of the plans through the carrier's network of providers, with no reimbursement for any out-of-network benefits other than emergency care, urgent care, and continuity of care. A carrier's network of providers shall be subject to review and approval or disapproval by the Commissioner of Banking and Insurance, in consultation with the Commissioner of Health, pursuant to regulations promulgated by the Department of Banking and Insurance, including review and approval or disapproval before plans with benefits provided through a carrier's network of providers pursuant to this section may be offered by the carrier. Policies or contracts written on this basis shall be rated in a separate rating pool for the purposes of establishing a premium, but for the purpose of determining a carrier's losses, these policies or contracts shall be aggregated with the losses on the carrier's other business written pursuant to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.).

§ 17B:27A-19.12 Small employer health benefits plan to offer coverage for domestic partner.

54. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State on or after the effective date of P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to a covered person for a covered person's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3).

The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.13 Small employer health benefits plan, mammogram examination benefits.

8. a. Every small employer health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in conducting:

(1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and

(2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the carrier of the medical necessity of the additional screening and diagnostic testing.

b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

c. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.14 High deductible health plan, small employer, deductible inapplicable, certain circumstances.

16. Notwithstanding the provisions of subsection k. of section 3 of P.L.1992, c.162 (C.17B:27A-19) regarding deductibles for a high deductible health plan, a health benefits plan offered pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall not apply a deductible for any benefits for which a deductible is not applicable pursuant to any law enacted after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.). This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.15 Small employer health benefits plan, coverage for contraceptives.

8. a. A small employer health benefits plan required pursuant to section 3 of P.L.1992, c.162 (C.17B:27A-19) shall provide coverage for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:

(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:

(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.

(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration.

(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.

(2) Voluntary male and female sterilization.

(3) Patient education and counseling on contraception.

(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:

(a) Management of side effects;

(b) Counseling for continued adherence to a prescribed regimen;

(c) Device insertion and removal;

(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and

(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.

b. The coverage provided shall include prescriptions for dispensing contraceptives for:

(1) (Deleted by amendment, P.L.2021, c.376)

(2) up to a 12-month period at one time.

c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the health benefits plan, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.

(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).

d. This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.

§ 17B:27A-19.16 Coverage for certain dependents until age 31 by small employer health benefits plan.

5. a. As used in this section, "dependent" means a covered person's child by blood or by law who:

(1) is 30 years of age or younger;

(2) is unmarried;

(3) has no dependent of his own;

(4) is a resident of this State or is enrolled as a full-time student at an accredited public or private institution of higher education; and

(5) (a) is not actually provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan or health benefits plan, or entitled to benefits under Title XVIII of the Social Security Act, Pub.L.74-271 (42 U.S.C. s.1395 et seq.) at the time dependent coverage pursuant to this section begins or will begin; and

(b) there is evidence of prior, creditable coverage or receipt of benefits under a benefits plan or by law as set forth in subparagraph (a) of this paragraph.

b. (1) A small employer health benefits plan that provides coverage for a covered person's dependent under which coverage of the dependent terminates at a specific age on or before the dependent's 30th birthday, and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this section of P.L.2008, c.38, shall, upon application of the dependent as set forth in subsection c. of this section, provide coverage to the dependent after that specific age, until the dependent's 31st birthday.

(2) Nothing herein shall be construed to require:

(a) coverage for services provided to a dependent before the effective date of this section of P.L.2008, c.38; or

(b) that an employer pay all or part of the cost of coverage for a dependent as provided pursuant to this section.

c. (1) A dependent covered by a covered person's plan, which coverage under the plan terminates at a specific age on or before the dependent's 30th birthday, may make a written election for coverage as a dependent pursuant to this section, until the dependent's 30th birthday:

(a) within 30 days prior to the termination of coverage at the specific age provided in the plan;

(b) within 30 days after meeting the requirements for dependent status as set forth in subsection a. of this section, when coverage for the dependent under the plan previously terminated; or

(c) during a 30-day period in each year following the year coverage terminates at the specific age as provided in the plan, which period shall begin on the anniversary date on which the dependent's coverage terminates at the specific age as provided in the plan, if the dependent meets the requirements for dependent status as set forth in subsection a. of this section during the 30-day period.

(2) (Deleted by amendment, P.L.2008, c.38)

d. (1) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall consist of coverage which is identical to the coverage provided to that dependent prior to the termination of coverage at the specific age provided in the plan. If coverage is modified under the plan for any similarly situated dependents for coverage prior to the termination of coverage at the specific age provided in the plan, the coverage shall also be modified in the same manner for the dependent.

(2) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall not be conditioned upon, or discriminate on the basis of, lack of evidence of insurability.

e. (1) The covered person's plan may require payment of a premium by the covered person or dependent, as appropriate, subject to the approval of the Commissioner of Banking and Insurance, for any period of coverage relating to a dependent's written election for coverage pursuant to subsection c. of this section. The premium shall not exceed 102% of the applicable portion of the premium previously paid for that dependent's coverage under the plan prior to the termination of coverage at the specific age provided in the plan.

(2) The applicable portion of the premium previously paid for the dependent's coverage under the plan shall be determined pursuant to regulations promulgated by the Commissioner of Banking and Insurance, based upon the difference between the plan's rating tiers for adult and dependent coverage or family coverage, as appropriate, and single coverage, or based upon any other formula or dependent rating tier deemed appropriate by the commissioner which provides a substantially similar result.

(3) Payments of the premium may, at the election of the payor, be made in monthly installments.

f. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following:

(1) the date upon which the dependent is disqualified for dependent status as set forth in subsection a. of this section;

(2) the date upon which coverage ceases under the plan by reason of a failure to make a timely payment of any premium required under the plan by the covered person or dependent for coverage provided pursuant to this section. The payment of any premium shall be considered to be timely if made within 30 days after the due date or within a longer period as may be provided for by the plan; or

(3) the date upon which the plan, under which coverage is provided to a dependent, ceases to provide coverage to the covered person.

Nothing herein shall be construed to permit a carrier to refuse a written election for coverage by a dependent pursuant to subsection c. of this section, based upon the dependent's prior disqualification pursuant to paragraph (1) of this subsection, other than a disqualification based on age or lack of evidence of prior, creditable coverage or receipt of benefits.

g. Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to a covered person by the carrier:

(1) in the certificate of coverage or other equivalent document prepared for covered persons and delivered on or about the date of commencement of the covered persons' coverage; and

(2) (Deleted by amendment, P.L.2008, c.38)

(3) in a notice delivered to covered persons on a quarterly basis.

h. This section shall apply to those plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.17 Small employer health benefits plans to provide benefits for orthotic and prosthetic appliances.

7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

(2) an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, if the covered person's physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports.

As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3), "licensed podiatrist" has the meaning assigned to it in R.S.45:5-1 et seq., and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18).

b. On and after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), a small employer health benefits plan shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

d. The provisions of this section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.18 Small employer health benefits plan to provide coverage for hearing aids, cochlear implant for covered persons.

8. a. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of this act, shall provide coverage for medically necessary expenses incurred in the purchase of a hearing aid or cochlear implant for a covered person, as provided in this section.

b. A health benefits plan shall provide coverage that includes the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. A carrier may limit the benefit provided in this section to one hearing aid for each hearing-impaired ear every 24 months.

c. A small employer health benefits plan shall provide coverage of the cost of treatment related to cochlear implants, including procedures for the implantation of cochlear devices and costs for any parts, attachments, or accessories of the device, including replacement of obsolete external cochlear implant processors.

d. The benefits shall be provided to the same extent as for any other condition under the health benefits plan.

e. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.19 Small employer health benefits plan to provide installment payments to obstetrical provider for maternity services.

7. a. Every small employer health benefits plan that provides benefits for maternity services, and that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide for reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a covered person's pregnancy.

b. For the purposes of this section, "obstetrical provider licensed in New Jersey" means:

(1) an obstetrician/gynecologist licensed by the State Board of Medical Examiners; or

(2) a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife.

c. This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.20 Small employer health benefits plan to provide benefits for treatment of autism or other developmental disability.

7. Notwithstanding any other provision of law to the contrary, a small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, renewed, or approved for issuance or renewal in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

a. The carrier shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability.

b. When the covered person's primary diagnosis is autism or another developmental disability, the carrier shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.

c. When the covered person is under 21 years of age and the covered person's primary diagnosis is autism, the carrier shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.

(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

(c) The adjusted maximum benefit amount shall apply to a health benefits plan that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

(d) Notwithstanding the provisions of this paragraph to the contrary, a carrier shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The carrier may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the carrier and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.

e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.

f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

g. The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.

h. The provisions of this section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.21 Small employer health benefits plan to provide coverage for oral anticancer medications.

7. a. A small employer health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of this act, shall provide coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis no less favorable than the plan provides for intravenously administered or injected anticancer medications.

b. Pursuant to subsection a. of this section, coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medications.

c. A small employer health benefits plan shall not achieve compliance with the provisions of this section by imposing an increase in patient cost sharing, including any copayment, deductible or coinsurance, for anticancer medications, whether intravenously administered or injected or orally administered, that are covered under the plan as of the effective date of this act.

d. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.22 Small employer health benefits plan to provide coverage for sickle cell anemia.

8. Every small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide coverage for medical expenses incurred by a covered person for the treatment of sickle cell anemia and, if the plan provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the plan shall provide coverage for prescription drug expenses incurred by a covered person for the treatment of sickle cell anemia.

The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.23 Small employer health benefits plan to provide coverage for prescription eye drops.

7. a. A small employer health benefits plan which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services, provided that:

(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and

(2) the refill requested by the subscriber or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.

b. The provisions of this section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.24 Small employer health benefits plan, coverage for synchronization of prescribed medications.

8. a. Every small employer health benefits plan delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State on or after the effective date of this act, which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall, on at least one occasion per year for each covered person:

(1) apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a 30 days' supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person's chronic medications;

(2) provide coverage for a drug prescribed for the treatment of a chronic illness dispensed in accordance with a plan among the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and

(3) determine dispensing fees based exclusively on the total number of prescriptions dispensed; dispensing fees shall not be prorated or based on the number of the days' supply of medication prescribed or dispensed.

b. This section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

c. This section shall not apply to prescriptions for opioid analgesics. "Opioid analgesic" means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.

§ 17B:27A-19.24a Carrier, small-employer health benefits plan, prescription drug formulary, flexibility, limitations.

9. a. Except as provided in subsection b. of this section, a carrier that offers a small employer health benefits plan that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), may use a prescription drug formulary to limit or exclude coverage for prescription drugs, provided that the carrier offers at least one plan with an open formulary and the carrier demonstrates to the satisfaction of the board that utilization and medical review panels are in place to allow formulary flexibility as necessary in the best interest of the insured person.

b. A carrier that offers a small employer health benefits plan that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), shall not adopt a protocol, policy, or program that establishes the specific sequence in which prescription drugs for a specified medical condition, and medically appropriate for a particular patient, are required to be administered in order to be covered by a health benefits plan.

c. Notwithstanding the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to the contrary, the department shall, as appropriate and no later than in time for plan year 2025, update rules and regulations to ensure consistency with the provisions of this section and P.L.2023, c.194 (C.17B:27A-33.1 et al.) immediately upon filing with the Office of Administrative Law. The rules and regulations adopted pursuant to this subsection shall be in effect only for plan year 2025. The rules and regulations shall thereafter be adopted, amended, or readopted for plan years 2026 and thereafter by the department in accordance with the requirements of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

§ 17B:27A-19.24b Carrier, prescription drug formulary, exceptions and appeals process.

10. a. A carrier that uses a prescription drug formulary pursuant to section 9 of P.L.2023, c.194 (C.17B:27A-19.24a) shall establish a clinically sound and well-communicated exceptions and appeals process, or incorporate into the carrier's existing appeals process, the requirements of this section.

b. The process shall provide insureds with step-by-step directions to initiate the exceptions and appeals process and, for a prescription drug that is nonpreferred, not require an insured who obtains that prescription drug to pay an amount greater than the cost-sharing tier level associated with the preferred prescription drug if the prescriber determines that therapeutically similar drug is medically inappropriate.

c. A carrier shall show cause before denying payment for a prescription drug when a prescriber has deemed the carrier's recommended substitute medically inappropriate.

d. An insured may apply to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) to appeal a carrier decision, and the program shall render a decision as promptly as the patient's condition mandates.

e. The department shall collect information from each carrier subject to this section to conduct an annual evaluation of the exceptions and appeals processes established pursuant to this section with regard to the appropriateness of the burden of the process on consumers and clinicians and the effects on patient health outcomes.

§ 17B:27A-19.25 Small employer health benefits plan to provide benefits for treatment of substance use disorder.

7. a. A small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide unlimited benefits for inpatient and outpatient treatment of substance use disorder at in-network facilities. The services for the treatment of substance use disorder shall be prescribed by a licensed physician, licensed psychologist, or licensed psychiatrist and provided by licensed health care professionals or licensed or certified substance use disorder providers in licensed or otherwise State-approved facilities, as required by the laws of the state in which the services are rendered.

b. The benefits for the first 180 days per plan year of inpatient and outpatient treatment of substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. The facility shall notify the carrier of both the admission and the initial treatment plan within 48 hours of the admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, a carrier shall provide necessary exceptions to their network to ensure admission in a treatment facility within 24 hours.

c. Providers of treatment for substance use disorder to persons covered under a covered health benefits plan shall not require pre-payment of medical expenses during this 180 days in excess of applicable co-payment, deductible, or co-insurance under the plan.

d. The benefits for outpatient visits shall not be subject to concurrent or retrospective review of medical necessity or any other utilization management review.

e. (1) The benefits for the first 28 days of an inpatient stay during each plan year shall be provided without any retrospective review or concurrent review of medical necessity and medical necessity shall be as determined by the covered person's physician.

(2) The benefits for days 29 and thereafter of inpatient care shall be subject to concurrent review as defined in this section. A request for approval of inpatient care beyond the first 28 days shall be submitted for concurrent review before the expiration of the initial 28-day period. A request for approval of inpatient care beyond any period that is approved under concurrent review shall be submitted within the period that was previously approved. No carrier shall initiate concurrent review more frequently than at two-week intervals. If a carrier determines that continued inpatient care in a facility is no longer medically necessary, the carrier shall within 24 hours provide written notice to the covered person and the covered person's physician of its decision and the right to file an expedited internal appeal of the determination pursuant to an expedited process pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.5, as applicable. The carrier shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered person and the covered person's physician. If the determination is to uphold the denial, the covered person and the covered person's physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.6, as applicable. An independent utilization review organization shall make a determination within 24 hours. If the carrier's determination is upheld and it is determined continued inpatient care is not medically necessary, the carrier shall remain responsible to provide benefits for the inpatient care through the day following the date the determination is made and the covered person shall only be responsible for any applicable co-payment, deductible and co-insurance for the stay through that date as applicable under the policy. The covered person shall not be discharged or released from the inpatient facility until all internal appeals and independent utilization review organization appeals are exhausted. For any costs incurred after the day following the date of determination until the day of discharge, the covered person shall only be responsible for any applicable cost-sharing, and any additional charges shall be paid by the facility or provider.

f. (1) The benefits for the first 28 days of intensive outpatient or partial hospitalization services shall be provided without any retrospective review of medical necessity and medical necessity shall be as determined by the covered person's physician.

(2) The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization services shall be subject to a retrospective review of the medical necessity of the services.

g. Benefits for inpatient and outpatient treatment of substance use disorder after the first 180 days per plan year shall be subject to the medical necessity determination of the carrier and may be subject to prior authorization or, retrospective review and other utilization management requirements.

h. Medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health.

i. The benefits for outpatient prescription drugs to treat substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements.

j. The first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange provided in this subsection.

k. Except as stated above, the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the health benefits plan.

l. The benefits required by this section are to be provided to all covered persons with a diagnosis of substance use disorder. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this section.

m. The provisions of this section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

n. The Attorney General's Office shall be responsible for overseeing any violations of law that may result from P.L.2017, c.28 (C.17:48-6nn et al.), including fraud, abuse, waste, and mistreatment of covered persons. The Attorney General's Office is authorized to adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations to implement any of the provisions of P.L.2017, c.28 (C.17:48-6nn et al.).

o. As used in this section:

"Concurrent review" means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and as appropriate, the discharge plans.

"Substance use disorder" is as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include substance use disorder withdrawal.

§ 17B:27A-19.26 Small employer health benefits plan to provide coverage regardless of gender identity, expression.

7. a. Notwithstanding any other law or regulation to the contrary, a small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance on or after the effective date of this act, shall not contain any provision that discriminates, and the carrier shall not discriminate, on the basis of a covered person's or prospective covered person's gender identity or expression or on the basis that the covered person or prospective covered person is a transgender person.

b. The discrimination prohibited by this section shall include:

(1) denying, cancelling, limiting or refusing to issue or renew a contract on the basis of a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person;

(2) demanding or requiring a payment or premium that is based in whole or in part on a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person;

(3) designating a covered person's or prospective covered person's gender identity or expression, or the fact that a covered person or prospective covered person is a transgender person, as a preexisting condition for which coverage will be denied or limited; or

(4) denying or limiting coverage, or denying a claim, for services including but not limited to the following, due to a covered person's gender identity or expression or for the reason that the covered person is a transgender person:

(a) health care services related to gender transition if coverage is available for those services under the contract when the services are not related to gender transition, including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training; or

(b) health care services that are ordinarily or exclusively available to individuals of one sex when the denial or limitation is due only to the fact that the covered person is enrolled as belonging to the other sex or has undergone, or is in the process of undergoing, gender transition.

c. For the purposes of this section:

"Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's assigned sex at birth.

"Gender identity" means a person's internal sense of their own gender, regardless of the sex the person was assigned at birth.

"Gender transition" means the process of changing a person's outward appearance, including physical sex characteristics, to accord with the person's actual gender identity.

"Transgender person" means a person who identifies as a gender different from the sex assigned to the person at birth.

d. The provisions of this section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

e. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service.

§ 17B:27A-19.27 Small employer health benefits plan to cover digital tomosynthesis of the breast.

7. a. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in conducting digital tomosynthesis to detect or screen for breast cancer in women 40 years of age and over; and for diagnostic purposes in women of any age.

b. In the case of digital tomosynthesis conducted to detect or screen for breast cancer in women 40 years of age and over, no deductible, coinsurance or other cost sharing shall be applied; and in the case of digital tomosynthesis conducted for diagnostic purposes in women of any age, the same deductibles, coinsurance, and other cost sharing as apply to similar services under the health benefits plan shall be applied.

c. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.28 Small employer health benefits plan to provide coverage for donated human breast milk.

7. a. A small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the provision of pasteurized donated human breast milk, which may include human milk fortifiers if indicated by the prescribing licensed medical practitioner, provided that:

(1) the covered person is an infant under the age of six months;

(2) the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health ; and

(3) a licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or

(4) a licensed medical practitioner has issued an order for an infant who meets any of the following conditions:

(a) a body weight below healthy levels determined by the licensed medical practitioner;

(b) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or

(c) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health.

b. The provisions of this section shall apply to those small employer health benefits plans in which the carrier has reserved the right to change the premium.

c. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service.

d. The benefits shall be provided to the same extent as for any other prescribed items under the plan.

e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the carrier shall not be required to provide coverage of expenses pursuant to this section.

§ 17B:27A-19.29 Small employer health benefits plan to provide coverage for breastfeeding support.

7. a. A small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2019, c.343 (C.17:48-6ss et al.), shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for health plan enrollees, with no cost-sharing.

b. Coverage of breastfeeding equipment shall include:

(1) Purchase of a single-user breast pump, subject to the following conditions:

(a) A plan shall cover the purchase of a double electric breast pump. If an enrollee requests a manual pump in lieu of the double electric breast pump, the health plan shall cover the purchase of a manual pump.

(b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding.

(c) A plan shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph.

(d) Coverage shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the plan enrollee.

(e) Coverage for breast pumps shall include repair or replacement if necessary.

(2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions:

(a) When recommended by a licensed health care provider, a plan shall provide coverage for a multi-user breast pump.

(b) A small employer health benefits plan may determine whether a rental or purchase is covered.

(c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump.

(d) A small employer health benefits plan may require a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump.

(3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider.

(4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the small employer health benefits plan cannot ensure an enrollee receives breastfeeding equipment within 48 hours, an enrollee may purchase the equipment and the health plan shall reimburse all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts.

(5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the small employer health benefits plan shall reimburse all out-of-pocket rental expenses incurred by an enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment.

c. Coverage of comprehensive lactation counseling and lactation consultation shall include:

(1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions:

(a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits.

(b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need.

(2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need.

(3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups.

(4) A plan shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting.

(5) A small employer health benefits plan shall not impose medical management techniques not described in this section.

d. Except as otherwise authorized pursuant to this section, a small employer health benefits plan shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided.

e. As used in this section:

"Cost-sharing" means deductible, co-insurance or co-payments, or similar charges.

"Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump.

"Lactation consultant" means an individual who is an International Board Certified Lactation Consultant.

"Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services.

Lactation care and services shall include, but not be limited to:

(1) lactation assessment through the systematic collection of subjective and objective data;

(2) analysis of data and creation of a plan of care;

(3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider;

(4) evaluation of outcomes;

(5) provision of lactation education to parents and health care providers; and

(6) the recommendation and use of assistive devices.

"Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as:

(1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding;

(2) acting as an advocate for breastfeeding as the norm for feeding infants and young children;

(3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals;

(4) using principles of adult education when teaching clients, health care providers, and others in the community; and

(5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately.

"Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is:

(1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or

(2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice.

"Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication.

f. This section shall apply to those plans in which the small employer health benefits plan has reserved the right to change the premium.

§ 17B:27A-19.30 Small employer health benefits plan to meet essential health benefits requirements.

2. a. A small employer health benefits plan subject to P.L.1992, c.162 (C.17B:27A-17 et seq.) shall provide coverage under every plan delivered, issued, executed or renewed in this State, on or after the effective date of this act, that meets the essential health benefits requirements provided by this section.

b. Pursuant to section 3 of P.L.2019, c.354 (C.17B:27A-60), the commissioner shall define essential health benefits to include at least the following general categories and the items and services covered within the categories:

(1) ambulatory patient services;

(2) emergency services;

(3) hospitalization;

(4) maternity and newborn care;

(5) mental health and substance use disorder services, including behavioral health treatment;

(6) prescription drugs;

(7) rehabilitative and habilitative services and devices;

(8) laboratory services;

(9) preventive and wellness services and chronic disease management; and

(10) pediatric services, including oral and vision care.

c. A small employer health benefits plan shall provide for a level of coverage that is designed to provide benefits that are actuarially equivalent to:

(1) 60 percent of the full actuarial value of the benefits provided under the plan;

(2) 70 percent of the full actuarial value of the benefits provided under the plan; or

(3) 80 percent of the full actuarial value of the benefits provided under the plan.

d. The level of coverage of a plan shall be determined on the basis that the essential health benefits described in subsection b. of this section are provided to a standard population, and without regard to the actual population to which the plan may provide benefits.

e. The commissioner shall develop guidelines to provide for a de minimis variation in the actuarial calculations used in determining the level of coverage of a plan to account for differences in actuarial estimates.

§ 17B:27A-19.31 Small employer health benefits plan to cover preventive services.

7. a. An small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage, without requiring any cost sharing, for the following preventive services:

(1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;

(2) immunizations that have in effect a recommendation from the Department of Health, which shall in making its recommendations consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians;

(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

(4) with respect to women, any additional preventive care and screenings not described in paragraph (1) as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

b. (1) Except as provided in paragraph (2) of this subsection, nothing in this section shall:

(a) require a plan which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or

(b) preclude a plan which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider.

(2) If a plan does not have in its network a provider who can provide an item or service described in subsection a. of this section, the plan shall cover the item or service when performed by an out-of-network provider and shall not impose cost sharing with respect to that item or service.

c. (1) A plan shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued.

(2) (a) Except as provided in subparagraph (b) of this paragraph, a plan that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year.

(b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section.

d. This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

e. With respect to an annual wellness visit for a covered member who is over three years of age, a carrier is required to cover only one wellness visit per plan year or calendar year, as provided for under the health benefits plan contract, but may not impose a waiting period for the wellness visit.

§ 17B:27A-19.32 Small employer health benefits plan to provide certain coverage for prescription drugs.

7. a. Notwithstanding any other provision of law to the contrary, a carrier that offers a small employer health benefits plan that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), shall ensure that at least 25 percent of all plans, or at least one plan if the carrier offers less than four plans, offered by the carrier in each rating area and in each of the bronze, silver, gold, and platinum levels of coverage, in the small employer market pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), shall conform with the following:

(1) (a) a health benefits plan that provides a silver, gold, or platinum level of coverage, as defined in 45 C.F.R. s.156.140, shall limit a covered person's cost-sharing, including any copayment or coinsurance, for prescription drugs, including specialty drugs, to no more than $150 per month for each prescription drug for up to a 30-day supply of any single drug;

(b) a health benefits plan that provides a bronze level of coverage, as defined in 45 C.F.R. s.156.140, shall ensure that any required covered person's cost-sharing, including any copayment or coinsurance, does not exceed $250 per month for each prescription drug for up to a 30-day supply of any single drug;

(c) a health benefits plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall be exempt from the requirements of subparagraphs (a) and (b) of this paragraph;

(2) except as provided in paragraph (3) of this subsection, the limits described in paragraph (1) of this subsection shall apply at any point in the benefit design, including before and after any applicable deductible is reached; and

(3) for prescription drug benefits offered in conjunction with a high-deductible health plan, the plan shall not provide prescription drug benefits until the expenditures applicable to the deductible under the plan have met the amount of the minimum annual deductibles in effect for self-only and family coverage under section 223(c)(2)(A)(i) of the federal Internal Revenue Code (26 U.S.C. s.223(c)(2)(A)(i)) for self-only and family coverage, respectively. Once the foregoing expenditure amount has been met under the plan, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in paragraph (1) of this subsection.

b. The provisions of this section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.33 Small employer health benefits plan to cover adolescent depression screenings.

7. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of this act, shall provide coverage for expenses incurred in screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service.

The benefits shall be provided to the same extent as for any other condition under the health benefits plan, except that the carrier shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance.

This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.34 Small employer health benefits plan to cover newborn home nurse visitation.

11. a. Every small employer health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159). The plan shall:

(1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159);

(2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant;

(3) ensure that the plan does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and

(4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing:

(a) a value-based payment methodology;

(b) an invoice claim process;

(c) a capitated payment arrangement;

(d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or

(e) any other payment arrangement agreed to by the carrier and an agency or organization providing services under the program.

b. Any copayment, coinsurance, or deductible that may be required under the health benefits plan for such services shall be waived.

c. Every carrier that is subject to the provisions of this section shall submit to the Department of Banking and Insurance, in a form and manner prescribed by the department, a report on the claims submitted for services provided under the newborn home nurse visitation program.

The information contained in the report shall be shared with the Department of Children and Families and used by that department to assess the newborn home nurse visitation program pursuant to subsection a. of section 4 of P.L.2021, c.187 (C.26:2H-161).

d. (1) Except as provided in paragraphs (2) and (3) of this subsection, the contract shall specify that no deductible, coinsurance, copayment, or any other cost-sharing requirement may be imposed on the coverage required pursuant to this section.

(2) A small employer health benefits plan that qualifies as a high deductible health plan shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement permitted for a high deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).

(3) A small employer health benefits plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement to the extent permitted for a catastrophic plan under federal law.

e. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.35 Small employer health benefits plan, coverage, insulin for diabetes treatment.

22. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide coverage to an enrollee or other person covered thereunder for insulin for the treatment of diabetes, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

The benefits shall be provided to the same extent as for any other condition under the health benefits plan.

This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.36 Small employer health benefits plan, coverage, epinephrine auto-injector device.

23. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide coverage for at least one epinephrine auto-injector device, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of an epinephrine auto-injector device shall not be subject to any deductible, and no copayment or coinsurance for the purchase of an epinephrine auto-injector device shall exceed $25 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

Nothing in this section shall prevent a carrier from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section.

The benefits shall be provided to the same extent as for any other condition under the health benefits plan.

This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.37 Small employer health benefits plan, coverage, prescription asthma inhaler.

24. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide benefits to an enrollee or other person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.

Nothing in this section shall prevent a carrier from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section.

The benefits shall be provided to the same extent as for any other condition under the health benefits plan.

This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

§ 17B:27A-19.38 Biomarker precision medical testing coverage, small employer health benefits plans.

7. a. Each small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or is approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide benefits for biomarker precision medical testing, as defined by subsection g. of this section.

b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of a covered person when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for a covered person's disease or condition is recognized by:

(1) labeled indications for an FDA-approved or -cleared test;

(2) indicated tests for an FDA-approved drug;

(3) actions to address warnings and precautions on FDA-approved drug labels;

(4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or

(5) nationally recognized clinical practice guidelines.

c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of a covered person.

d. (1) If utilization review is required, a carrier shall provide a decision pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.).

(2) The covered person and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the covered person shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination.

e. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan, including determinations of clinical review criteria used for utilization review of health care services along with copayment, deductible, and coinsurance provisions.

f. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

g. As used in this section:

"Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression.

"Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing.

"Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. The guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.

§ 17B:27A-19.39 Small employer health benefits plan, HIV preexposure prophylaxis, HIV postexposure prophylaxis.

9. a. (1) Except as provided in paragraph (2) of this subsection, every small employer health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L.2025, c.196 (C.45:14-67.13) without requiring prior authorization or step therapy.

(2) If the federal Food and Drug Administration has authorized or approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the plan to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy.

b. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the small employer health benefits plan to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria:

(1) the service or procedure is within the scope of practice of the treating pharmacist; and

(2) the service or procedure would otherwise be covered under the plan if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant.

c. A small employer health benefits plan shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the plan to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service.

d. A small employer health benefits plan shall not:

(1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and

(2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L.2025, c.196 (C.45:14-67.13) in excess of a 90-day supply for a single patient within a given two year period.

e. Nothing in this section shall be construed to require a small employer health benefit plan to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit.

f. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

g. As used in this section:

“HIV preexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12).

“HIV postexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12).

“Step therapy” means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits.

§ 17B:27A-19.40 Benefits provided under small employer health benefits plans.

8. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2025, c.200 (C. 17:48-6bbb et al.), shall provide benefits to any person covered thereunder for expenses incurred in obtaining medically necessary treatment for women with a diagnosis of perimenopause, menopause, and symptoms associated with perimenopause and menopause, including, but not limited to:

(1) hormonal therapies such as hormone replacement therapy and bioidentical hormone treatments;

(2) non-hormonal treatments, including medications to manage menopausal symptoms;

(3) behavioral health care services;

(4) pelvic floor physical therapy;

(5) bone health treatments, including screenings and medications due to hormonal changes related to perimenopause and menopause;

(6) preventative services that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force for early detection and treatment of health conditions related to perimenopause and menopause such as osteoporosis and cancer; and

(7) counseling and education regarding menopause management.

b. A small employer health benefits plan shall provide clear and accessible information to a covered person regarding covered perimenopause and menopause treatments.

c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

d. The provisions of this section shall apply to all enrollee agreements in which the insurer has reserved the right to change the premium.

e. As used in this section:

“Menopause” means the permanent end of a female’s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period.

“Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles.

§ 17B:27A-20 Coinsurance, deductibles applicable

4. Plans required to be offered under P.L.1992, c.162 (C.17B:27A-17 et seq.) may be subject to coinsurance and deductibles, which may vary by selected portions of the coverage. The department and the boards of directors of the New Jersey Individual Health Coverage Program and New Jersey Small Employer Health Benefits Program may promulgate regulations to create standard plans or plan design requirements. The standard plans or plan design requirements may include minimum cost-sharing standards, provided that the standards enable carriers to design and offer plans for the bronze, silver, gold, and platinum metal levels as defined under the actuarial value calculations pursuant to the federal "Patient Protection and Affordable Care Act," Pub.L.111-148, as amended by the "Health Care and Education Reconciliation Act of 2010," Pub.L.111-152. In promulgating these regulations, the commissioner and boards of directors shall consider the best interests of consumers, the health of the markets, and plan design that promotes utilization of high value primary and preventative care to improve the health of the State's population. Any minimum standard regulations and standard plans promulgated by the commissioner or boards of directors pursuant to this section shall be reviewed and adjusted annually to achieve the goals of this section.

§ 17B:27A-20.1 Rules, regulations.

11. The department shall, no later than in time for plan year 2025 and immediately upon filing with the Office of Administrative Law, adopt rules and regulations, notwithstanding the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to the contrary, requiring no additional limitations on copayments, coinsurance, or deductibles for small employer health benefits plans pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) beyond those set forth in the federal Patient Protection and Affordable Care Act, Pub.L.111-148, as amended by the federal "Health Care and Education Reconciliation Act of 2010," Pub.L.111-152 for plans issued pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.). The rules and regulations adopted pursuant to this section shall be in effect only for plan year 2025. Rules and regulations shall thereafter be adopted, amended, or readopted for plan years 2026 and thereafter by the department in accordance with the requirements of section 4 of P.L.1992, c.162 (C.17B:27A-20) and the requirements of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

§ 17B:27A-21 Standard coordination of benefits provisions applicable

5. Coverage provided pursuant to this act shall be subject to standard coordination of benefits provisions for all persons covered under the policy or contract. Notwithstanding the provision of any other law to the contrary, the health benefits plan with the lowest actuarial value provided under this act shall not extend to any injury for which coverage is available or applicable pursuant to section 4 of P.L.1972, c.70 (C.39:6A-4), and that health benefits plan shall not be used as a substitute for any insurance required to be maintained pursuant to section 4 of P.L.1972, c.70 (C.39:6A-4).

§ 17B:27A-21.1 Eligibility for enrollment in small employer health benefits plan

5. Notwithstanding any other provision of law to the contrary, a carrier shall not consider a person's eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the equivalent statute in another state, when determining the person's eligibility for enrollment in, or the provision of benefits under, a small employer health benefits plan delivered, issued or executed in this State.

§ 17B:27A-22 Preexisting condition provisions.

6. a. No health benefits plan subject to this act shall include any provision excluding coverage for a preexisting condition regardless of the cause of the condition.

b. (Deleted by amendment, P.L.2019, c.353)

c. (Deleted by amendment, P.L.2019, c.353)

§ 17B:27A-23 Policies, contracts renewable; exceptions.

7. Every policy or contract issued to small employers in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) shall be renewable with respect to all eligible employees or dependents at the option of the policy or contract holder, or small employer except that a carrier may discontinue or not renew a health benefits plan in accordance with the provisions of this section:

a. A carrier may discontinue such coverage 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;

b. (Deleted by amendment, P.L.1997, c.146).

c. The number of employees covered under the health benefits plan is less than the number or percentage of employees required by participation requirements under the health benefits policy or contract;

d. Noncompliance with a carrier's employment contribution requirements;

e. Any carrier doing business pursuant to the provisions of P.L.1992, c.162 (C17B:27A-17 et seq.) ceases doing business in the small employer market if the following conditions are satisfied:

(1) The carrier gives notice to cease doing business in the small employer market to the commissioner not later than eight months prior to the date of the planned withdrawal from the small employer market, during which time the carrier shall continue to be governed by P.L.1992, c.162 (C.17B:27A-17 et seq.) with respect to business written pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) For the purposes of this subsection, "date of withdrawal" means the date upon which the first notice to small employers is sent by the carrier pursuant to paragraph (2) of this subsection;

(2) No later than two months following the date of the notification to the commissioner that the carrier intends to cease doing business in the small employer market, the carrier shall mail a notice to every small business employer insured by the carrier and all covered persons that the policy or contract of insurance will not be renewed. This notice shall be sent by certified mail to the small business employer not less than six months in advance of the effective date of the nonrenewal date of the policy or contract;

(3) (Deleted by amendment, P.L.2023, c.194).

f. In the case of policies or contracts issued in connection with membership in an association or trust of employers, an employer ceases to maintain its membership in the association or trust, but only if such coverage is terminated under this provision uniformly without regard to any health status-related factor relating to any covered individual;

g. (Deleted by amendment, P.L.1995, c.50).

h. A decision by the small employer carrier to cease offering and not renew a particular type of group health benefits plan in the small employer market, if the board discontinues a standard health benefits plan or as permitted or required pursuant to subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19), and pursuant to the regulations adopted by the commissioner;

i. In the case of a health maintenance organization plan issued to a small employer:

(1) an eligible person who no longer resides, lives, or works in the carrier's approved service area, but only if coverage is terminated under this paragraph uniformly without regard to any health status-related factor of covered individuals; or

(2) a small employer that no longer has any enrollee in connection with such plan who lives, resides, or works in the service area of the carrier and the carrier would deny enrollment with respect to such plan pursuant to subsection a. of section 10 of P.L.1992, c.162 (C.17B:27A-26).

§ 17B:27A-24 Reasonable specified minimum participation.

8. Any small employer carrier may require a reasonable specified minimum participation of eligible employees, which shall not exceed 75%, or reasonable minimum employer contributions in determining whether to accept a small group pursuant to this act. The standards so established by the carrier shall be first approved by the board and shall be applied uniformly to all small groups, except that in no event shall a carrier require an employer to contribute more than 10% to the annual cost of the policy or contract, or an amount as otherwise provided by the board, and any minimum participation standards established by the carrier shall be reasonable. In establishing the percentage of employee participation, a one-to-one credit shall be given for each employee covered by a spouse's health benefits coverage, Medicare, Medicaid, NJ FamilyCare or another group health benefits plan. In calculating an employer's participation, the carrier shall include all insured employees, regardless of whether the employees chose an indemnity plan or a health maintenance organization, or a combination thereof.

§ 17B:27A-25 Premium rates; other plan requirements.

9. a. (1) (Deleted by amendment, P.L.1997, c.146).

(2) (Deleted by amendment, P.L.1997, c.146).

(3) (a) For all policies or contracts providing health benefits plans for small employers issued pursuant to section 3 of P.L.1992, c.162 (C.17B:27A-19), and including policies or contracts offered by a carrier to a small employer who is a member of a Small Employer Purchasing Alliance pursuant to the provisions of P.L.2001, c.225 (C.17B:27A-25.1 et al.) the premium rate charged by a carrier to the highest rated small group purchasing a small employer health benefits plan issued pursuant to section 3 of P.L.1992, c.162 (C.17B:27A-19) shall not be greater than 200% of the premium rate charged for the lowest rated small group purchasing that same health benefits plan; provided, however, that the only factors upon which the rate differential may be based are age, gender and geography. Such factors shall be applied in a manner consistent with regulations adopted by the commissioner. For the purposes of this paragraph (3), policies or contracts offered by a carrier to a small employer who is a member of a Small Employer Purchasing Alliance shall be rated separately from the carrier's other small employer health benefits policies or contracts.

(b) A health benefits plan issued pursuant to subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19) shall be rated in accordance with the provisions of section 7 of P.L.1995, c.340 (C.17B:27A-19.3), for the purposes of meeting the requirements of this paragraph.

(4) (Deleted by amendment, P.L.1994, c.11).

(5) Any policy or contract issued after January 1, 1994 to a small employer who was not previously covered by a health benefits plan issued by the issuing small employer carrier, shall be subject to the same premium rate restrictions as provided in paragraph (3) of this subsection, which rate restrictions shall be effective on the date the policy or contract is issued.

(6) The board shall establish, pursuant to section 17 of P.L.1993, c.162 (C.17B:27A-51):

(a) up to six geographic territories, none of which is smaller than a county; and

(b) age classifications which, at a minimum, shall be in five-year increments.

b. (Deleted by amendment, P.L.1993, c.162).

c. (Deleted by amendment, P.L.1995, c.298).

d. Notwithstanding any other provision of law to the contrary, P.L.1992, c.162 (C.17B:27A-17 et seq.) shall apply to a carrier which provides a health benefits plan to one or more small employers through a policy issued to an association or trust of employers.

A carrier which provides a health benefits plan to one or more small employers through a policy issued to an association or trust of employers after the effective date of P.L.1992, c.162 (C.17B:27A-17 et seq.), shall be required to offer small employer health benefits plans to non-association or trust employers in the same manner as any other small employer carrier is required pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.).

e. Nothing contained herein shall prohibit the use of premium rate structures to establish different premium rates for individuals and family units.

f. No insurance contract or policy subject to P.L.1992, c.162 (C.17B:27A-17 et seq.), including a contract or policy entered into with a small employer who is a member of a Small Employer Purchasing Alliance pursuant to the provisions of P.L.2001, c.225 (C.17B:27A-25.1 et al.), may be entered into unless and until the carrier has made an informational filing with the commissioner of a schedule of premiums, not to exceed 12 months in duration, to be paid pursuant to such contract or policy, of the carrier's rating plan and classification system in connection with such contract or policy, and of the actuarial assumptions and methods used by the carrier in establishing premium rates for such contract or policy.

g. (1) Beginning January 1, 1995, a carrier desiring to increase or decrease premiums for any policy form or benefit rider offered pursuant to subsection i. of section 3 of P.L.1992, c.162 (C.17B:27A-19) subject to P.L.1992, c.162 (C.17B:27A-17 et seq.) may implement such increase or decrease upon making an informational filing with the commissioner of such increase or decrease, along with the actuarial assumptions and methods used by the carrier in establishing such increase or decrease, provided that the anticipated minimum loss ratio for all policy forms shall not be less than 80% of the premium, calculated based on a three-year rolling average, therefor as provided in paragraph (2) of this subsection. The commissioner may disapprove any informational filing on a finding that it is incomplete and not in substantial compliance with P.L.1992, c.162 (C.17B:27A-17 et seq.), or that the rates are inadequate or unfairly discriminatory. Until December 31, 1996, the informational filing shall also include the carrier's rating plan and classification system in connection with such increase or decrease.

(2) Each calendar year, a carrier shall return, in the form of aggregate benefits for all of the standard policy forms offered by the carrier pursuant to subsection a. of section 3 of P.L.1992, c.162 (C.17B:27A-19), at least 80% of the aggregate premiums collected for all of the standard policy forms, other than alliance policy forms, and at least 80% of the aggregate premiums collected for all of the non-standard policy forms during that calendar year. A carrier shall return at least 80% of the premiums collected for all of the alliances during that calendar year, which loss ratio may be calculated in the aggregate for all of the alliances or separately for each alliance. Carriers shall annually report, no later than August 1st of each year, the loss ratio calculated pursuant to this section for all of the standard, other than alliance policy forms, non-standard policy forms and alliance policy forms for the previous calendar year, provided that a carrier may annually report the loss ratio calculated pursuant to this section for all of the alliances in the aggregate or separately for each alliance. The loss ratio for the previous year shall be calculated based on a three-year rolling average. In each case where the loss ratio fails to substantially comply with the 80% loss ratio requirement, the carrier shall issue a dividend or credit against future premiums for all policyholders with the standard, other than alliance policy forms, nonstandard policy forms or alliance policy forms, as applicable, in an amount sufficient to assure that the aggregate benefits paid in the previous calendar year plus the amount of the dividends and credits shall equal 80% of the aggregate premiums collected for the respective policy forms in the previous calendar year. All dividends and credits must be distributed by December 31 of the year following the calendar year in which the loss ratio requirements were not satisfied. The annual report required by this paragraph shall include a carrier's calculation of the dividends and credits applicable to standard, other than alliance policy forms, non-standard policy forms and alliance policy forms, as well as an explanation of the carrier's plan to issue dividends or credits. The instructions and format for calculating and reporting loss ratios and issuing dividends or credits shall be specified by the commissioner by regulation. Such regulations shall include provisions:

(a) for the distribution of a dividend or credit in the event of cancellation or termination by a policyholder; and

(b) requiring a carrier's minimum loss ratio to be calculated by aggregating the data for a three-year period which includes the data for the previous calendar year whose minimum loss ratio is being calculated, including three months of runout through the first quarter of the subsequent year and the data for the two years immediately preceding the year for which the minimum loss ratio is being calculated.

For purposes of this paragraph, "alliance policy forms" means policies purchased by small employers who are members of Small Employer Purchasing Alliances.

(3) The loss ratio of a health benefits plan issued pursuant to subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19) shall be calculated in accordance with the provisions of section 7 of P.L.1995, c.340 (C.17B:27A-19.3), for the purposes of meeting the requirements of this subsection.

h. (Deleted by amendment, P.L.1993, c.162).

i. The provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) shall apply to health benefits plans which are delivered, issued for delivery, renewed or continued on or after January 1, 1994.

j. (Deleted by amendment, P.L.1995, c.340).

k. A carrier who negotiates a reduced premium rate with a Small Employer Purchasing Alliance for members of that alliance shall provide a reduction in the premium rate filed in accordance with paragraph (3) of subsection a. of this section, expressed as a percentage, which reduction shall be based on volume or other efficiencies or economies of scale and shall not be based on health status-related factors.

§ 17B:27A-25.1 Findings, declarations relative to small employer health benefits purchasing alliances

1. The Legislature finds and declares that:

a. Small employers, that is, employers that employ between two and 50 employees, have traditionally been at an economic disadvantage with respect to the purchase and provision of health benefits for their employees because certain administrative and premium rate savings that are available to larger employers are not available to them by virtue of their size;

b. Providing for the establishment of purchasing alliances comprised of groups of small employers would enable small employers to take advantage of the economies of scale in the delivery of health benefits currently available to large employer groups; and

c. Working within the framework of the Small Employer Health Benefits Program established by P.L.1992, c.162 (C.17B:27A-17 et seq.), small employer purchasing alliances, with the voluntary participation of insurance carriers, would have access to the standard health benefits plans developed under that law at a reduced premium, along with the protections afforded under that law, including: guaranteed access to health benefits coverage for their employees; guaranteed renewability of health plans regardless of the health status of employees or their dependents; and prohibitions against the use of certain rating factors such as health status, prior claims history or occupation.

§ 17B:27A-25.2 Definitions relative to small employer benefits purchasing alliances

2. As used in this act:

"Board" means a small employer purchasing alliance board of directors provided for in section 4 of this act.

"Carrier" means a small employer carrier as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).

"Commissioner" means the Commissioner of Banking and Insurance.

"Dependent" means the same as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).

"Eligible employee" means the same as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).

"Eligible group of small employers" means a group of small employers which: (1) are engaged in the same or similar type of trade or business; (2) are members of a common trade association, professional association, or other association; or (3) are located in a common geographic area.

"Health benefits plan" means a small employer health benefits plan approved by the commissioner pursuant to section 17 of P.L.1992, c.162 (C.17B:27A-33).

"Health status-related factor" means the same as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).

"Member" means a small employer who is a member of a purchasing alliance as provided for in section 3 of this act.

"Small Employer Purchasing Alliance," "purchasing alliance" or "alliance" means a small employer purchasing alliance as established pursuant to section 3 of this act.

"Small employer" means the same as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).

§ 17B:27A-25.3 Small Employer Purchasing Alliance, formation

3. Any eligible group of small employers may join together, by means of a joint contract under the procedures established by this act, to form a "Small Employer Purchasing Alliance" for the purpose of negotiating a reduced premium for its members purchasing a small employer health benefits plan or plans for their eligible employees and the employees' dependents. The joint contract shall be executed by all members of the purchasing alliance.

§ 17B:27A-25.4 Board of directors

4. The purchasing alliance, which may be a corporation, shall be governed by a board of directors, elected by the members of the purchasing alliance. No person may serve as an officer or director of an alliance who has a prior record of administrative, civil or criminal violations within the financial services industry. The directors shall serve for terms of three years, and shall serve until their successors are elected and qualified. The directors shall serve without compensation, except for reimbursement for actual expenses.

§ 17B:27A-25.5 Bylaws, contents

5. The board shall adopt by-laws for the operation of the purchasing alliance, which shall be effective upon ratification by a two-thirds majority of the members. The by-laws shall include, but not be limited to:

a. The establishment of procedures for the organization and administration of the alliance.

b. Procedures for the qualifications and admission of the members of the alliance. The bases for denial of membership shall include, but not be limited to:

(1) Performance of an act or practice that constitutes fraud or intentional misrepresentation of material fact;

(2) Previous denial of membership in the alliance; or

(3) Previous expulsion from the alliance.

c. Procedures for the withdrawal of members from the alliance.

d. Procedures for the expulsion of members from the alliance. The bases for expulsion shall include, but not be limited to:

(1) Failure to pay membership or other fees required by the purchasing alliance;

(2) Failure to pay premiums in accordance with the terms of the health benefits plan or the terms of the joint contract; or

(3) Performance of an act or practice that constitutes fraud or intentional misrepresentation of material fact.

e. Procedures for the termination of the alliance.

§ 17B:27A-25.6 Further authority of alliance

6. In addition to the powers authorized under this act, a purchasing alliance shall have the authority to:

a. Set reasonable fees for membership in the alliance that will finance reasonable and necessary costs incurred in administering the purchasing alliance;

b. Negotiate premium rates with carriers on behalf of the members of the alliance; and

c. Contract with third parties for any services necessary to carry out the powers and duties authorized or required pursuant to this act.

§ 17B:27A-25.7 Restrictions on alliances

7. A purchasing alliance established pursuant to the provisions of this act shall not:

a. Purchase health care services, assume risk for the cost or provision of health care services or otherwise contract with health care providers for the provision of health care services to eligible employees or their dependents;

b. Exclude a small employer, eligible employee or dependent from membership in the purchasing alliance who agrees to pay fees for membership and the premium for health benefits coverage and who abides by the by-laws and rules of the purchasing alliance;

c. Engage in any act or practice that results in the selection of member small employers or eligible employees based on any health status-related factor; or

d. Engage in any trade practice or activity prohibited pursuant to chapter 30 of Title 17B of the New Jersey Statutes.

§ 17B:27A-25.8 Certificate from alliance to commissioner

8. a. Within 30 days after its organization, the purchasing alliance board shall file with the commissioner a certificate which shall list the members of the alliance, the names of the board of directors and the chairman, treasurer, and secretary of the purchasing alliance, and the address at which communications for the purchasing alliance are to be received, a copy of the certificate of incorporation of the purchasing alliance, if any, and a copy of the joint contract executed by all of the members. Any change in the information required by the provisions of this section shall be filed with the commissioner within 30 days of the change.

b. If the commissioner determines that the premium reduction, permitted pursuant to subsection k. of section 9 of P.L.1992, c.162 (C.17B:27A-25) and filed by a carrier in the informational filing required pursuant to subsection f. of that section, results in rates that are excessive, inadequate or unfairly discriminatory, the commissioner may disapprove or deny the premium reduction. If, after notice and a hearing pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14b-1 et seq.), a carrier or purchasing alliance is found by the commissioner to be in violation of any provision of this act, the commissioner may disapprove or deny the premium reduction permitted pursuant to subsection k. of section 9 of P.L.1992, c.162 (C.17B:27A-25).

§ 17B:27A-25.9 Rules, regulations

10. The commissioner shall promulgate rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to effectuate the provisions of this act.

§ 17B:27A-26 Health maintenance organization coverage; exceptions

10. a. No health maintenance organization shall be required to offer coverage or accept applications pursuant to section 3 of this act to a small employer if the small employer does not have eligible individuals who live, work, or reside in the service area for such plan, or if the health maintenance organization reasonably anticipates and demonstrates to the satisfaction of the commissioner that it will not have the capacity in its network of providers within the service area to deliver service adequately to the members of such groups because of its obligations to existing group contract holders and enrollees. Upon denying health insurance coverage in any service area as a result of insufficient network capacity in accordance with this subsection, the health maintenance organization shall not offer coverage in the small employer market within such service area for a period of at least 180 days after the date the coverage is denied.

b. No small employer carrier shall be required to offer coverage or accept applications pursuant to this act for any period of time in which the commissioner determines that the requiring of the issuing of policies or contracts pursuant to this act would place the carrier in a financially impaired position.

c. A health maintenance organization which complies with the basic health benefits, underwriting and rating standards established by the federal government pursuant to subchapter XI of Pub.L.93-222 (42.U.S.C. s.300e et seq.), and which also provides the comprehensive health benefit plans coverage required by subsection f. of section 3 of P.L.1992, c.162 (C.17B:27A-19), shall be deemed in compliance with this act.

§ 17B:27A-27 Continued coverage for certain terminated employees, dependents.

11. a. (1) Every policy or contract issued to a small employer in this State, including, but not limited to, policies or contracts which are subject to this act and which are delivered, issued, renewed, or continued on or after January 1, 1994, shall offer continued coverage under the plan to any employee whose employment was terminated for a reason other than for cause and to any employee covered by such plan whose hours of employment were reduced to less than 25 subsequent to the effective date of coverage for that employee.

(2) Every policy or contract issued to a small employer in this State, including, but not limited to, policies or contracts which are subject to P.L.1992, c.162 (C.17B:27A-17 et seq.) and which are delivered, issued, renewed, or continued on or after the effective date of P.L.2004, c.162, shall offer continued coverage under the plan to: (a) any spouse who is a qualified beneficiary under the plan by reason of being the spouse of a covered employee on the day before the qualifying event; (b) to any dependent child who is a qualified beneficiary under the plan by reason of being the dependent child of a covered employee on the day before the qualifying event, subject to the applicable terms of the plan; and (c) to any such spouse or dependent child who is a qualified beneficiary under the plan whenever that spouse or dependent child is no longer entitled to coverage under the plan by reason of the death of the employee or the divorce of the employee from the spouse.

(3) The employee, spouse or dependent child shall make a written election for continued coverage within 30 days of a qualifying event. For the purposes of this section, "qualifying event" shall mean: (a) the date of termination of employment; (b) the date on which a reduction in an employee's hours of employment becomes effective; (c) the date of death of the employee; (d) the date of the divorce of the employee from the employee's spouse; or (e) the date the dependent child ceases to be an eligible dependent.

(4) For the purposes of paragraphs (1) and (2) of this subsection a., the date on which a health benefits plan is continued shall be the anniversary date of the issuance of the plan.

b. Coverage continued pursuant to subsection a. of this section shall consist of coverage which is identical to the coverage provided under the policy or contract to similarly situated qualified beneficiaries. If coverage is modified under the policy or contract for any group of similarly situated qualified beneficiaries, this coverage shall also be modified in the same manner for persons who are qualified beneficiaries entitled pursuant to subsection a. of this section to continued coverage. Continuation of coverage may not be conditioned upon, or discriminate on the basis of, lack of evidence of insurability.

c. The health benefits plan may require payment of a premium by the employee, spouse or dependent child for any period of continuation coverage as provided for in this section, except that the premium shall not exceed 102%, or 150% in the case of continuation of coverage pursuant to paragraph (2) of subsection g. of this section, of the applicable premium paid for similarly situated beneficiaries under the health benefits plan for a specified period, and may, at the election of the payor, be made in monthly installments. No premium payment shall be due before the 30th day after the day on which the covered employee made the initial election for continued coverage.

d. Coverage continued pursuant to this section shall continue until the earlier of the following:

(1) The date upon which the employer under whose health benefits plan coverage is continued ceases to provide any health benefits plan to any employee or other qualified beneficiary;

(2) The date on which the continued coverage ceases under the health benefits plan by reason of a failure to make timely payment of any premium required under the plan by the former employee, spouse, or dependent child having the continued coverage. The payment of any premium shall be considered to be timely if made within 30 days after the due date or within such longer period as may be provided for by the policy or contract; or

(3) The date after the date of election on which the qualified beneficiary first becomes:

(a) Covered under any other health benefits plan, as an employee or otherwise, which does not contain a provision which limits or excludes coverage with respect to any preexisting condition of a covered employee or any spouse or dependent child who is included under the coverage provided the covered employee, for such period of the limitation or exclusion; or

(b) Entitled to benefits under Title XVIII of the Social Security Act, Pub.L.89-97 (42 U.S.C.s.1395 et seq.).

e. Notice shall be provided to employees in the certificate of coverage prepared for employees by the carrier on or about the commencement of coverage and by the small employer at the time of the qualifying event as to their continuation rights under the plan. A qualified beneficiary may elect continuation coverage offered pursuant to this section no later than 30 days after the qualifying event. For the purposes of this section, "qualified beneficiary" means any person covered under a small employer group policy who has a qualifying event.

f. The provisions of this section shall not apply to any person who is a qualified beneficiary for the purposes of continuation of coverage as provided in accordance with section 10002 of Title X of Pub.L.99-272 (29 U.S.C.s.1161 et seq.).

g. Continuation of coverage provided for under this section shall not exceed 18 months from the qualifying event, except that:

(1) In the case of a spouse or dependent child who is a qualified beneficiary, continuation of coverage shall extend until the date 36 months after the date the spouse's or dependent child's benefits under the policy or contract would otherwise have terminated by reason of the death of the employee, the divorce of the employee from the spouse or a dependent child ceasing to be a dependent child under the applicable provisions of the policy or contract; and

(2) In the case of an employee who is determined to have been disabled under Title II or XVI of the Social Security Act (42 U.S.C.ss.401-433 or 42 U.S.C.ss.1381-1383) at the time of termination of employment or at any time during the first 60 days of continuation of coverage, 29 months after the date benefits under the policy or contract would have terminated pursuant to paragraph (1) of subsection a. of this section; provided, however, that if the employee is no longer disabled, continuation of coverage shall terminate on the later date of 18 months or the month that begins more than 31 days after the date of final determination under Title II or Title XVI of the Social Security Act (42 U.S.C.ss.401-433 or 42 U.S.C.ss.1381-1383) that the employee is no longer disabled. The employee shall provide notification of the disability determination under Title II or XVI of the Social Security Act (42 U.S.C.ss.401-433 or 42 U.S.C.ss.1381-1383) to the carrier within 60 days of the date of that determination, and within 18 months of the date benefits under the policy or contract would have terminated pursuant to paragraph (1) of subsection a. of this section

§ 17B:27A-28 New Jersey Small Employer Health Benefits Program created

12. There is created a nonprofit entity to be known as the New Jersey Small Employer Health Benefits Program. All carriers issuing health benefits plan policies and contracts in this State shall be members of this program. The program shall be administered by the board of directors established pursuant to section 13 of P.L.1992, c.162 (C.17B:27A-29).

§ 17B:27A-29 Meetings, organization of board; terms.

13. a. The board shall consist of 13 public members appointed by the Governor who shall include:

(1) Two carriers that sell plans in the small employer market;

(2) One carrier that sells plans in the individual market or the small employer market;

(3) Two representatives of or individuals employed by businesses that purchase in small employer health benefits plans;

(4) Two health care provider representatives;

(5) Two insurance producers licensed to sell health insurance pursuant to P.L.1987, c.293 (C.17:22A-1 et seq.);

(6) One representative of organized labor;

(7) One representative of an association representing small businesses in the State; and

(8) Two persons with knowledge or expertise in New Jersey regulated health insurance markets who represent the general public.

The Commissioner of Health and the commissioner, or the commissioner's designee, shall serve on the board as ex officio members. No carrier shall have more than one representative on the board.

The public members shall be appointed for a term of three years, except that of the members first appointed, five shall be appointed for a term of one year, four for a term of two years and four for a term of three years.

A vacancy in the membership of the board shall be filled for an unexpired term in the manner provided for the appointment.

The board shall continue in its existing form until there is established a quorum of members newly appointed pursuant to the provisions of P.L.2023, c.194 (C.17B:27A-33.1 et al.).

b. (Deleted by amendment, P.L.2023, c.194).

c. (Deleted by amendment, P.L.1995, c.298).

d. All meetings of the board shall be subject to the requirements of the "Open Public Meetings Act," P.L.1975, c.231 (C.10:4-6 et seq.).

e. At least two copies of the minutes of every meeting of the board shall be delivered forthwith to the commissioner.

f. To the extent that any provision of P.L.2023, c.194 (C.17B:27A-33.1 et al.) is in conflict with any provision of section 2 of P.L.2019, c.141 (C.17B:27A-58), the provisions of section 2 of P.L.2019, c.141 (C.17B:27A-58) shall govern.

§ 17B:27A-29.1 Immunity from liability for board

11. A member of the board and an employee of the board shall not be liable in an action for damages to any person for any action taken or recommendation made by him within the scope of his functions as a member or employee, if the action or recommendation was taken or made without malice. 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 (C.59:1-1 et seq.) on account of acts or omissions in the scope of their employment.

§ 17B:27A-29.2 Rules, regulations for voluntary risk pooling arrangement

12. The board may, if necessary, adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to establish a voluntary risk pooling arrangement for program members.

If the board determines that such an arrangement is necessary, it shall submit the proposed rules and regulations to the Legislature for review on a day that the Legislature is in session and to the commissioner for his approval. If the Legislature does not take action in 30 days to amend or otherwise change the rules and regulations, the rules and regulations shall be effective upon approval by the commissioner or upon such later date as the board determines.

§ 17B:27A-30 Submission of plan of operation

14. Within 90 days after the election of the initial board, the board shall submit to the commissioner a plan of operation which shall establish the administration of the program pursuant to the provisions of this act. The plan of operation and any subsequent amendments thereto shall be submitted to the commissioner who shall, after notice and hearing, approve the plan if he finds that it is reasonable and equitable and sufficiently carries out the provisions of this act. The plan of operation shall become effective after the commissioner has approved it in writing. The plan or any subsequent amendments thereto shall be deemed approved if not expressly disapproved by the commissioner in writing within 90 days of receipt by the commissioner.

§ 17B:27A-31 Contents of plan of operation

15. The plan of operation shall constitute a public record and shall include, but not be limited to, the following:

a. A method of handling and accounting for assets and moneys of the program and an annual fiscal reporting to the commissioner;

b. A means of providing for the filling of vacancies on the board, subject to the approval of the commissioner; and

c. (Deleted by amendment, P.L.1993, c.162).

d. (Deleted by amendment, P.L.1995, c.298).

e. (Deleted by amendment, P.L.1995, c.298).

f. (Deleted by amendment, P.L.1995, c.298).

g. Any additional matters which are appropriate to effectuate the provisions of this act.

§ 17B:27A-32 Authority of board

16. The board shall have the authority to:

a. Enter into contracts as are necessary or proper to carry out the provisions and purposes of this act;

b. 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;

c. Establish rules, conditions, and procedures pertaining to the assessment of members by the program;

d. Assess members in accordance with the provisions of this act, including such interim assessments as may be reasonable and necessary for organizational and reasonable operating expenses. Such interim assessments shall be credited as offsets against any regular assessments due following the close of the fiscal year;

e. Appoint from among its members appropriate legal, actuarial, and other committees as necessary to provide technical assistance in the operation of the program, policy and other contract design, and any other function within the authority of the program; and

f. Contract for an independent actuary or any other professional services the board deems necessary to carry out its duties under P.L.1992, c.162 (C.17B:27A-17 et seq.).

§ 17B:27A-33 Formulation of five health benefits plans

17. Subject to the approval of the commissioner, the board shall formulate the five health benefits plans to be made available by small employer carriers in accordance with the provisions of this act, and shall promulgate five standard forms pursuant thereto. The board may establish benefit levels, deductibles and co-payments, exclusions, and limitations for such health benefits plans in accordance with the law. The board shall ensure that the means exist for a carrier to offer high deductible health benefits plan options that are consistent with section 301 of Title III of the "Health Insurance Portability and Accountability Act of 1996," Pub.L. 104-191, regarding tax-deductible medical savings accounts.

The board shall submit the forms so established to the commissioner for approval. The commissioner shall approve the forms if the commissioner finds them to be consistent with the provisions of section 3 of P.L.1992, c. 162 (C.17B:27A-19). Any form submitted to the commissioner by the board shall be deemed approved if not expressly disapproved in writing within 60 days of its receipt by the commissioner. Such forms may contain, but shall not be limited to, the following provisions:

a. Utilization review of health care services, including review of medical necessity of hospital and physician services;

b. Managed care systems, including large case management;

c. Provisions for selective contracting with hospitals, physicians, and other participating and nonparticipating providers;

d. Reasonable benefits differentials which are applicable to participating and nonparticipating providers;

e. Notwithstanding the provisions of section 4 of P.L.1992, c.162 (C.17B:27A-20) to the contrary, the board may, from time to time, adjust coinsurance and deductibles;

f. Such other provisions which may be quantifiably established to be cost containment devices;

g. The department shall publish annually a list of the premiums charged for each of the five small employer health benefits plans and for any rider package by all carriers writing such plans. The department shall also publish the toll free telephone number of each such carrier.

§ 17B:27A-33.1 Short title.

7. Sections 7 through 11 of P.L.2023, c.194 (C.17B:27A-33.1 et al.) shall be known and may be cited as the "Small Business Health Insurance Affordability Act."

§ 17B:27A-33.2 Annual review, small-employer health benefits plans, publish findings, report, Department of Banking and Insurance website.

8. a. The board shall annually review the small employer health benefits plans offered pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) to ensure that each plan meets the requirements of section 2 of P.L.2019, c.354 (C.17B:27A-19.30), provides consumer choice and affordability, and maintains a relative level of consistency compared to previous years and to other plans in the small employer market. The board shall publish the findings of its review on the website of the Department of Banking and Insurance.

b. The board shall annually adjust the design of the small employer health benefits plans, including the out-of-pocket limits under those plans, to ensure premium affordability and to align the plans with the requirements of section 2 of P.L.2019, c.354 (C.17B:27A-19.30). The adjustment shall be based on the annual review conducted pursuant to subsection a. of this section. The board may consider proposals for adjustments to plan design to improve affordability from carriers offering small employer health benefits plans pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.).

c. The board shall annually review the appropriateness of geographic rating areas and may adjust, by rule, as needed to achieve the goals of this subsection.

d. The board shall examine and, to the extent practicable, track where small employers who do not continue coverage through a small employer health benefits plan offered pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) elect to purchase coverage. The board shall have the authority to develop a sample survey that insurance producers shall provide to clients. Insurance producers shall report to the board all information received through the survey, which shall be de-identified by the insurance producer. The sample survey shall include, but may not be limited to, information concerning where small employers purchase health benefits coverage. The board shall publish a report on the results of the surveys received from insurance producers pursuant to this subsection on the website of the Department of Banking and Insurance.

§ 17B:27A-41 Violations, penalty

25. Any carrier which violates this act shall be subject to a penalty assessment, as determined by the commissioner.

§ 17B:27A-43 Violations, penalties

27. A carrier which violates any provision of this act shall be liable to a penalty of not less than $2,000 and not greater than $5,000 for each violation. The penalty shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with "the penalty enforcement law," N.J.S.2A:58-1 et seq.

§ 17B:27A-44 Assessments not charged to policyholders, public

28. No assessment provided for under this act shall be charged, directly or indirectly, to policyholders or the public, provided that a carrier may charge such an assessment to policyholders to the extent that the charging of the assessment is necessary to enable the carrier to earn a constitutionally adequate rate of return.

§ 17B:27A-45 Standard claim form

29. The board, in conjunction with the board of the New Jersey Individual Health Coverage Program established pursuant to section 9 of P.L.1992, c.161 (C.17B:27A-10) shall promulgate one standard claim form.

In order to provide a standard system of payment for medical services, all claim forms for any claimant's use under a group health insurance policy issued or delivered in this State shall conform to the form adopted by the board.

§ 17B:27A-47 Coverage obtained through out-of-State trust, compliance required

12. Group hospital or medical coverage obtained through an out-of-State trust covering a group of 49 or fewer employees or participating persons who are residents of this State shall comply with the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.), regardless of the situs of delivery of the policy.

§ 17B:27A-48 Multiple employer arrangement; requirements

13. A multiple employer arrangement covering a group of 49 or fewer employees or participating persons of an individual employer who are residents of this State shall register with the board of directors established pursuant to section 13 of P.L.1992, c.162 (C.17B:27A-29).

The multiple employer arrangement shall be required to offer the health benefits plans established by the board. The premium rates charged for the multiple employer arrangement health benefits plan shall conform to the requirements of section 9 of P.L.1992, c.162 (C.17B:27A-25) and the coverage shall comply with the provisions of subsection b. of section 3 and sections 6 and 7 of P.L.1992, c.162 (C.17B:27A-19, 22 and 23), regardless of the situs of delivery of the multiple employer arrangement.

§ 17B:27A-49 Notification to commissioner by carrier of multiple employer arrangement

14. A carrier shall notify the commissioner by December 31 of each year of any health care coverage or benefits, stop-loss coverage or administrative services only contracts it provides or enters into with a multiple employer arrangement that provides health care benefits to employees and their dependents in this State.

§ 17B:27A-50 Change of coverage by small employer; restrictions

15. a. A small employer who purchases a health benefits plan or rider pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) shall not be permitted to purchase a health benefits plan or rider with a greater actuarial value until the first anniversary date of the small employer's existing health benefits plan.

b. If, after the first anniversary date of a small employer's health benefits plan, the small employer purchases a health benefits plan or rider of greater actuarial value than the existing health benefits plan or rider, the small employer shall not be permitted to change his health benefits plan or rider to one of lesser actuarial value until the anniversary date of the small employer's existing health benefits plan.

c. Nothing in this section shall be construed to prohibit a small employer who has purchased a health benefits plan or rider pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) from purchasing a health benefits plan or rider of lesser actuarial value prior to the anniversary date of the existing health benefits plan or rider, if the existing plan or rider was purchased at least 12 months prior to the latest anniversary date of the plan or rider.

§ 17B:27A-51 Board actions subject to provisions of section; "action" defined; procedure

17. Effective January 1, 1994, all actions adopted by the board shall be subject to the provisions of this section, notwithstanding the provisions of P.L.1968, c.410 (C.52:14B-1 et seq.) to the contrary.

a. For the purposes of this section, "action" includes, but is not limited to:

(1) the establishment and modification of health benefits plans;

(2) procedures and standards for the: (a) assessment of members and the apportionment thereof; (b) filing of policy forms; (c) making of rate filings; (d) evaluation of material submitted by carriers with respect to loss ratios; and (e) establishment of refunds to policy or contract holders; and

(3) the promulgation or modification of policy forms.

"Action" shall not include the hearing and resolution of contested cases, personnel matters and applications for withdrawal or exemptions.

b. Prior to the adoption of an action of the board, the board shall publish notice of its intended action in three newspapers of general circulation in this State, and may publish the notice of intended action in any trade or professional publication which it deems necessary. The notice of intended action shall include procedures for obtaining a detailed description of the intended action and the time, place and manner by which interested persons may present their views. The board shall provide the notice of intended action and a detailed description of the intended action by mail, or otherwise, to affected trade and professional associations, carriers subject to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) and such other interested persons or organizations which may request notification. The board shall forward the notice of intended action and the detailed description of the intended action concurrently to the Office of Administrative Law for publication in the New Jersey Register.

The board shall not charge any fee for placement upon the mailing list of associations, carriers or other persons to be notified, but the board may charge a fee to an association, carrier or other person requesting a copy of the text of the intended action, which fee shall not be in excess of the actual cost of reproducing and mailing the copy.

A copy of the text of the intended action shall be available in the Department of Insurance in accordance with the provisions of P.L.1963, c.73 (C.47:1A-1 et seq.).

c. The board shall hold a public hearing on the establishment and modification of health benefits plans, and the board may hold a public hearing on any other intended action. Notice of a hearing shall be given in the notice of intended action provided for in subsection b. of this section.

d. Whether or not a public hearing is held, the board shall afford all interested persons an opportunity to comment in writing on the intended action. Written comments shall be submitted to the board within the time established by the board in the notice of intended action, which time shall not be less than 20 calendar days from the date of notice.

The board shall give due consideration to all comments received. Within a reasonable period of time following submission of the comments pursuant to this subsection, the board shall prepare for public distribution a report listing all parties who provided written submissions concerning the intended action, summarizing the content of the submissions and providing the board's response to the data, views and arguments contained in the submissions. A copy of the report shall be filed with the Office of Administrative Law for publication in the New Jersey Register.

e. The board may adopt the intended action immediately following the expiration of the public comment period provided in subsection d. of this section, or the hearing provided for in subsection c. of this section, whichever date is later. The final action adopted by the board shall be submitted for publication in the New Jersey Register to the Office of Administrative Law, and shall be effective on the date of the submission or such later date as the board may establish.

f. Actions filed with the Office of Administrative Law pursuant to this section shall be filed subject to the provisions of subsections (a), (c), (d) and (e) of section 5 of P.L.1968, c.410 (C.52:14B-5).

g. Nothing in this section shall be construed to prohibit the board from adopting any action pursuant to the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

h. Nothing in this section shall be construed to prohibit the commissioner from adopting any rule or regulation pursuant to the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), or from taking any other action required or authorized by P.L.1992, c.162 (C.17B:27A-17 et seq.).

§ 17B:27A-53 Other insurance purchases not required

21. A carrier shall not require a small employer to purchase any other insurance coverage, including, but not limited to, life insurance, accident insurance or disability insurance, as a condition of or in conjunction with the purchase of a health benefits plan pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.).

§ 17B:27A-54 Commissioner authorized to approve establishment of arrangement; rules, regulations

22. Notwithstanding any other law to the contrary, the commissioner is authorized to approve the establishment of an arrangement by an insurance company operating pursuant to Title 17B of the New Jersey Statutes and authorized to issue health benefits plans in this State, that is entered into on or after June 1, 1993 and which provides for selective contracting with health care providers and reasonable benefit differentials applicable to participating and nonparticipating health care providers.

The agreement for an arrangement shall be filed and approved by the commissioner before it becomes effective. The commissioner shall approve the agreement if he determines, in consultation with the Commissioner of Health, that the arrangement promotes health care cost containment while adequately preserving quality of care. The commissioner may adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to enforce and administer the arrangements.

§ 17B:27A-55 Written notice required for issuance, renewal of high deductible health plan; declaration of understanding.

18. a. An insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State shall not issue or renew a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223) on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the application for the contract or policy is accompanied by a written notice, approved by the Commissioner of Banking and Insurance, identifying and containing a one page, double-sided declaration of understanding for high deductible health plans for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). At the time a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223) is issued or renewed, the contract holder or policyholder shall sign and return a copy of the one page, double-sided declaration of understanding to the insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization. The contract holder or policyholder is responsible for retaining a copy of the one page, double-sided declaration of understanding.

b. The declaration of understanding shall include a signature line representing the recipient's receipt and understanding of the declaration, and shall also include, but not be limited to, information as to the terms of the plan, presented in plain and simple language, concerning:

(1) covered services;

(2) applicable deductibles;

(3) the responsibility of the contract holder or policyholder and any other covered persons for applicable deductibles;

(4) claims processing; and

(5) any other information required by State or federal law.

c. The Commissioner of Banking and Insurance shall enforce the provisions of this section. An insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization found in violation of this section shall be liable for a civil penalty of not more than $1,000 for each day that the payer is in violation if reasonable notice in writing is given of the intent to levy the penalty and, at the discretion of the commissioner, the payer has 30 days, or such additional time as the commissioner shall determine to be reasonable, to remedy the condition which gave rise to the violation and fails to do so within the time allowed. The penalty shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.).

d. Nothing in this section shall be construed to prohibit the promulgation of regulations by the Commissioner of Banking and Insurance to establish standards for the declaration of understanding required pursuant to this section, which standards may require the declaration of understanding to include additional information not stated in this section as deemed appropriate by the commissioner.

§ 17B:27A-56 Provision of biannual surveys to DOBI by health insurers.

19. a. Any health insurer, as a condition of transacting business in this State, offering a contract, policy, or plan that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall provide biannual surveys to the Department of Banking and Insurance, based upon information requested and collected from subscribers, insureds, enrollees, and covered persons covered by qualifying high deductible health plans. Each survey shall request, but is not limited to requesting, information concerning: the income levels of the subscribers, insureds, enrollees, or covered persons, covered by qualifying high deductible health plans; the type of contract, policy, or plan which previously provided coverage to those individuals; the amount of out-of-pocket expenses incurred by those individuals; and the percentage of income used by those individuals to pay deductibles.

b. All disclosures made pursuant to this section shall be made in accordance with section 2713 of the "Health Insurance Portability and Accountability Act of 1996," Pub.L.104-191 (42 U.S.C. s.300gg-13).

§ 17B:27A-57 "Health Insurance Exchange Trust Fund."

1. a. There is established in the Department of the Treasury a nonlapsing revolving fund to be known as the "Health Insurance Exchange Trust Fund." This fund shall be the repository for monies collected pursuant to subsection c. of this section, any federal financial participation available, and other monies received as grants or otherwise appropriated for the purposes of supporting health insurance outreach and enrollment efforts through an exchange. The monies in the fund shall be used only for the purpose of supporting the exchange through initial start-up costs associated with establishment of the exchange, exchange operations, outreach, enrollment, and other means of supporting the exchange, including any efforts that can increase market stabilization and that may result in a net benefit to policyholders.

b. The State Treasurer shall be the custodian of the fund and all disbursements from the fund shall be made by the State Treasurer upon vouchers signed by the Commissioner of Banking and Insurance. The monies in the fund shall be invested and reinvested by the Director of the Division of Investment in the Department of the Treasury to the same extent that other trust funds that are in the custody of the State Treasurer are invested and reinvested, in the manner provided by law. Interest received on the monies in the fund shall be credited to the fund.

c. The commissioner may apply a monthly assessment to each individual health benefits plan sold in the individual market. The assessment shall be paid by the carrier and deposited into the fund and shall be used only for the purpose of supporting the exchange through initial start-up costs associated with establishment of the exchange, exchange operations, outreach, enrollment, and other means of supporting the exchange, including any efforts that can increase market stabilization and that may result in a net benefit to policyholders. The assessment may be applied at a rate of:

(1) .5 percent of the total monthly premium charged by a carrier for each health benefits plan during any period that the State is on a federally-facilitated exchange;

(2) 1 percent of the total monthly premium charged by a carrier for each health benefits plan during any period that the State is on a State-based exchange using the federal platform; or

(3) 3.5 percent of the total monthly premium charged by a carrier for each health benefits plan during any period that the State is on a State-based exchange. The commissioner shall have the discretion to adjust this rate to ensure that the State-based exchange is fully funded, but in no case shall the assessment be applied at a rate that exceeds 4 percent of the total monthly premium charged by a carrier. If the commissioner determines it is necessary to adjust the rate above 3.5 percent pursuant to this paragraph, the commissioner shall, in advance of the adjustment, post on the department's website a report describing the reasons and justifications for the adjustment, which shall be consistent with the purposes of supporting the exchange as provided in this section.

After the 2020 plan year, the commissioner shall notify a carrier of its assessment rate for the subsequent year at least 20 days prior to the date the carrier is required to file its rate filing with the department. In the case of an assessment for the 2020 plan year, the commissioner shall notify carriers as soon as is practicable of the assessment amount.

d. Any unexpended balance in the fund at the end of a year shall be available for expenditure by the commissioner in the subsequent year. The commissioner shall consider any unexpended balance from a previous year when calculating the assessment pursuant to subsection c. of this section.

§ 17B:27A-58 Authority to operate a State-based exchange, coordinate operations with other entities; advisory committee.

2. a. Notwithstanding any other law to the contrary, the Department of Banking and Insurance shall have the authority to operate a State-based exchange and coordinate the operations of the exchange with the operations of the New Jersey Individual Health Coverage Program and the New Jersey Small Employer Health Benefits Program, including reorganization of the boards, as the commissioner deems appropriate. The department's authority to regulate the insurance market shall be separate and distinct from the department's duty to oversee exchange operations, to ensure the best interests of and protection for consumers of the State. The commissioner may require that all plans in the individual and small employer markets be made available for comparison on the State-based exchange, but nothing in this section shall allow the commissioner to require all plans in the individual and small employer markets to be purchased exclusively on the State-based exchange. The department shall coordinate the operations of the exchange with the operations of the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) and the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.) to determine eligibility for those programs as soon as practicable.

b. The Commissioner of Human Services, in consultation with the Commissioner of Banking and Insurance, shall submit a proposal for available federal financial participation funds to the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services pursuant to 42 C.F.R. 433.112 for the Medicaid eligibility platform and the exchange to be integrated. Notwithstanding the foregoing, the Department of Banking and Insurance may proceed to implement the provisions of this act, including the operation of the State-based exchange.

c. The Commissioner of Banking and Insurance shall have the authority to require that plans offered on the exchange conform with standardized plan designs that provide for standardized cost-sharing for covered health services.

d. The Commissioner of Banking and Insurance shall establish an advisory committee to provide advice to the commissioner concerning the operation of the exchange and the implementation of the New Jersey Easy Enrollment Health Insurance Program established pursuant to P.L.2022, c.39 (C.17B:27A-59.1 et al.). The advisory committee shall include at least nine members, as follows:

(1) The Commissioner of Banking and Insurance, or a designee, who shall serve ex-officio;

(2) The Commissioner of Human Services, or a designee, who shall serve ex-officio;

(3) the Commissioner of Health, or a designee, who shall serve ex-officio; and

(4) six public members, who shall be residents of the State, appointed by the Commissioner of Banking and Insurance. Each public member shall have demonstrated experience in one or more of the following areas: health insurance consumer advocacy; individual health insurance coverage; small employer health insurance coverage; health benefits plan marketing; the provision of health care services; or academic or professional research relating to health insurance.

§ 17B:27A-59 Rules, regulations.

4. The Department of Banking and Insurance shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), to effectuate the purposes of this act.

§ 17B:27A-59.1 Definitions.

1. As used in this act:

"Commissioner" means the Commissioner of Banking and Insurance.

"Department" means the Department of Banking and Insurance.

"Insurance affordability assistance" means:

(1) the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.);

(2) the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.);

(3) premium tax credits; or

(4) cost-sharing reductions.

"Premium tax credits" means the tax credits described in section 36B of the Internal Revenue Code.

"Program" means the New Jersey Easy Enrollment Health Insurance Program established pursuant to this act.

"Individual" means an individual who is identified through a State income tax return under section 6 of this act as not having minimum essential coverage.

§ 17B:27A-59.2 "New Jersey Easy Enrollment Health Insurance Program" established.

2. a. The Department of Banking and Insurance shall establish and have the authority to operate the New Jersey Easy Enrollment Health Insurance Program. The department shall integrate the program with the State-based exchange established pursuant to P.L.2019, c.141 (C.17B:27A-57 et seq.), and may enter into an agreement with a third party for operation of the program. The purpose of the program shall be to:

(1) establish a State-based reporting system to provide information about the health insurance status of State residents through the use of State income tax returns and approved eFile vendors to identify individuals without minimum essential coverage and determine whether the individual is interested in obtaining minimum essential coverage;

(2) determine or assess, as feasible, whether an individual who is interested in obtaining minimum essential coverage qualifies for insurance affordability assistance;

(3) proactively contact an individual who is interested in obtaining minimum essential coverage to assist in enrolling the individual in insurance affordability assistance and minimum essential coverage; and

(4) maximize enrollment of eligible individuals in insurance affordability assistance and minimum essential coverage to improve access to care and reduce insurance costs for all residents of the State.

b. The Commissioner of Banking and Insurance, in coordination with the Commissioner of Human Services, the Commissioner of Labor and Workforce Development, and the State Treasurer, shall develop and implement systems, policies, and practices that encourage, facilitate, and streamline determination of eligibility for insurance affordability assistance and enrollment in minimum essential coverage to achieve the purposes of the program.

c. To facilitate the most efficient implementation of the program, the Commissioner of Banking and Insurance, the Commissioner of Human Services, the Commissioner of Labor and Workforce Development, and the State Treasurer may enter into agreements, adopt regulations and guidelines, establish accounts, conduct trainings, provide public information, educate tax preparers, and take any other steps as may be necessary to accomplish the purpose of the program.

d. Notwithstanding the provisions of subsection a. of R.S.54:50-8 to the contrary, the State Treasurer shall share with the Commissioner of Banking and Insurance the taxpayer information that is necessary for the purposes of this act and P.L.2018, c.31 (C.54A:11-1 et seq.).

e. The Commissioners of Human Services and Banking and Insurance shall apply and secure any State plan amendments or necessary waivers from the federal Department of Health and Human Services in order to implement the provisions of this act.

§ 17B:27A-59.3 Assistance eligibility, Department of Banking and Insurance.

3. a. The Department of Banking and Insurance may assess or determine, as appropriate, eligibility for insurance affordability assistance as soon as possible after an individual files a State income tax return on which the individual indicates pursuant to paragraph (3) of subsection c. of section 6 of this act, that the individual or another individual indicated on the tax return is seeking coverage.

b. (1) To the extent practicable, the department may verify an individual's eligibility for insurance affordability assistance with information on a State income tax return and other data from third-party data sources, including data described in section 1413 of the Affordable Care Act or available pursuant to section 6 of this act, without requesting additional information from the individual.

(2) If additional documentation from an individual is required to establish eligibility for insurance affordability assistance, the department shall take steps to obtain such information while limiting the burden on the individual.

c. The Department of Banking and Insurance may make, or refer to the Department of Human Services to make, an assessment or determination, as appropriate, of eligibility for the State Medicaid program or the NJ FamilyCare Program. The Department of Banking and Insurance may utilize and share with the Department of Human Services any information provided to the Department of Banking and Insurance in making assessments or determinations pursuant to this subsection.

§ 17B:27A-59.4 Special enrollment period, New Jersey individual health insurance market, established.

4. a. The Department of Banking and Insurance shall establish a special enrollment period for the New Jersey individual health insurance market to facilitate the objectives of the program.

The enrollment period described in this section shall last for a period of time, to be determined by the Department of Banking and Insurance, that shall not be shorter than 30 days.

b. Information about the enrollment period described in subsection a. of this section shall be communicated to the public and affected individuals through measures that may include language in the instructions for the State individual income tax return, if inclusion of the language is approved by the State Treasurer.

c. The Department of Banking and Insurance shall conduct outreach to individuals described in subsection b. of this section, using methods that may include written notices and the provision of individualized assistance by insurance agents and brokers, navigators, tax preparers, and contractors and staff.

Notwithstanding any other provision of this act, the Department of Banking and Insurance may compensate an entity for outreach described in this subsection in a manner that reflects, in whole or in part, the number of individuals enrolled under this section and section 3 of this act by that entity or any other reasonable manner.

§ 17B:27A-59.5 Data privacy, security safeguards.

5. a. The Department of Banking and Insurance shall develop data privacy and data security safeguards to govern the conveyance, storage, and utilization of data under the program.

b. The safeguards developed under subsection a. of this section shall ensure that the conveyance, storage, and utilization of data under the program comply with applicable requirements of federal and State law.

§ 17B:27A-59.6 Tax return, individual not covered, minimum essential coverage.

6. a. If a State income tax return indicates that an individual is not covered under minimum essential coverage at the time the tax return is filed, consistent with the provisions of P.L.2018, c.31 (C.54A:11-1 et seq.), the tax return shall include the following information as to each such individual included in the tax return:

(1) the age of each individual;

(2) election by the individual filing the tax return of one of the two checkoff boxes described in subsection c. of this section for each individual included in the tax return;

(3) if the individual who files a tax return chooses the checkoff box described in paragraph (3) of subsection c. of this section, any information determined by the department as essential to determining eligibility for insurance affordability assistance for the individual filing the tax return or any individual included in the tax return, if the information:

(a) is not available from a reliable third-party data source;

(b) is not otherwise required to be provided on the return; and

(c) does not pertain to citizenship or immigration status; and

(4) notification of the potential waiver of the State shared responsibility tax pursuant to subsection d. of this section.

b. For an individual who files a tax return and chooses the checkoff box described in paragraph (3) of subsection c. of this section, the return or separate form shall facilitate the collection of contact information, including a phone number, electronic mail address, and mailing address, from the individual who filed the tax return and provide an option to indicate the individual's preferred method for the department to contact the individual who filed the tax return to facilitate either determination of eligibility for insurance affordability assistance or enrollment in minimum essential coverage.

c. (1) In accordance with this section, the State Treasurer shall include with the income tax return form a separate form that is required only for individuals who file a tax return indicating that an individual included in the tax return is not covered under minimum essential coverage at the time the tax return is filed.

(2) The separate form shall include two checkoff boxes as described in paragraphs (3) and (4) of this subsection for each individual included in the tax return and the information described in paragraphs (2) and (3) of subsection a. and in subsection b. of this section.

(3) One checkoff box shall give an individual who files a tax return the choice to have the department:

(a) based on information in the individual's tax return, determine eligibility for insurance affordability assistance for the individual filing the tax return and any other individual included in that tax return who does not have minimum essential coverage; and

(b) obtain additional data that may be relevant to determine eligibility for insurance affordability assistance for the individual filing the tax return and any other individual included in that tax return who does not have minimum essential coverage.

(4) One checkoff box shall allow an individual who files a tax return the choice to not have the department make the determination described in paragraph (3) of this subsection for the individual filing the tax return and any other individual included in that tax return who does not have minimum essential coverage.

(5) The State Treasurer, in consultation with the Department of Banking and Insurance, shall:

(a) develop language for the checkoff boxes described in paragraphs (3) and (4) of this subsection;

(b) develop language for the instructions for the State income tax return that includes a description of the effects of choosing the checkoff boxes described in paragraphs (3) and (4) of this subsection, including the purposes for which the information disclosed under this section may be used; and

(c) ensure that the language developed under subparagraph (a) of this paragraph is as simple, clear, and easy to understand as possible.

(6) If an individual who files a tax return makes the election described in paragraph (3) of this subsection, the State Treasurer shall convey to the department all eligibility-relevant information contained on the return for all individuals included in that tax return.

d. The State Treasurer shall waive the State shared responsibility tax imposed pursuant to section 3 of P.L.2018, c.31 (C.54A:11-3) applicable to months of the year that the tax return is filed for any taxpayer who chooses the checkoff box described in paragraph (3) of subsection c. of this section. If the taxpayer fails to enroll in minimum essential coverage and maintain that coverage in each month following the enrollment period, the taxpayer shall be liable for any payments to which the taxpayer would have otherwise been subject.

e. The State Treasurer shall coordinate the requirements of this subsection with the requirements of the "New Jersey Health Insurance Market Preservation Act," P.L.2018, c.31 (C.54A:11-1 et seq.).

§ 17B:27A-59.7 Consenting to information sharing, system established.

7. a. An individual that consents to share information through the system established pursuant to section 8 of this act shall be eligible for a special enrollment period pursuant to subsection b. of this section. The Department of Banking and Insurance shall determine, in accordance with sections 3 and 4 of this act, whether the individual is eligible for the State Medicaid program or the NJ FamilyCare Program, premium tax credits, or cost-sharing reductions.

b. (1) The Department of Banking and Insurance shall establish a special enrollment period for the New Jersey individual health insurance market.

(2) The enrollment period described in this section shall last for a period of time, to be determined by the Department of Banking and Insurance, that shall not be shorter than 30 days.

c. The Department of Banking and Insurance shall conduct outreach to affected individuals, using methods that may include written notices and the provision of individualized assistance by insurance agents and brokers, navigators, tax preparers, and contractors and staff.

§ 17B:27A-59.8 Unemployment claim, indication of interest in obtaining minimum coverage, information sharing, consent.

8. a. The Department of Labor and Workforce Development shall implement a system through which an individual who has filed a claim for unemployment insurance benefits may, as part of the claim filing application, indicate that the individual is interested in obtaining minimum essential coverage and consent to the sharing of relevant information collected by the Department of Labor and Workforce Development with the Department of Banking and Insurance and the Department of Human Services to determine whether the individual qualifies for the State Medicaid program or the NJ FamilyCare Program, or any other insurance affordability assistance and to support minimum essential coverage outreach and enrollment efforts. If an individual indicates that the individual is interested in obtaining minimum essential coverage and consents to share information pursuant to this subsection, then the Department of Labor and Workforce Development shall notify the Department of Banking and Insurance, which may assess or determine, as appropriate, eligibility for insurance affordability assistance or make, or refer to the Department of Human Services to make, an assessment or determination, as appropriate, of eligibility for the State Medicaid program or the NJ FamilyCare Program.

b. The Department of Labor and Workforce Development shall enter into an agreement with the Department of Banking and Insurance and the Department of Human Services, before the system described in subsection a. of this section begins to operate, that enables the system to operate in compliance with all applicable State and federal requirements related to privacy, data security, and funding.

c. The consent request described in subsection a. of this section shall be prominently placed on the claim filing application in clear and understandable language that is easy to read.

d. The Department of Labor and Workforce Development shall cooperate with the Department of Banking and Insurance and the Department of Human Services to claim the maximum amount of available federal funding for the establishment and operation of the system established pursuant to this section.

e. To facilitate the most efficient implementation of the system, the Commissioner of Banking and Insurance, the Commissioner of Human Services, and the Commissioner of Labor and Workforce Development may enter into agreements, adopt regulations and guidelines, establish accounts, conduct trainings, provide public information, educate tax preparers, and take any other steps as may be necessary to accomplish the purpose of the system.

§ 17B:27A-60 Essential health benefits defined.

3. In defining the essential health benefits pursuant to P.L.2019, c.354 (C.17B:27A-7.26 et al.), the commissioner shall:

a. ensure that the essential health benefits shall be at least as comprehensive as the essential health benefits required of plans subject to the essential health benefits requirements of the Affordable Care Act as of January 1, 2019;

b. ensure that the essential health benefits reflect an appropriate balance among the categories described in P.L.2019, c.354 (C.17B:27A-7.26 et al.), so that benefits shall not be unduly weighted toward any category;

c. not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;

d. take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;

e. ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life;

f. provide that if a stand-alone dental plan is offered through the exchange, another health plan offered through the exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required; and

g. periodically review the essential health benefits under P.L.2019, c.354 (C.17B:27A-7.26 et al.), and provide a report to the Governor and the Legislature that provides:

(1) an assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost;

(2) an assessment of whether the essential health benefits need to be modified or updated to account for changes in medical evidence or scientific advancement;

(3) information on how the essential health benefits will be modified to address any gaps in access or changes in the evidence base; and

(4) an assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations described in P.L.2019, c.354 (C.17B:27A-7.26 et al.);

h. periodically update the essential health benefits to address any gaps in access to coverage or changes in the evidence base the commissioner identifies in the review conducted pursuant to this section; and

i. establish limits on the dollar amounts of cost-sharing that may be imposed pursuant to a plan with respect to self-only coverage or coverage other than self-only coverage for a plan year. The limits initially established pursuant to this subsection shall not exceed the dollar amounts in effect under section 1302 of the Patient Protection and Affordable Care Act, Pub. L. 111-148 (42 U.S.C. s.18022), as those limits were in effect on June 1, 2020.

§ 17B:27A-61 Carrier seeking rate increase.

1. In addition to any other applicable laws or regulations, a carrier that seeks a rate increase as part of an informational filing for an individual or small employer health benefits plan shall comply with all of the provisions of this act. The Department of Banking and Insurance shall review informational filings that are subject to this act in the manner set forth in the provisions of this act.

§ 17B:27A-62 Information to support, justify rate requests.

2. a. An informational rate filing by a carrier for an individual or small employer health benefits plan offered in this State shall contain information to support and justify rate requests. A rate increase shall be subject to expanded review by the department pursuant to the provisions of this act if the informational rate filing requests a rate increase of 10 percent or more annually.

b. A rate increase meets or exceeds 10 percent annually if the average increase for all enrollees weighted by premium volume for any plan within the product meets or exceeds the 10 percent threshold.

c. With respect to small employer plans, rate increases submitted on a quarterly basis shall be considered both for each specific quarter and in combination with any previous quarterly rate increase or increases applicable to the same calendar year when determining whether the rate increase meets or exceeds the 10 percent threshold for expanded review.

d. For the purposes of this act, "informational filing" means a submission, by a carrier to the department, of rate-filings 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 required by the department.

§ 17B:27A-63 Additional information requested by department.

3. a. If the department determines that a carrier's requested rate increase exceeds the 10 percent threshold for expanded rate review set forth in section 2 of this act, the department shall require the carrier to submit to the department, in addition to any other information required to be filed, a written description justifying the rate increase that complies with all of the provisions of this section.

b. The carrier shall include in its written description all information prescribed by the department, including:

(1) a simple and brief narrative describing the data and assumptions that were used to develop the rate increase;

(2) an explanation of the most significant factors causing the rate increase, including a brief description of the relevant claims and non-claims expense increases reported in the rate increase summary;

(3) a brief description of the overall experience of the plan, including historical and projected expenses, and loss ratios; and

(4) an actuarial memorandum that contains the reasoning and assumptions supporting the data.

c. (1) Upon completion of the department's review of the rate filing, the department shall promptly make available to the public a consumer-friendly version of the written description justifying the rate increase as provided by the carrier, excluding information that is a trade secret or that is confidential commercial or financial information.

(2) The department shall include on its website, along with each written description posted on the website, information that explains:

(a) the purpose and role of the expanded rate review process; and

(b) how the public can submit comments to the department on the written description justifying the rate increase.

§ 17B:27A-64 Disclosure of information.

4. a. Any information filed with the department pursuant to this act may be disclosed in accordance with P.L.1963, c.73 (C.47:1A-1 et seq.), except that confidential information shall not be disclosed by the department to any person other than employees and representatives of the department.

b. A carrier shall separately identify any confidential information filed with the department pursuant to this act. Any information that is not identified as confidential information shall be considered public information and subject to disclosure.

c. As used in this section, "confidential information" means information contained in an actuarial memorandum filed with the department pursuant to this act that has been certified by the actuary preparing the memorandum as confidential or proprietary information.

§ 17B:27A-65 Definitions relative to certain assessments.

1. As used in this act:

"Commissioner" means the Commissioner of Banking and Insurance.

"Entity subject to this act" or "entity" means an insurance company, health service corporation, hospital service corporation, medical service corporation, health maintenance organization, or dental plan organization authorized to issue health benefits or dental benefits plans in this State. "Entity" shall include a multiple employer welfare arrangement that is initially registered pursuant to the "Self-Funded Multiple Employer Welfare Arrangement Regulation Act," P.L.2001, c.352 (C.17B:27C-1 et seq.) after the date of enactment of this act. "Entity" shall not include a dental service corporation or a multiple employer welfare arrangement that is registered pursuant to the "Self-Funded Multiple Employer Welfare Arrangement Regulation Act," P.L.2001, c.352 (C.17B:27C-1 et seq.) as of the date of enactment of this act.

"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through an entity subject to this act, including a vision or dental plan as defined pursuant to section 1 of P.L.2014, c.70 (C.26:2S-26). For the purposes of this act, "health benefits plan" shall not include the following plans, policies or contracts: Medicaid, Medicare, Medicare Advantage, Medicare supplement, accident only, credit, disability, long-term care, TRICARE supplement coverage, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.), small employer health benefits plans issued pursuant to P.L.1992, c.162 (C.17B:27A-17),and hospital confinement indemnity coverage.

"Net written premiums" means the premiums earned in this State on health benefits plans, less return premiums thereon and dividends paid or credited to policy or contract holders on the health benefits plan business. Net earned premium shall include the aggregate premiums earned on the entity's insured group and individual business, excluding premiums from any Medicaid or NJ FamilyCare contracts.

§ 17B:27A-66 Filing of net written premiums.

2. a. An entity subject to this act shall annually file with the commissioner its net written premiums for the preceding year, no later than April 1 of each year.

b. The commissioner shall calculate and issue to the entity a certified assessment, which shall be 2.5% of the entity's net written premiums.

c. An entity shall annually pay the assessment issued pursuant to subsection b. of this section to the State Treasurer no later than May 1 of each year, as prescribed by the commissioner.

d. If the commissioner determines that the amount of the assessment calculated pursuant to this section shall reduce the State's total revenue, the commissioner may reduce the assessment.

§ 17B:27A-67 "Health Insurance Affordability Fund."

3. a. There is established in the Department of the Treasury a nonlapsing revolving fund to be known as the "Health Insurance Affordability Fund." This fund shall be the repository for all monies collected pursuant to this act. As directed by the commissioner, in consultation with the Commissioners of the Department of Human Services and the Department of Health, the monies in the fund shall be used only for the purposes of increasing affordability in the individual market and providing greater access to health insurance to the uninsured, including minors, with a primary focus on households with an income below 400 percent of the federal poverty level, expanding eligibility, or modifying the definition of affordability in the individual market, through subsidies, reinsurance, tax policies, outreach and enrollment efforts, buy-in programs, such as the NJ FamilyCare Advantage Program, or any other efforts that can increase affordability for individual policyholders or that can reduce racial disparities in coverage for the uninsured.

b. The monies in the fund shall be invested and reinvested by the Director of the Division of Investment in the Department of the Treasury to the same extent that other trust funds that are in the custody of the State Treasurer are invested and reinvested, in the manner provided by law. Interest received on the monies in the fund shall be credited to the fund.

c. The report required pursuant to section 3 of P.L.2019, c.141 shall set forth the impacts of the measures taken pursuant to this act on affordability and reductions in racial disparities in health insurance coverage, including impacts by income level, race, and immigration status. The report shall make recommendations to increase affordability and reduce the uninsured rate in New Jersey, as appropriate, based on the data available to the department.

d. (1) The assessments collected pursuant to section 2 of this act shall be deposited to the Health Insurance Affordability Fund and shall be used for the purposes set forth in subsection a. of this section. Beginning in State Fiscal Year 2021, and each State fiscal year thereafter, if 100 percent of the money appropriated from the Health Insurance Affordability Fund is not used for the purposes set forth in subsection a. of this section on the effective date of an annual appropriations act for the State fiscal year, or if an amendment or supplement to an annual appropriations act for the State fiscal year appropriates money from the Health Insurance Affordability Fund to a purpose not set forth in subsection a. of this section, the Director of the Division of Budget and Accounting in the Department of the Treasury shall, not later than five days after the enactment of the annual appropriations act, or an amendment or supplement thereto, that appropriates money from the Health Insurance Affordability Fund to a purpose not set forth in subsection a. of this section, certify to the Director of the Division of Taxation and the Commissioner of Banking and Insurance that the requirements of this section have not been met.

(2) The Commissioner of Banking and Insurance shall, no later than five days after certification by the Director of the Division of Budget and Accounting in the Department of the Treasury pursuant to paragraph (1) of this subsection that the requirements of this section have not been met by the annual appropriations act, or an amendment or supplement to the annual appropriations act, notify each entity that the assessment imposed pursuant to section 2 of this act shall no longer be paid or collected.

Chapter 27B

§ 17B:27B-1 Definitions relative to third party administrators, billing services.

1. As used in this act:

"Benefits payer" means an insurer authorized to issue health or dental benefits plans in this State, or any other person who undertakes to provide and assumes financial risk for the payment of health or dental benefits and is obligated to pay claims for health or dental benefits to providers or other claimants.

"Client" means a health care provider that contracts with a third party billing service to remit claims to benefits payers on behalf of the provider or other claimant.

"Commissioner" means the Commissioner of Banking and Insurance.

"Enrollee" means a person entitled to receive benefits under a health benefits plan.

"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense or dental benefits for covered services.

"Health care provider" or "provider" means an individual or entity which provides a covered benefit or service.

"Insurer" means a licensed health insurer, health, hospital or medical service corporation, health maintenance organization, dental service corporation or dental plan organization.

"Third party administrator" means a person or entity that: processes claims and pays claims on behalf of a benefits payer without the assumption of financial risk for the payment of health or dental benefits. Third party administrator shall include: (1) an entity not licensed as an insurer that is not an affiliate or subsidiary of an insurer, that processes claims on behalf of a benefits payer; (2) an entity that is a subsidiary or affiliate of an insurer that processes claims on behalf of the insurer; and (3) an entity that is a subsidiary or affiliate of an insurer that only processes claims on behalf of benefits payers other than insurers. Third party administrator shall not include an employee, affiliate or subsidiary of a benefits payer formed for the purpose of processing and paying claims solely on behalf of the benefits payer, nor shall it include a collection agency or bureau or pharmacy benefits manager.

"Third party billing service" means a person or entity that is paid by a health care provider to process claims or claims payments on behalf of the health care provider.

§ 17B:27B-2 Licensure, registration required for third party administrators.

2. a. On or after January 1, 2002, no person shall act as, offer to act as, or hold himself out to be, a third party administrator in this State unless licensed or registered by the commissioner in accordance with this act. Every third party administrator that is either: (1) an entity that is not licensed as an insurer and is not an affiliate or subsidiary of an insurer; or (2) an entity that is an affiliate or a subsidiary of an insurer that only processes or pays claims on behalf of benefits payers other than insurers shall be licensed under the provisions of this act. Every third party administrator that is an entity that is a subsidiary or affiliate of an insurer that processes claims on behalf of both the insurer and benefits payers other than the insurer shall be registered with the commissioner pursuant to the provisions of this act.

b. Application for licensure shall be made to the commissioner on a form provided by the commissioner. The commissioner shall establish by regulation the information that shall accompany the application, which may include, but need not be limited to:

(1) a copy of the applicant's basic organizational documents, which shall include articles of incorporation, articles of association, partnership agreement, management agreement, trust agreement or other documents governing the operation of the applicant that are applicable to the applicant's form of business organization;

(2) a copy of the executed bylaws, rules and regulations, or other documents relating to the operation of the applicant's internal affairs;

(3) the names, addresses and official positions of the persons responsible for the conduct of the affairs of the applicant, including, but not limited to, if applicable: the members of the board of directors, executive committee or other governing board or committee; the principal officers or partners; shareholders owning or having the right to acquire 10% or more of the voting securities of the corporation or partnership interest of a partnership, or equity interest, in the case of another form of business organization; each person who has loaned funds to the applicant for the operation of its business; a statement of any criminal convictions and civil, regulatory or enforcement action, including actions related to professional licensing, taken or pending against any principal officer or owner of the applicant; and the relationship with any other business entity, including a parent corporation;

(4) a copy of the applicant's most recent financial statements audited by an independent certified public accountant. If the financial affairs of the applicant's parent company are audited by an independent certified public accountant, but those of the applicant are not, then a copy of the most recent audited financial statement of the applicant's parent company, audited by an independent certified public accountant, shall be submitted. A consolidated financial statement of the applicant and its parent company shall satisfy this requirement unless the commissioner determines that additional or more recent financial information is required for the proper administration of this act;

(5) a copy of the applicant's business plan, including information on staffing levels and the activities undertaken or to be undertaken in this State. The plan shall include a statement of the administrator's capability for providing a sufficient number of experienced and qualified personnel in the areas of claims processing and record keeping and a three-year projection of anticipated operating results, a statement of the sources of working capital and any other sources of funding and provision for contingencies that enable the applicant to perform the work for which it has contracted;

(6) a list of the benefits payers under contract with the applicant and a copy of the standard contract or contracts used by the applicant in the course of business; and

(7) a power of attorney, duly executed by the applicant, if not domiciled in this State, appointing the commissioner and his successors in office as the true and lawful attorney of the applicant in and for this State upon whom all lawful process in any legal action or proceeding against the organization on a cause of action arising in this State may be served.

With respect to an applicant for licensure that is an affiliate or subsidiary of an insurer, the commissioner shall establish by regulation the information necessary to be filed, which shall not be unnecessarily duplicative of any information already on file with the Department of Banking and Insurance.

An application for licensure shall be approved if not disapproved by the commissioner within 60 days of receipt of a completed application. An application shall be deemed to be complete if all of the information required to be submitted to the commissioner by regulation has been submitted by the applicant.

c. Registration shall be on a form prescribed by the commissioner, which shall include: (1) a copy of the applicant's basic organizational documents, as required by the commissioner; (2) the names and official positions of the persons responsible for the conduct of the affairs of the applicant; (3) a copy of the applicant's most recent financial statements, or a consolidated financial statement of the applicant and its parent company; (4) such other information as the commissioner may require. An application for registration shall be approved if not disapproved by the commissioner within 60 days of receipt of a completed application. For the purposes of this subsection, an application shall be complete if all of the information required to be submitted to the commissioner by regulation has been submitted by the applicant. Information required pursuant to this subsection shall not be unnecessarily duplicative of any information already on file with the Department of Banking and Insurance.

§ 17B:27B-3 Additional information required for licensure, registration.

3. In addition to the information required by section 2 of this act, the applicant for licensure or registration shall file with the commissioner:

a. a description of the applicant's proposed method of marketing its services;

b. a statement setting forth the means by which the applicant is to be compensated;

c. a description of the complaint and appeals procedures instituted by the applicant; and

d. a description of the quality assurance procedures established by the applicant.

An applicant shall make available for inspection by the commissioner copies of all standard contracts with benefits payers or other persons with whom it does business, including subcontractors and reinsurers. In the case of an applicant for registration, the information required to be filed with the commissioner shall apply only to services provided to benefits payers other than an insurer.

§ 17B:27B-4 Issuance of license, approval of application for registration.

4. The commissioner may issue a license to an applicant or approve an application for registration as a third party administrator if he finds that the applicant meets the standards established by this act, including, but not limited to, the following:

a. all of the materials required by this act or by the commissioner have been filed;

b. the persons responsible for conducting the applicant's affairs are competent, trustworthy and possess good reputations, and have appropriate experience, training and education;

c. the applicant has demonstrated the ability to assure that its services will be performed in a manner which will ensure the efficient operation of its business, including appropriate financial controls;

d. the standard contract forms to be used by the applicant are acceptable;

e. the applicant has adequate financial arrangements with the benefits payers for which it will perform its services and adequate arrangements for complying with the provisions of P.L.1999, c.154 (C.17B:30-23 et al.); and

f. the compensation arrangements made between the applicant and benefits payers do not result in the assumption of financial risk by the applicant.

In the case of an applicant for registration, the provisions of subsections d., e., and f. of this section shall apply only to services provided by the applicant to benefits payers other than an insurer.

§ 17B:27B-5 Denial of license, registration.

5. The commissioner may deny an application for licensure or registration as a third party administrator if he finds that any of the standards established by this act have not been met or for any other reasonable grounds. If the application for licensure or registration is denied, the commissioner shall notify the applicant in writing by certified mail, return receipt requested, setting forth his reasons for denial. The applicant may request a hearing by notice to the commissioner no later than the 30th day following receipt of the notice of denial.

§ 17B:27B-6 Provisions of written agreement; requirements.

6. A third party administrator shall not conduct any business with a benefits payer in the absence of a written agreement between the administrator and the benefits payer, except that this shall not apply to a third party administrator registered under the provisions of section 2 of this act with respect to services performed for an insurer. The agreement shall be retained as part of the official records of the administrator for the duration of the agreement and for five years thereafter. The provisions of the agreement shall include, but shall not be limited to:

a. the services to be provided by the administrator and the means by which the administrator is to be compensated;

b. the responsibilities of the benefits payer to the administrator with respect to claims to be paid by the administrator on behalf of a benefits payer, including: the provision of enrollment and eligibility information; arrangement for a preliminary or escrowed deposit of funds by the benefits payer, if any; the method used for the transmittal of funds from the benefits payer to the administrator; notification by the benefits payer of modifications in the benefits payer's benefits plan; provisions setting forth the respective liability of the administrator and benefits payer for payment of ineligible claims; liability for claims payments that are overdue; and provisions regarding the procurement of reinsurance or stop-loss insurance; and

c. the responsibilities of the administrator to the benefits payer, including: the maintenance of appropriate back-up systems against the loss of records; establishment and maintenance of appropriate financial controls; provisions regarding the benefits payer's rights with respect to conducting claims audits by an outside auditor; the maintenance of appropriate insurance coverage, which may include, but not be limited to, general liability insurance, valuable papers insurance and errors and omissions coverage; appropriate access by the benefits payer to the administrator's records; and procedures for making available the claims experience or other information to the benefits payer at its request, including, but not limited to, monthly reports.

§ 17B:27B-7 Access to books, records.

7. a. The commissioner shall have access to all books and records of a third party administrator for the purposes of examination, audit and inspection. Any trade secrets, proprietary information or the identity and addresses of enrollees contained in the books and records shall be kept confidential, except that the commissioner may use the information in any proceeding instituted against the administrator.

b. The benefits payer shall own the records generated by the administrator pertaining to the benefits payer, except that the administrator shall retain the right to continuing access to books and records to permit the administrator to fulfill all of its contractual obligations to the benefits payer.

c. In the event that an agreement between an administrator and a benefits payer is canceled, notwithstanding the provisions of section 6 of this act to the contrary, the administrator may, with the written agreement of the benefits payer, transfer all records to a new administrator instead of retaining them for five years.

§ 17B:27B-8 Payment to third party administrators not based solely on claims denials.

8. If a third party administrator adjudicates claims under a health benefits plan, the commissions, fees or charges that the benefits payer pays the administrator, shall not be based solely on the number or amount of claims denied by the administrator. This provision shall not prohibit an administrator from receiving performance-based compensation if that compensation is not predicated on denial of claims or coverage.

§ 17B:27B-9 Fiduciary responsibility of third party administrators.

9. a. A third party administrator shall be deemed to act in a fiduciary capacity on behalf of the benefits payer in the receipt and transmittal of the benefits payer's funds, and shall have all responsibility attendant to a fiduciary as established by law. Funds transmitted shall be kept in a separate account and shall not be commingled with any other funds. If an account is jointly held by the administrator and the benefits payer, it shall be deposited in a State or federally chartered insured depository institution, and the administrator shall provide a monthly accounting of all transactions in that account. A benefits payer shall have the responsibility to make funds necessary to pay the claims available to the administrator in a timely manner, as provided in the contract. An administrator shall not be liable to any party for the failure of the benefits payer to make funds available to pay claims.

b. An administrator shall maintain in force a fidelity bond in its own name on its officers and employees, in an amount established by the commissioner by regulation.

§ 17B:27B-10 Separate accounts for funds remitted.

10. All funds remitted to an administrator by a benefits payer licensed or authorized to do business in this State shall be held by the third party administrator in a separate account maintained in the name of the benefits payer or in a separate account maintained jointly in the names of the benefits payer and the administrator. If funds have been collected by the administrator from a provider or enrollee on behalf of a benefits payer, they shall be maintained in a separate account maintained in the name of the benefits payer, maintained jointly in the names of the benefits payer and the administrator or remitted to the benefits payer, as provided in the contract. Copies of all records pertaining to the collection of funds shall be made available to the benefits payer as provided in the contract.

§ 17B:27B-11 Prompt delivery of communications to enrollees.

11. Any policies, certificates, booklets, termination notices or other written communications delivered by the benefits payer to the third party administrator for delivery to enrollees shall be delivered by the administrator promptly, in accordance with the instructions of the benefits payer.

§ 17B:27B-12 Notification of material changes to commissioner.

12. A third party administrator shall immediately notify the commissioner of any material change in its ownership, control or other fact or circumstance affecting its qualification for a license.

§ 17B:27B-13 Annual reports.

13. A third party administrator shall file an annual report for the preceding calendar year with the commissioner on or before March 1 of each year, in a form and manner prescribed by the commissioner. The annual report shall contain the complete names and addresses of all benefits payers with which the administrator had a contract in effect during the preceding calendar year. The commissioner shall establish a filing fee for the report, by regulation.

§ 17B:27B-14 Suspension, revocation of license, registration.

14. The commissioner may suspend or revoke a license or registration issued pursuant to this act if he finds that the third party administrator:

a. is in an unsound financial condition;

b. is using methods or practices in the conduct of its business that render its further transaction of business in this State hazardous or injurious to the benefits payers with which it has contracted or the public;

c. has failed to pay any judgment rendered against it in this State within 60 days after the judgment has become final;

d. has violated any lawful rule or order of the commissioner or any provision of State law;

e. has refused to be examined or produce its accounts, records and files for examination, or if any of its officers has refused to give information with respect to its affairs or has refused to perform any other legal obligation as to an examination, when required by the commissioner;

f. has, without just cause, refused or failed to pay proper claims or perform services arising under its contracts;

g. at any time fails to meet any qualification for which issuance of the license could have been refused had that failure then existed and been known to the commissioner;

h. has been convicted of, or has entered a plea of guilty or nolo contendere to a felony or crime of the first, second or third degree in this State, without regard to whether adjudication was held;

i. is under suspension or revocation in another state; or

j. has willfully reimbursed enrollees for benefits not eligible under the benefits payer's benefits plan.

If the commissioner finds that one or more grounds exist for the suspension or revocation of a certificate of authority issued under this act, the commissioner may, in lieu of suspension or revocation, impose a fine upon the administrator.

§ 17B:27B-15 Immediate suspension of license, registration, grounds.

15. The commissioner may, without advance notice or hearing, immediately suspend the license or registration of a third party administrator if he finds that one or more of the following circumstances exist:

a. the administrator is insolvent or impaired;

b. a proceeding for receivership, conservatorship, rehabilitation or other delinquency proceeding regarding the administrator has been commenced in another state; or

c. the financial condition or business practices of the administrator otherwise pose an imminent threat to the public health, safety or welfare of the residents of this State.

§ 17B:27B-16 Certification required for third party billing services.

16. On or after January 1, 2002, no person shall act as, offer to act as or hold himself out to be a third party billing service in this State unless certified by the commissioner in accordance with this act. Application for certification shall be made to the commissioner on a form provided by the commissioner. The commissioner shall establish by regulation the information that shall accompany the application, which shall include, but need not be limited to:

a. a copy of the applicant's basic organizational documents, which shall include articles of incorporation, articles of association, partnership agreement, management agreement, trust agreement or other documents governing the operation of the applicant that are applicable to the applicant's form of business organization;

b. a copy of the executed bylaws, rules and regulations, or other documents relating to the operation of the applicant's internal affairs;

c. the names, addresses and official positions of the persons responsible for the conduct of the affairs of the applicant, including, but not limited to, if applicable: the members of the board of directors, executive committee or other governing board or committee, the principal officers or partners, shareholders owning or having the right to acquire 10% or more of the voting securities of the corporation or partnership interest of a partnership or equity interest, in the case of another form of business organization;

d. if the applicant accepts monies from benefits payers on behalf of clients, the application shall include a copy of the applicant's most recent financial statements audited by an independent certified public accountant;

e. a copy of the applicant's business plan, including information on staffing levels and the activities undertaken or to be undertaken in this State. The plan shall include a statement of the third party billing service's capability for providing a sufficient number of experienced and qualified personnel in the areas of claims processing and record keeping;

f. a list of the applicant's clients and a copy of the standard contract or contracts used by the applicant in the course of business; and

g. if the applicant accepts monies from benefits payers on behalf of clients, the application shall be accompanied by a power of attorney, duly executed by the applicant, if not domiciled in this State, appointing the commissioner and his successors in office as the true and lawful attorney of the applicant in and for this State upon whom all lawful process in any legal action or proceeding against the organization on a cause of action arising in this State may be served.

§ 17B:27B-17 Additional information to be filed by third party billing services.

17. In addition to the information otherwise required by this act or by the commissioner, a third party billing service shall file with the commissioner:

a. a description of the applicant's proposed method of marketing its services;

b. a statement setting forth the means by which the applicant is to be compensated;

c. a description of the quality assurance procedures established by the applicant; and

d. a copy of the standard contract or contracts used by the applicant in contracting with providers.

§ 17B:27B-18 Approval of applications for certification.

18. The commissioner may approve an application for certification as a third party billing service if he finds that the applicant meets the standards established by this act, including, but not limited to, the following:

a. all of the material required by this act or by the commissioner have been filed;

b. the persons responsible for conducting the applicant's affairs are competent, trustworthy and possess good reputations, and have appropriate experience, training and education;

c. the applicant has demonstrated the ability to ensure that its services will be performed in a manner which will result in the efficient operation of its business, including, if the applicant accepts payments from benefits payers on behalf of its clients, appropriate financial controls;

d. the standard contract forms to be used by the applicant are acceptable; and

e. the applicant has adequate arrangements for complying with the provisions of P.L.1999, c.154 (C.17B:30-23 et al.).

§ 17B:27B-19 Denial of applications for certification.

19. The commissioner may deny an application for certification as a third party billing service if he finds that any of the standards established by this act have not been met or for any other reasonable grounds. If the application for certification is denied, the commissioner shall notify the applicant in writing by certified mail, return receipt requested, setting forth his reasons for denial. The applicant may request a hearing by notice to the commissioner no later than the 30th day following receipt of the notice of denial.

§ 17B:27B-20 Written agreements required for conducting business as third party billing service.

20. A third party billing service shall not conduct any business with a client in the absence of a written agreement between the billing service and the client. The agreement shall be retained as part of the official records of the third party billing service for the duration of the agreement.

The agreement shall include the services to be provided by the third party billing service on behalf of the client; financial arrangements to be used if the third party billing service accepts monies from benefits payers on behalf of a client; provisions setting forth the respective liability of the client and the third party billing service for the accuracy and eligibility of submitted claims, and for the prompt submission of claims pursuant to the provisions of P.L.1999, c.154 (C.17B:30-23 et al.); and the responsibilities of the third party billing service to the client with respect to the maintenance of appropriate back-up systems against the loss of records, and the maintenance of appropriate insurance coverage by the third party billing service against the risk of loss.

§ 17B:27B-21 Fiduciary responsibility of third party billing services.

21. A third party billing service that accepts monies from health benefits payers on behalf of a client shall be deemed to act in a fiduciary capacity on behalf of the client in the receipt and transmittal of funds and shall have all responsibility attendant to a fiduciary as established by law. Monies transmitted by benefits payers or on behalf of clients shall be kept in a separate account maintained in the name of the client or jointly in the names of the client and the third party billing service and shall not be commingled with any other funds of the third party billing service or other clients of the third party billing service.

§ 17B:27B-22 Notification of material changes to commissioner.

22. a. A third party billing service shall immediately notify the commissioner of any material change in its ownership, control, or other fact or circumstance affecting its qualification for certification.

b. A third party billing service shall file such reports, at such times as may be required by the commissioner, including reports that will verify compliance with the provisions of P.L.1999, c.154 (C.17B:30-23 et al.).

§ 17B:27B-23 Suspension, revocation of certification.

23. The commissioner may suspend or revoke a certification issued pursuant to this act if he finds that the third party billing service:

a. is using methods or practices in the conduct of its business that render its further transaction of business in this State hazardous or injurious to its clients or the public;

b. has failed to pay any judgment rendered against it within 60 days after the judgment has become final;

c. has violated any lawful rule or order of the commissioner or any provision of the laws of this State;

d. has, without just cause, refused or failed to perform services arising under its contracts with clients;

e. has been convicted of, or has entered a plea of guilty or nolo contendere to a felony or crime of the first, second or third degree in this State, without regard to whether adjudication was held; or

f. is under suspension or revocation in another State.

If the commissioner finds that one or more grounds exist for the suspension or revocation of a certification issued under this act, the commissioner may, in lieu of suspension or revocation, impose a fine upon the third party billing service.

§ 17B:27B-24 Violations, penalties.

24. The commissioner may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $250 nor more than $5,000 for each day that a third party administrator or third party billing service is in violation of this act. A penalty imposed by the commissioner pursuant to this section may be in lieu of, or in addition to, suspension or revocation of a license pursuant to this act. A penalty may be recovered in a summary proceeding pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.).

§ 17B:27B-25 Rules, regulations.

25. The commissioner shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to carry out the purposes of this act.

Chapter 27C

§ 17B:27C-1 Short title.

1. This act shall be known and may be cited as the "Self-Funded Multiple Employer Welfare Arrangement Regulation Act."

§ 17B:27C-2 Purposes of act.

2. The purposes of this act are to:

a. provide for the registration of self-funded or partially self-funded multiple employer welfare arrangements;

b. regulate self-funded or partially self-funded multiple employer welfare arrangements in order to ensure the financial integrity of the arrangements;

c. provide reporting requirements for self-funded or partially self-funded multiple employer welfare arrangements; and

d. provide for sanctions against self-funded or partially self-funded multiple employer welfare arrangements that do not comply with the provisions of this act.

§ 17B:27C-3 Definitions relative to self-funded multiple employer welfare arrangements.

3. For purposes of this act:

"Association" means a group of 100 or more persons organized and maintained in good faith for purposes other than that of obtaining insurance, in active existence for more than one year, having a constitution and bylaws that provide that: the association holds regular meetings not less than annually to further the purposes of the members; except for credit unions, the association collects dues or solicits contributions from members; and the members have voting privileges and representation on the governing board and committees.

"Commissioner" means the Commissioner of Banking and Insurance.

"Employee welfare benefit plan" has the meaning set forth in subsection (1) of 29 U.S.C. s.1002.

"Large employer" means a member employer with more than 50 eligible employees, as defined by section 1 of P.L.1992, c.162 (C.17B:27A-17).

"Multiple employer welfare arrangement" has the meaning set forth in subsection (40) of 29 U.S.C. s.1002.

"Self-funded multiple employer welfare arrangement" means a self-funded or partially self-funded multiple employer welfare arrangement that provides for health benefits plans that has two or more employers who each have two or more employees and that has one or more of the employer members either domiciled in this State or its principal headquarters or principal administrative office located in this State.

"Small employer" means the same as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).

§ 17B:27C-4 Annual registration, fee.

4. A self-funded multiple employer welfare arrangement shall register annually with the commissioner and pay a registration fee established by the commissioner which shall not exceed $1,000.

§ 17B:27C-5 Deposit, maintenance of cash, securities.

5. a. A self-funded multiple employer welfare arrangement shall deposit and continuously maintain with a financial institution licensed in this State, cash or securities as defined in N.J.S. 17B:18-37, having an admitted asset value of not less than $200,000. The deposit shall be held for the benefit and protection of all covered members of the self-funded multiple employer welfare arrangement. The self-funded multiple employer welfare arrangement shall further maintain a cash reserve for loss in an amount established by a qualified actuary as being adequate to provide for all incurred losses including unpaid claims.

b. A self-funded multiple employer welfare arrangement shall maintain aggregate stop-loss coverage, with a retention level of 125 percent of expected claims per year, including provisions to cover incurred, unpaid claims liability in the event of the termination or liquidation of the self-funded multiple employer welfare arrangement, and specific stop-loss coverage, with a retention level determined annually by a qualified actuary based on sound actuarial principles. Any stop-loss contract maintained pursuant to this subsection shall contain a provision that the stop-loss insurer shall give the self-funded multiple employer welfare arrangement and the commissioner a minimum of 180 days' notice of cancellation or nonrenewal. If the self-funded multiple employer welfare arrangement fails to secure replacement coverage within 90 days after receipt of the notice of cancellation or nonrenewal, the trustees of the self-funded multiple employer welfare arrangement shall provide for the orderly liquidation of the self-funded multiple employer welfare arrangement.

§ 17B:27C-6 Required filings.

6. Each self-funded multiple employer welfare arrangement shall file all of the following with the commissioner:

a. No later than May 15th of each calendar year or four months and 15 days after the end of each fiscal year of the self-funded multiple employer welfare arrangement, financial statements audited by a certified public accountant and on forms prescribed by the commissioner, an actuarial opinion rendered by a qualified actuary, a report of its Risk-Based Capital (RBC) as of the end of the immediately preceding calendar year, in a form and containing such information as is required by the instructions adopted by the National Association of Insurance Commissioners for health insurers, as amended from time to time and proof of the deposit required in accordance with section 5 of this act. The opinion shall be based on standards adopted from time to time by the Actuarial Standards Board and on any additional standards that the commissioner may prescribe by regulation. For purposes of this section and section 5 of this act, "qualified actuary" means a member in good standing of the American Academy of Actuaries who meets the requirements set forth in regulations of the commissioner.

b. Within 60 days after the end of each fiscal quarter, unaudited financial statements on forms prescribed by the commissioner, affirmed by an appropriate officer or agent of the self-funded multiple employer welfare arrangement.

c. Within 60 days after the end of each fiscal quarter, a report on forms prescribed by the commissioner certifying that the self-funded multiple employer welfare arrangement maintains cash or liquid assets in a claim reserve account sufficient to meet the requirements of section 5 of this act.

d. The information required to be filed pursuant to subsections a., b., and c. of this section shall be certified by an officer of the self-funded multiple employer welfare arrangement.

e. A majority of the board of trustees of a self-funded multiple employer welfare arrangement shall represent participating employer members, and at least one trustee shall be a non-participating independent trustee chosen by a majority vote of the trustees.

f. The self-funded multiple employer welfare arrangement shall establish and maintain a website upon which all of the filings required pursuant to this section and information concerning its governance and financial performance shall be publicly available for a period of at least five years after the reporting period. This website shall also, at all times, indicate the status of the deposit required to be continuously maintained with a financial institution licensed in this State, pursuant to subsection a. of section 5 of P.L.2001, c.352 (C.17B:27C-5) and the name of that institution.

§ 17B:27C-7 Liability of members.

7. a. The liability of each member for the obligations of the self-funded multiple employer welfare arrangement shall be individual, several and proportionate, but not joint, except as provided in this section.

b. Each member shall have a contingent assessment liability pursuant to subsection c. of this section. Each benefit plan issued by a self-funded multiple employer welfare arrangement shall contain a statement of the contingent liability. Both the application for benefits and the benefit plan shall contain in contrasting color, not less than 10-point type, the following statement: "This is a fully assessable benefit plan. In the event that the self-funded multiple employer welfare arrangement is unable to pay its obligations, members shall be required to contribute on a pro rata earned premium basis the funds necessary to meet any unfilled obligations."

c. All self-funded multiple employer welfare arrangements shall provide that members are assessed in accordance with the provisions of this section. Each self-funded multiple employer welfare arrangement may assess all members if its prior fiscal year statement of operations reflected a loss. Each self-funded multiple employer welfare arrangement shall assess all members if the arrangement's fund balance or reserve at the end of any accounting period is less than the amount required by law. The minimum assessment shall be the amount necessary to comply with the requirements of sections 5 and 9 of this act. Each member's assessment shall be computed by applying the earned premium for each employer's benefit plan during the prior fiscal year as a percent of the amount of the total of all employers' earned premium for the same year. Each member's assessment shall be that member's percent times the total assessment levied. In the event a member fails to pay an assessment, the other members shall be liable on a proportionate basis for an additional assessment. The self-funded multiple employer welfare arrangement, acting on behalf of all members who paid the additional assessment, shall take appropriate legal action to recover the assessment from any member who fails to pay an assessment.

d. In the event of a rehabilitation, liquidation, conservation or dissolution of a self-funded multiple employer welfare arrangement, the court, pursuant to section 11 of this act, may assess the members in the amounts needed to pay all incurred but unpaid claims and all projected claims, together with the costs and expenses of collecting the assessments, a reasonable loading factor for uncollected assessments and the costs and expenses of the rehabilitation, liquidation, conservation or dissolution.

e. The following notice shall be provided to employers and employees who obtain coverage from a self-funded multiple employer welfare arrangement:

NOTICE

THE SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENT IS NOT AN INSURANCE COMPANY AND DOES NOT PARTICIPATE IN ANY OF THE GUARANTEE FUNDS CREATED BY NEW JERSEY LAW. THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF A SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENT BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED.

THE HEALTH CARE BENEFITS THAT YOU HAVE PURCHASED OR ARE APPLYING TO PURCHASE ARE BEING ISSUED BY A SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENT. THE SELF-FUNDED MULTIPLE EMPLOYER WELFARE ARRANGEMENT IS REQUIRED TO MAINTAIN SUFFICIENT RESERVES TO PAY FOR ALL INCURRED LOSSES INCLUDING UNPAID CLAIMS.

IT IS IMPORTANT THAT YOU CHECK WITH YOUR EMPLOYER TO DETERMINE WHICH, IF ANY, STATE MANDATED HEALTH CARE BENEFITS MAY BE COVERED BY YOUR ARRANGEMENT.

FOR ADDITIONAL INFORMATION ABOUT THE MULTIPLE EMPLOYER WELFARE ARRANGEMENT YOU SHOULD ASK QUESTIONS OF YOUR TRUST ADMINISTRATOR AT _______________(this blank should include the "800" consumer service telephone number).

§ 17B:27C-8 Inapplicability of insurance laws in certain circumstances.

8. a. Except as provided by this act, the insurance laws of this State do not apply to the operation of self-funded multiple employer welfare arrangements. A self-funded multiple employer welfare arrangement is not an insurance company or insurer under the laws of this State.

b. Any self-funded multiple employer welfare arrangement shall offer all products that it is actively marketing to any employer, and accept any employer and any employee of that employer who applies for any of those products; provided, however that a self-funded multiple employer welfare arrangement may limit participation to members of the association.

c. Assessments payable by small employer members, except for dental plans, shall be established in accordance with the rating requirements of section 9 of P.L.1992, c.162 (C.17B:27A-25) and regulations promulgated thereunder.

d. If the member is a small employer, the health benefits to be provided by the self-funded multiple employer welfare arrangement shall at all times be equal to or greater than benefits required to be provided in the lowest benefit level standard plan promulgated by the New Jersey Small Employer Health Benefits Program pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.).

e. A large employer participating in a multiple employer welfare arrangement shall not be required to adhere to the plan or design elements, or any required coverage offerings applicable to small employers, including but not limited to deductibles, co-pays, and co-insurance amounts. After the effective date of P.L.2015, c.172, large employer members of a multiple employer welfare arrangement shall continue to offer all health benefits mandated by State law and in effect on October 1, 2014. Any new or additional health benefits mandated by State law required to be offered after October 1, 2014 shall not be required to be offered by large employers participating in a multiple employer welfare arrangement. Except as provided in P.L.2001, c.352 (C.17B:27C-1 et seq.) as amended by P.L.2015, c.172, multiple employer welfare arrangements with large employers shall be otherwise subject to the requirements of State and federal law.

f. Notwithstanding any other provision to the contrary, if the member is a large employer, the rate manual used to calculate program rates may include appropriate classification factors such as claims experience and utilization, age, gender, tobacco use, and geography, and such specific underwriting adjustments as may be certified in accordance with subsection d. of section 6 of P.L.2001, c.352 (C.17B:27C-6).

g. The self-funded multiple employer welfare arrangement may provide to its members a health and wellness program consistent with the United States Department of Labor's requirements.

h. The self-funded multiple employer welfare arrangement may provide to its members an internet-based system for the administration, billing and claims processing of its benefits.

§ 17B:27C-9 Examination of loss reserves.

9. a. The commissioner may, upon reasonable notice, conduct an examination of the loss reserves of a self-funded multiple employer welfare arrangement as often as the commissioner in his discretion may deem necessary. The expenses of the examination shall be paid by the self-funded multiple employer welfare arrangement so examined. The commissioner shall also annually review the RBC report of the self-funded multiple employer welfare arrangement.

b. If the commissioner finds that the reserves are inadequate, he shall notify the self-funded multiple employer welfare arrangement of the inadequacy. Capital and surplus shall be automatically considered inadequate if they do not meet or exceed the following: (1) for the calendar year ending December 31, 2002, 80 percent of the regulatory action level RBC determined in accordance with the RBC instructions; (2) for the calendar year ending December 31, 2003, 90 percent of the regulatory action level RBC determined in accordance with the RBC instructions; (3) for the calendar year ending December 31, 2004, 95 percent of the regulatory action level RBC determined in accordance with the RBC instructions; and (4) for the calendar years ending on or after December 31, 2005, the regulatory action level RBC determined in accordance with the RBC instructions. Within 30 days the self-funded multiple employer welfare arrangement shall file and implement a plan to correct the inadequacy. The inadequacy shall be corrected within 90 days of the implementation of the plan to correct the inadequacy.

§ 17B:27C-10 Revocation, suspension of certificate of registration; violations, penalties.

10. a. The commissioner may revoke or suspend the certificate of registration of any self-funded multiple employer welfare arrangement that fails to correct any inadequacy pursuant to section 9 of this act or violates any provision of this act.

b. Any person who violates any provision of this act or the rules and regulations issued pursuant thereto shall be liable to a penalty of not more than $1,000 for a first offense and not more than $5,000 for each subsequent offense.

§ 17B:27C-11 Rehabilitation, liquidation, conservation, dissolution.

11. Any rehabilitation, liquidation, conservation or dissolution of a self-funded multiple employer welfare arrangement shall be conducted under the supervision of the State Superior Court in the county in which the self-funded multiple employer welfare arrangement has its principal office.

§ 17B:27C-12 Rules, regulations.

12. The commissioner, in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), may adopt rules and regulations necessary to effectuate the purposes of this act.

Chapter 27D

§ 17B:27D-1 Findings, declarations relative to mandated health benefits

1. The Legislature finds and declares that:

a. Health benefits coverage, while providing important protection for individuals, is costly for individuals and businesses that insure their employees;

b. Mandated health benefits have social, financial and medical implications for patients, providers and health benefits plans; and

c. It is, therefore, in the public interest to conduct a review of proposed mandated health benefits by an expert body to provide the Legislature with adequate and independent documentation defining the social and financial impact and medical efficacy of the proposed mandate.

§ 17B:27D-2 Definitions relative to mandated health benefits

2. As used in this act:

"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State.

"Commission" means the Mandated Health Benefits Advisory Commission established pursuant to this act.

"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier. For the purposes of this act, health benefits plan shall not include the following plans, policies or contracts: accident only, credit, disability, long-term care, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.) or hospital confinement indemnity coverage.

"Mandated health benefit" or "mandate" means: a benefit or coverage that is required by law to be provided by a carrier and includes: coverage for specific health care services, treatments or practices; or direct reimbursement to specific health care providers.

§ 17B:27D-3 Mandated Health Benefits Advisory Commission

3. There is established the Mandated Health Benefits Advisory Commission to study the social, financial and medical impact of proposed mandated health benefits.

§ 17B:27D-4 Membership; terms; vacancies.

4. The commission shall consist of 17 voting members as follows: the Commissioners of Health, Human Services and Banking and Insurance or their designees, who shall serve ex officio; three public members appointed by the President of the Senate, who shall include a representative of a commercial health insurance company, a physician licensed in this State who is a member of the Medical Society of New Jersey, and a representative of the New Jersey Business and Industry Association, no more than two of whom shall be from the same political party; three public members appointed by the Speaker of the General Assembly, who shall include a representative of a health service corporation, a physician licensed in this State, and a representative of organized labor, no more than two of whom shall be from the same political party; and eight public members appointed by the Governor, who shall include a medical educator from Rutgers, The State University whose major field of expertise is the study and evaluation of the cost of health care and health insurance, a representative of the New Jersey Association of Health Plans, a representative of the New Jersey Hospital Association, a representative of the New Jersey State Nurses Association, a representative of the New Jersey Dental Association, a representative of a consumer advocacy organization and two representatives of the general public who are knowledgeable about health benefits plans.

The President of the Senate may appoint two members of the Senate, no more than one of whom shall be from the same political party, to serve as nonvoting members of the commission. The Speaker of the General Assembly may appoint two members of the General Assembly, no more than one of whom shall be from the same political party, to serve as nonvoting members of the commission. The legislative members shall serve during their legislative term of office.

Of the voting members first appointed, four shall serve for a term of two years, four for a term of three years, and three for a term of four years.

Voting members appointed thereafter shall serve four-year terms, and any vacancy shall be filled by appointment for the unexpired term only. A member is eligible for reappointment. Vacancies in the membership of the commission shall be filled in the same manner as the original appointments were made.

§ 17B:27D-5 Election of chairman, vice chairman, appointment of secretary; meetings.

5. a. The commission shall organize and hold its first meeting within 90 days after the appointment of its members and shall elect a chairman and a vice chairman from among its members. The commission may appoint a secretary, who need not be a member of the commission.

b. The members of the commission shall serve without compensation but may be allowed their actual and necessary expenses incurred in the performance of their duties within the limits of funds appropriated or otherwise made available to the commission for this purpose.

c. The Department of Banking and Insurance, in consultation with the Department of Health, shall assist the commission in the performance of its duties.

d. The commission shall be entitled to call upon the services of any State, county or municipal department, board, commission or agency as it may require and as may be available to it for these purposes, and to incur such traveling and other miscellaneous expenses as it may deem necessary for the proper execution of its duties and as may be within the limit of funds appropriated or otherwise made available to it for these purposes.

e. The commission shall meet regularly, and at a minimum of four times per year. Special meetings may be called by the chairman of the commission.

§ 17B:27D-6 Duties of commission relative to review of bills.

6. It shall be the duty of the commission to review any bill introduced in either House of the Legislature that would require a carrier to provide a mandated health benefit, as provided in this section.

a. Whenever a bill containing a mandated health benefit is introduced in the Legislature, the chairman of the standing reference committee to which the bill has been referred in the House in which it was introduced shall, upon introduction of the bill, request the commission to prepare a written report that assesses the social and financial effects and the medical efficacy of the proposed mandated health benefit.

If the bill is subsequently amended, a prime sponsor or the presiding officer of the House in which the bill is pending may request the commission to amend or revise its report to reflect the changes made by the amendment.

b. (1) For the period ending December 31, 2003, the commission shall complete its review of a bill within 90 days after the date the review is requested, and provide its comments and recommendations in writing to the prime sponsor, committee chairman and presiding officer of the House in which the bill is pending. The commission may request an extension prior to the 90th day, in which case the presiding officer of the House in which the bill is pending may grant an extension of up to 45 days for the commission to complete its review.

(2) Beginning January 1, 2004, the commission shall complete its review of a bill within 60 days after the date the review is requested, and provide its comments and recommendations in writing to the prime sponsor, committee chairman and presiding officer of the House in which the bill is pending. The commission may request an extension prior to the 60th day, in which case the presiding officer of the House in which the bill is pending may grant an extension of up to 45 days for the commission to complete its review.

c. The House or standing reference committee, as applicable, shall not consider or vote upon the bill until either: (1) the commission completes its review and provides its comments and recommendations in writing to the prime sponsor, committee chairman and presiding officer of the House in which the bill is pending, or (2) the 90th or 60th day, as applicable, after the date the review is requested, if no extension was granted, or the designated day for the end of the extension period, whichever is later.

d. (1) If the presiding officer of the House in which the bill is pending determines that the bill is an urgent matter, the presiding officer shall so notify in writing the commission and the chairman of the standing reference committee to which the bill was referred, and the House or committee may consider and vote upon the bill as soon as practicable.

(2) If the chairman of the standing reference committee to which the bill is referred, in consultation with the Commissioner of Health, determines that the bill is of such an urgent nature that it would seriously impair the public health to wait for the commission to issue its report, the chairman shall so notify in writing the presiding officer of the House in which the bill is pending, and the commission, of that determination, and the standing reference committee, with the agreement of the presiding officer of the House, may consider and vote upon the bill as soon as practicable.

§ 17B:27D-7 Contents of review of bill.

7. The review of a bill containing a proposed mandated health benefit by the commission shall include the following:

a. The social impact of mandating the health benefit, which shall include:

(1) the extent to which the proposed mandated health benefit and the services it would provide are needed by, available to and utilized by the population of New Jersey;

(2) the extent to which insurance coverage for the proposed mandated health benefit already exists or, if no coverage exists, the extent to which the lack of coverage results in inadequate health care or financial hardship for the affected population of New Jersey;

(3) the demand for the proposed mandated health benefit from the public and the source and extent of opposition to mandating the health benefit;

(4) relevant findings bearing on the social impact of the lack of the proposed mandated health benefit; and

(5) such other information with respect to the social impact as the commission deems appropriate.

b. The financial impact of mandating the health benefit, which shall include:

(1) the extent to which the proposed mandated health benefit would increase or decrease the cost for treatment or service;

(2) the extent to which similar mandated health benefits in other states have affected charges, costs and payments for services;

(3) the extent to which the proposed mandated health benefit would increase the appropriate use of the treatment or service;

(4) the impact of the proposed mandated health benefit on total costs to carriers and on administrative costs;

(5) the impact of the proposed mandated health benefit on total costs to purchasers and benefit costs;

(6) the impact of the proposed mandated health benefit on the total cost of health care within New Jersey; and

(7) such other information with respect to the financial impact as the commission deems appropriate.

c. The medical efficacy of mandating the health benefit, which shall include:

(1) if the proposed health benefit mandates coverage of a particular treatment or therapy, the recommendation of a clinical study or review article in a major peer-reviewed professional journal;

(2) if the proposed benefit mandates coverage of the services provided by an additional class of practitioners, the results of at least one professionally accepted, controlled trial comparing the medical results achieved by the additional class of practitioners and the practitioners already covered by benefits;

(3) the results of other research;

(4) the impact of the proposed benefit on the general availability of health benefits coverage in New Jersey; and

(5) such other information with respect to the medical efficacy as the commission deems appropriate.

d. The effects of balancing the social, economic and medical efficacy considerations, which shall include, but not be limited to:

(1) the extent to which the need for coverage outweighs the costs of mandating the health benefit; and

(2) the extent to which the problem of coverage may be solved by mandating the availability of the coverage as an option under a health benefits plan.

e. An analysis of information collected from various sources, including, but not limited to:

(1) a State data collection system;

(2) the Departments of Health and Banking and Insurance;

(3) health planning organizations;

(4) proponents and opponents of the proposed health benefit mandate, who shall be encouraged to provide appropriate documentation supporting their positions. The commission shall examine such documentation to determine whether:

(a) the documentation is complete;

(b) the assumptions upon which the research is based are valid;

(c) the research cited in the documentation meets professional standards;

(d) all relevant research respecting the proposed benefit has been cited in the documentation;

(e) the conclusions and interpretations in the documentation are consistent with the data submitted; and

(5) such other data sources as the commission deems appropriate.

In analyzing information from the various sources, the commission shall give substantial weight to the documentation provided by the proponents and opponents of the mandate to the extent that such documentation is made available to them.

§ 17B:27D-8 Development of system of data collection; review, comment.

8. In the course of studying and evaluating proposed mandated health benefits, the commission shall:

a. develop criteria for a system and program of data collection, for use by the Departments of Health and Banking and Insurance, to assess the impact of mandated health benefits, including the cost to employers and carriers, impact of treatment, cost savings in the health care system, number of providers, and other data as may be appropriate; and

b. review and comment to any State department, board, bureau, commission, or agency, with respect to any order or regulations proposed or implemented thereby that affect mandated health benefits.

§ 17B:27D-9 Report to Governor, Legislature

9. The commission shall report to the Governor and Legislature three years from the effective date of this act on its activities. The report shall include a summary of the bills reviewed by the commission and the commission's findings, and any recommendations the commission may have regarding the review process required pursuant to this act.

§ 17B:27D-10 Report by Mandated Health Benefits Advisory Commission.

13. a. Notwithstanding the provisions of any other law to the contrary, the Mandated Health Benefits Advisory Commission established pursuant to section 3 of P.L.2003, c.193 (C.17B:27D-3), shall prepare a report regarding the implementation and administration of P.L.2013, c.196 (C.26:2-184.3 et al.) at least once in each five-year period following the effective date of P.L.2013, c.196 (C.26:2-184.3 et al.).

b. The report shall provide a summary of the social and financial impact, as well as the medical efficacy, of the requirements imposed by P.L.2013, c.196 (C.26:2-184.3 et al.), and shall provide a summary of any recommendations the commission may have to improve the effectiveness of P.L.2013, c.196 (C.26:2-184.3 et al.).

c. The commission shall transmit a copy of a report prepared in accordance with this section to the Governor, and to the Legislature, in accordance with section 2 of P.L.1991, c.164 (C.52:14-19.1), within five days of the date the report is prepared.

§ 17B:27D-11 Work group regarding risk factors for breast cancer, breast imaging options.

14. a. The Department of Health, in conjunction with the Medical Society of New Jersey, shall convene a work group to review and report on strategies to improve the dialogue between patients and health care professionals regarding risk factors for breast cancer and breast imaging options. The work group shall review breast imaging standards, the federal Mammography Quality Standards Act and breast imaging results protocols, and shall recommend strategies to improve the dialogue between patients and health care professionals regarding breast density and breast imaging options.

b. The department shall invite to participate in the work group representatives of patient advocacy groups and health care professionals' organizations. The work group shall organize as soon as practicable following the appointment of its members. The members of the work group shall serve without compensation, but shall be reimbursed for necessary expenses incurred in the performance of their duties and within the limits of funds available to the work group.

c. The work group shall be entitled to call to its assistance and avail itself of the services of the employees of any State, county, or municipal department, board, bureau, commission, or agency as the work group may require and as may be available to the work group for its purposes.

d. The work group shall report its findings and recommendations to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), along with any legislative bills that it desires to recommend for adoption by the Legislature, on an annual basis. The work group shall submit its first report no later than 12 months after the initial meeting of the work group.

Chapter 27E

§ 17B:27E-1 Purpose of act on long-term care insurance

1. The purpose of this act is to promote the public interest, to promote the availability of long-term care insurance policies, to protect applicants for long-term care insurance from unfair or deceptive sales or enrollment practices, to establish standards for long-term care insurance, to facilitate public understanding and comparison of long-term care insurance policies, and to facilitate flexibility and innovation in the development of long-term care insurance coverage.

§ 17B:27E-2 Application of act

2. The requirements of this act shall apply to policies delivered or issued for delivery in this State on or after the effective date of this act intended for use as long-term care insurance. This act is not intended to supersede the obligations of entities subject to this act to comply with the substance of other applicable insurance laws insofar as they do not conflict with this act, except that laws and regulations designed and intended to apply to Medicare supplement insurance policies shall not be applied to long-term care insurance.

§ 17B:27E-3 Short title

3. This act shall be known and may be cited as the "New Jersey Long-Term Care Insurance Act."

§ 17B:27E-4 Definitions relative to long-term care insurance.

4. As used in this act, unless the context requires otherwise:

"Applicant" means:

(1) In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits; and

(2) In the case of a group long-term care insurance policy, the proposed certificate holder.

"Certificate" means any certificate or evidence of coverage issued under a group long-term care insurance policy, which has been delivered or issued for delivery in this State.

"Commissioner" means the Commissioner of Banking and Insurance.

"Group long-term care insurance" means a long-term care insurance policy which is delivered or issued for delivery in this State and issued to:

(1) a group conforming to one of the descriptions set forth at N.J.S.17B:27-2 through 17B:27-8 inclusive, or N.J.S.17B:27-27; or

(2) any group not set forth in paragraph (1) of this definition, which in the opinion of the commissioner may be insured for group long-term care insurance in accordance with sound underwriting principles.

"Living organ donor" means a person who has donated all or part of an organ and is not deceased.

"Long-term care insurance" means any insurance policy, certificate or rider advertised, marketed, offered or designed to provide coverage for not less than 12 consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis, for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services, provided in a setting other than an acute care unit of a hospital. The term includes group and individual annuities and life insurance policies or riders which provide directly or which supplement long-term care insurance. The term also includes a policy or rider which provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. The term shall also apply to qualified long-term care insurance contracts. Long-term care insurance may be issued by insurers; fraternal benefit societies; health, hospital, or medical service corporations; prepaid health plans; or health maintenance organizations. Long-term care insurance shall not include any insurance policy which is offered primarily to provide basic Medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset-protection coverage, accident only coverage, or limited benefit health coverage. With regard to life insurance, this term does not include life insurance policies which accelerate the death benefit specifically for one or more qualifying events, and which provide the option of a lump-sum payment for those benefits and in which neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care. Notwithstanding any other provision contained herein, any product advertised, marketed or offered as long-term care insurance shall be subject to the provisions of this act.

"Policy" means any policy, contract, subscriber agreement, rider or endorsement providing long-term care insurance coverage delivered or issued for delivery in this State by an insurer; fraternal benefit society; health, hospital, or medical service corporation; prepaid health plan; health maintenance organization or any similar organization.

"Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract" means an individual or group insurance contract that meets the requirements of 26 U.S.C. s. 7702B(b), as follows:

(1) The only insurance protection provided under the contract is coverage of qualified long-term services. A contract shall not fail to satisfy the requirements of this paragraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate;

(2) The contract does not pay or reimburse expenses incurred for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act (42 U.S.C. s. 1395 et seq.) or would be so reimbursable but for the application of a deductible or coinsurance amount. The requirements of this paragraph do not apply to expenses that are reimbursable under Title XVIII of the Social Security Act (42 U.S.C. s. 1395 et seq.) only as a secondary payor. A contract shall not fail to satisfy the requirements of this paragraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate;

(3) The contract is guaranteed renewable, within the meaning of 26 U.S.C. s. 7702B(b)(1)(C);

(4) The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided in paragraph (5) of this definition;

(5) All refunds of premiums, and all policyholder dividends or similar amounts, under the contract are to be applied as a reduction in future premiums or to increase future benefits, except that a refund on the event of death of the insured or a complete surrender or cancellation of the contract shall not exceed the aggregate premiums paid under the contract; and

(6) The contract meets the consumer protection provisions set forth in 26 U.S.C. s. 7702B(g).

"Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract" also means the portion of a life insurance contract that provides long-term care insurance coverage by a rider or as part of the contract and that satisfies the requirements of 26 U.S.C. s. 7702B(b) and (e).

§ 17B:27E-5 Compliance required

5. a. Any policy, certificate or rider advertised, marketed or offered as long-term care insurance shall comply with the provisions of this act.

b. No group long-term care insurance coverage shall be offered to a resident of this State under a group policy issued in another state to a group described in paragraph (2) of the definition of "group long-term care insurance" in section 4 of this act, unless this State, or another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in this State, has made a determination that those requirements have been met.

§ 17B:27E-6 Prohibitions relative to long-term care insurance.

6. a. No long-term care insurance policy or certificate shall:

(1) Be cancelled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder;

(2) Contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company or affiliated company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder;

(3) Provide coverage for skilled nursing care only or provide significantly more coverage for skilled nursing care in a facility than coverage for lower levels of care; or

(4) Decline or limit coverage based solely on the status of the insured individual as a living organ donor; preclude an insured person from donating all or part of an organ as a condition of continuing to receive coverage; consider the status of a person as a living organ donor in determining the premium rate for coverage of the person under a policy of life or health insurance, provided that this shall not preclude consideration of other actuarial risks in determining premium rates for coverage; or otherwise discriminate in the offering, issuance, cancellation, amount of coverage, price, or other condition of coverage for an individual based solely, and without any additional actuarial risks, on the status of the person as a living organ donor.

b. (1) No long-term care insurance policy or certificate shall use a definition of "preexisting condition" which is more restrictive than the following: preexisting condition means a condition for which medical advice or treatment was recommended by, or received from a provider of health care services, within six months preceding the effective date of coverage of an insured person.

(2) No long-term care insurance policy or certificate shall exclude coverage for a loss or confinement which is the result of a preexisting condition unless that loss or confinement begins within six months following the effective date of coverage of an insured person.

(3) The definition of "preexisting condition" shall not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with that insurer's established underwriting standards. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in paragraph (2) of this subsection b. expires. No long-term care insurance policy or certificate shall exclude or use waivers or riders of any kind to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in paragraph (2) of this subsection b.

(4) A preexisting condition limitation shall only apply to the long-term care insurance coverage and shall not apply to any death benefit or other life insurance benefit provided by a long-term care insurance policy or certificate.

c. (1) No long-term care insurance policy or certificate shall be delivered or issued for delivery in this State if that policy or certificate:

(a) Conditions eligibility for any benefits on a prior hospitalization requirement;

(b) Conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care; or

(c) Conditions eligibility for any benefits, other than waiver of premium, post-confinement, post-acute care or recuperative benefits, on a prior institutionalization requirement.

(2) (a) A long-term care insurance policy or certificate containing post-confinement, post-acute care or recuperative benefits shall clearly label in a separate paragraph of the policy or certificate entitled "Limitations or Conditions on Eligibility for Benefits" those limitations or conditions, including any required number of days of confinement.

(b) A long-term care insurance policy or certificate which conditions eligibility for non-institutional benefits on the prior receipt of institutional care shall not require a prior institutional stay of more than 30 days.

d. Long-term care insurance applicants shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Long-term care insurance policies and certificates shall have a notice prominently printed on the first page or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason.

e. (1) An outline of coverage shall be delivered to a prospective applicant for long-term care insurance at the time of initial solicitation through means which prominently direct the attention of the recipient to the document and its purpose.

(a) The commissioner shall prescribe a standard format, including style, arrangement and overall appearance, and the content of an outline of coverage.

(b) In the case of insurance producer solicitations, an insurance producer shall deliver the outline of coverage prior to the presentation of an application or enrollment form.

(c) In the case of direct response solicitations, the outline of coverage shall be presented in conjunction with any application or enrollment form.

(2) The outline of coverage shall include:

(a) A description of the principal benefits and coverage provided in the policy;

(b) A statement of the principal exclusions, reductions, and limitations contained in the policy;

(c) A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described;

(d) A statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions;

(e) A description of the terms under which the policy or certificate may be returned and the premium refunded;

(f) A brief description of the relationship of cost of care and benefits; and

(g) A statement that discloses to the policyholder or certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract under 26 U.S.C. s. 7702B(b).

f. A certificate issued pursuant to a group long-term care insurance policy, which policy is delivered or issued for delivery in this State, shall include:

(1) A description of the principal benefits and coverage provided in the policy;

(2) A statement of the principal exclusions, reductions and limitations contained in the policy; and

(3) A statement that the group master policy determines governing contractual provisions.

g. At the time of policy delivery, a policy summary as prescribed by the commissioner pursuant to subsection e. of this section shall be delivered for an individual life insurance policy which provides long-term care benefits within the policy or by rider. In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, but regardless of request shall make that delivery no later than at the time of policy delivery. In addition to complying with all applicable requirements, the summary shall also include:

(1) An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits;

(2) An illustration of the amount of benefits, the length of benefit, and the guaranteed lifetime benefits if any, for each covered person;

(3) Any exclusions, reductions and limitations on benefits of long-term care;

(4) A statement as to whether any long-term care inflation protection option is available under this policy;

(5) If applicable to the policy type, the summary shall also include:

(a) A disclosure of the effects of exercising other rights under the policy;

(b) A disclosure of guarantees related to long-term care costs of insurance charges;

(c) Current and projected maximum lifetime benefits; and

(6) The provisions of the policy summary listed above may be incorporated into a basic illustration required to be delivered in accordance with regulations promulgated by the commissioner or into the life insurance policy summary which is required to be delivered in accordance with regulations promulgated by the commissioner.

h. Whenever a long-term care benefit, funded through a life insurance policy by the acceleration of the death benefit, is in benefit payment status, a monthly report as specified by the commissioner shall be provided to the policyholder or certificate holder. The report shall include:

(1) Any long-term care benefits paid out during the month;

(2) An explanation of any changes in the policy, such as death benefits or cash values, due to long-term care benefits being paid out; and

(3) The amount of long-term care benefits existing or remaining.

§ 17B:27E-7 Grounds for rescinding policy, denying a claim

7. a. For a policy or certificate that has been in force for less than six months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance for coverage.

b. For a policy or certificate that has been in force for at least six months but less than two years, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and which pertains to the condition for which benefits are sought.

c. After a policy or certificate has been in force for two years, it is not contestable upon the grounds of misrepresentation alone; such a policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.

d. If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments shall not be recovered by the insurer if the policy or certificate is rescinded.

e. In the event of the death of the insured, this section shall not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care. In this situation, the remaining death benefits under these policies shall be governed by N.J.S.17B:25-4 or 17B:27-12, as appropriate. In all other situations, this section shall apply to life insurance policies that accelerate benefits for long-term care.

§ 17B:27E-8 Conditions for delivery, issuance of policy

8. a. Except as provided in subsection b. of this section, a long-term care insurance policy shall not be delivered or issued for delivery in this State unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. If the policyholder or certificate holder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates.

b. When a group long-term care insurance policy is issued, the offer required in subsection a. of this section shall be made to the group policyholder.

§ 17B:27E-9 Regulations

9. The commissioner shall promulgate regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to effectuate the purposes of this act including, but not limited to, regulations dealing with disclosure requirements, eligibility, renewability, non-duplication of coverage, dependent coverage, preexisting conditions, termination of coverage, continuation or conversion, loss ratio, and other information that the commissioner feels necessary.

§ 17B:27E-10 Prior approval of commissioner required

10. a. Every long-term care insurance policy or contract, including any application, certificate, rider or endorsement to be issued or delivered in this State shall be filed with the commissioner for prior approval as provided in this section.

b. A policy, contract or related form filed with the commissioner for approval pursuant to this section shall be deemed approved upon the expiration of 60 days after the submission of the form unless disapproved in writing by the commissioner within that time. Any such disapproval shall be based only on the specific provisions of applicable statutes or regulations. A disapproved policy, contract or related form may be resubmitted.

c. A long-term care insurance policy, contract or related form submitted for approval pursuant to this section and disapproved by the commissioner before the expiration of 60 days after its submission shall be deemed withdrawn at the expiration of 60 days after the transmittal of the commissioner's specific objections unless the filer submits a complete written response to all of the commissioner's objections regarding the submission within the 60-day period.

d. A long-term care insurance policy, contract or related form resubmitted in response to the commissioner's objections pursuant to subsection b. of this section shall be deemed approved upon the expiration of 30 days after its resubmission unless disapproved in writing by the commissioner within that time. No disapproval by the commissioner of a resubmission shall be based on any objection not specified by the commissioner in his initial disapproval of the filing, except that the commissioner may disapprove that form based on any new provisions introduced in the resubmission or, if in addressing the specific objections cited in the commissioner's disapproval, the insurer changes or modifies any substantive provisions of the form. Any policy, contract or related form resubmitted for approval pursuant to this section and disapproved by the commissioner before the expiration of 30 days after its submission shall be deemed withdrawn at the expiration of 30 days after the transmittal of the commissioner's specific objections, unless the filer submits a complete written response to all of the commissioner's objections regarding the submission within the 30-day period.

e. Any form which is filed with the commissioner and approved or deemed approved may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith.

f. For the purposes of this section, "days" means calendar days, except that when the last day of any specified time period is a Saturday, Sunday, or State holiday, then the time period shall end on the next following business day. With respect to any specified time period pertaining to correspondence between an insurer and the commissioner, the time period shall commence on the date that correspondence is postmarked or submitted to a private delivery service.

§ 17B:27E-11 Insurer to file rates, rating schedule, supporting documentation

11. An insurer providing long-term care insurance issued on an individual basis in this State shall file, for the commissioner's approval, its rates, rating schedule and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this State. All filings of rates and rating schedules shall demonstrate that the benefits are reasonable in relation to the premium charged and that the rates are not excessive, inadequate or unfairly discriminatory.

§ 17B:27E-12 Additional penalties

12. In addition to any other penalties provided by the laws of this State, any insurer and any insurance producer found to have violated any requirement of this State relating to the regulation of long-term care insurance or the marketing of that insurance shall be subject to a fine of up to three times the amount of any commissions paid for each policy or certificate involved in the violation, or $10,000, whichever is greater.

Chapter 27F

§ 17B:27F-1 Definitions.

1. As used in P.L.2015, c.179 (C.17B:27F-1 et seq.):

"Anticipated loss ratio" means the ratio of the present value of the future benefits payments, including claim offsets after the point of sale, to the present value of the future premiums of a policy form over the entire period for which rates are computed to provide health insurance coverage.

"Average wholesale price" means the average wholesale price of a prescription drug determined by a national drug pricing publisher selected by a carrier. The average wholesale price shall be identified using the national drug code published by the National Drug Code Directory within the United States Food and Drug Administration.

"Brand-name drug" means a prescription drug marketed under a proprietary name or registered trademark name, including a biological product.

"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State.

"Contracted pharmacy" means a pharmacy that participates in the network of a pharmacy benefits manager through a contract with:

a. the pharmacy benefits manager directly;

b. a pharmacy services administration organization; or

c. a pharmacy group purchasing organization.

"Cost-sharing amount" means the amount paid by a covered person as required under the covered person's health benefits plan for a prescription drug at the point of sale.

"Covered person" means a person on whose behalf a carrier or other entity, who is the sponsor of the health benefits plan, is obligated to pay benefits pursuant to a health benefits plan.

"Department" means the Department of Banking and Insurance.

"Drug" means a drug or device as defined in R.S.24:1-1.

"Health benefits plan" means a benefits plan which pays hospital or medical expense benefits for covered services, or prescription drug benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier or any other sponsor. For the purposes of P.L.2015, c.179 (C.17B:27F-1), health benefits plan shall not include the following plans, policies or contracts: accident only, credit disability, long-term care, Medicare supplement coverage; TRICARE supplement coverage, coverage for Medicare services pursuant to a contract with the United States government, the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), coverage arising out of a worker's compensation or similar law, the State Health Benefits Program, the School Employees' Health Benefits Program, or a self-insured health benefits plan governed by the provisions of the federal "Employee Retirement Income Security Act of 1974," 29 U.S.C. s.1001 et seq., coverage under a policy of private passenger automobile insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.), or hospital confinement indemnity coverage.

"Maximum allowable cost" means the maximum amount a health insurer will pay for a generic drug or brand-name drug that has at least one generic alternative available.

"Network pharmacy" means a licensed retail pharmacy or other pharmacy provider that contracts with a pharmacy benefits manager either directly or by and through a contract with a pharmacy services administrative organization.

"Pharmacy" means any place in the State, either physical or electronic, where drugs are dispensed or pharmaceutical care is provided by a licensed pharmacist, but shall not include a medical office under the control of a licensed physician.

"Pharmacy benefits manager" means a corporation, business, or other entity, or unit within a corporation, business, or other entity, that, pursuant to a contract or under an employment relationship with a carrier, a self-insurance plan or other third-party payer, either directly or through an intermediary, administers prescription drug benefits on behalf of a purchaser.

"Pharmacy benefits manager compensation" means the difference between: (1) the amount of payments made by a carrier of a health benefits plan to its pharmacy benefits manager; and (2) the value of payments made by the pharmacy benefits manager to dispensing pharmacists for the provision of prescription drugs or pharmacy services with regard to pharmacy benefits covered by the health benefits plan.

"Pharmacy benefits management services" means the provision of any of the following services on behalf of a purchaser: the procurement of prescription drugs at a negotiated rate for dispensation within this State; the processing of prescription drug claims; or the administration of payments related to prescription drug claims.

"Pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers.

"Prescription" means a prescription as defined in section 5 of P.L.1977, c.240 (C.24:6E-4).

"Prescription drug benefits" means the benefits provided for prescription drugs and pharmacy services for covered services under a health benefits plan contract.

"Purchaser" means any sponsor of a health benefits plan who enters into an agreement with a pharmacy benefits management company for the provision of pharmacy benefits management services to covered persons.

§ 17B:27F-1.1 Pharmacy benefits manager, license, pharmacy services administrative, registration.

2. a. A corporation, business, or other entity shall not act as a pharmacy benefits manager without first obtaining a license from the department or as a pharmacy services administrative organization without first obtaining registration from the department. An applicant for licensure or registration shall provide to the department information that includes, but is not limited to, the following:

(1) the name of the applicant;

(2) the address and telephone number of the applicant;

(3) the name and address of the applicant's agent for service of process in the State;

(4) the name and address of each person owning 10 percent or greater interest in the applicant;

(5) the name and address of each person with management or control over the applicant;

(6) for pharmacy benefits managers, the information required under section 4 of P.L.1999, c.409 (C.17:48H-4);

(7) for pharmacy benefits managers, all contracts and documents between pharmacies, pharmacy benefits managers, and pharmacy services administrative organizations; and

(8) for pharmacy services administrative organizations, upon the department's request, any contracts and documents between pharmacies, pharmacy benefits managers, and pharmacy services administrative organizations.

b. A license or registration issued pursuant to this section shall be valid for a period of three years and may be renewed at the end of the three-year period. The commissioner shall establish fees for a license or registration issued or renewed pursuant to this section.

c. The department may issue a pharmacy benefits manager license to an applicant only if the department is satisfied that the applicant possesses the necessary organization, expertise, and financial integrity to supply the services sought to be offered. The department shall establish, by regulation, minimum standards for the issuance of a license to a pharmacy benefits manager. The minimum standards established pursuant to this subsection shall contain both prerequisites for the issuance of a license to a pharmacy benefits manager and requirements for maintenance of a license by a pharmacy benefits manager and shall address, without limitation:

(1) conflicts of interest between pharmacy benefits managers and health benefits plans;

(2) deceptive practices in connection with the performance of pharmacy benefits management services;

(3) anti-competitive practices in connection with the performance of pharmacy benefits management services;

(4) unfair claims practices in connection with the performance of pharmacy benefits management services;

(5) pricing models used by pharmacy benefits managers both for their services and for the payment of services to the pharmacy benefits manager;

(6) standards and practices used in the creation of pharmacy networks and contracting with network pharmacies and other providers, including promotion and use of independent and community pharmacies and patient access and minimizing excessive concentration and vertical integration of markets; and

(7) protection of consumers.

d. The department may issue a license to a pharmacy benefits manager subject to restrictions or limitations, including the type of services that may be supplied or the activities in which the pharmacy benefits manager may engage.

e. A license or registration issued pursuant to this section shall not be transferable.

f. The department may suspend, revoke or place on probation a licensee or registered entity if:

(1) the pharmacy benefits manager or pharmacy services administrative organization has engaged in fraudulent activity or any activity that constitutes a violation of State or federal law;

(2) the department has received consumer complaints that justify an action under this subsection to protect the safety and interests of consumers;

(3) the pharmacy benefits manager or pharmacy services administrative organization fails to pay the original issuance or renewal fee for the license or registration; or

(4) the pharmacy benefits manager or pharmacy services administrative organization fails to comply with any requirement set forth in P.L.2023, c.107 (C.17B:27F-1.1 et al.).

g. If a corporation, business, or other entity acts as a pharmacy benefits manager or pharmacy services administrative organization without obtaining a license or registration pursuant to this section, the corporation, business, or other entity shall be subject to the provisions of section 7 of P.L.2019, c.274 (C.17B:27F-10).

h. (1) Notwithstanding the provisions of subsection a. of this section, a pharmacy benefits manager that applied for, or received, certification or licensure as an organized delivery system prior to the effective date of P.L.2023, c.107 (C.17B:27F-1.1 et al.), in accordance with P.L.1999, c.409 (C.17:48H-1 et seq.), may continue to operate during the pendency of its application submitted pursuant to this section, but no more than 24 months after the effective date of this act.

(2) A corporation, business, or other entity that acts as a pharmacy benefits manager, and applies for, receives, and maintains a license as an organized delivery system, in accordance with P.L.1999, c.409 (C.17:48H-1 et seq.), shall not be required to maintain that license as an organized delivery system upon the issuance of a license pursuant to P.L.2023, c.107 (C.17B:27F-1.1 et al.), and during any subsequent applications for renewal of the license as a pharmacy benefits manager pursuant to the requirements of P.L.2023, c.107 (C.17B:27F-1.1 et al.).

i. A licensee shall be subject to the following except to the extent inconsistent with this act or where the commissioner determines that any provisions are inappropriate as applied to a pharmacy benefits manager:

(1) the unfair trade practices provisions of N.J.S.17B:30-1 et seq.;

(2) the provisions of P.L.1970, c.22 (C.17:27A-1 et seq.);

(3) the "Life and Health Insurers Rehabilitation and Liquidation Act," P.L.1992, c.65 (C.17B:32-31 et seq.);

(4) investment limitations pursuant to N.J.S.17B:20-1 et seq.; and

(5) the "Health Care Quality Act," P.L.1997, c.192 (C.26:2S-1 et al.).

§ 17B:27F-2 Duties, pharmacy benefits manager, contracts.

2. Upon execution or renewal of each contract, or at such a time when there is any material change in the term of the contract, a pharmacy benefits manager shall, with respect to contracts between a pharmacy benefits manager and a pharmacy services administrative organization, or between a pharmacy benefits manager and a contracted pharmacy:

a. (1) include in the contract the sources utilized to determine multiple source generic drug pricing, brand drug pricing, and the wholesaler in the State of New Jersey where pharmacies may acquire the product, including, but not limited to, the brand effective rate, generic effective rate, dispensing fee effective rate, maximum allowable cost or any other pricing formula for pharmacy reimbursement;

(2) update that pricing information every seven calendar days; and

(3) establish a reasonable process by which contracted pharmacies have a method to access relevant maximum allowable cost pricing lists, brand effective rate, generic effective rate, and dispensing fee effective rate, or any other pricing formulas for pharmacy reimbursement.

b. Additionally, a pharmacy benefits manager shall:

(1) maintain a procedure to eliminate drugs from the list of drugs subject to multiple source generic drug pricing and brand drug pricing, or modify maximum allowable cost rates, brand effective rate, generic effective rate, dispensing fee effective rate or any other applicable pricing formula in a timely fashion and make that procedure easily accessible to the pharmacy services administrative organizations or the pharmacies that they are contractually obligated with to provide that information according to the requirements of this section; and

(2) provide an internal appeal mechanism to resolve any dispute raised by a carrier or pharmacy, regardless of whether the carrier or pharmacy benefits manager has a contract to challenge maximum allowable costs for a specified drug. Any dispute regarding the determination of an internal appeal conducted pursuant to this subsection may be referred to arbitration. The Commissioner of Banking and Insurance shall contract with a nationally recognized, independent organization that specializes in arbitration to conduct the arbitration proceedings.

§ 17B:27F-3 Carrier, pharmacy benefits manager under contract, single maximum allowable cost list; prescription drug, source generic list, requirements.

3. a. A carrier, or a pharmacy benefits manager under contract with a carrier, shall use a single maximum allowable cost list to establish the maximum amount to be paid by a health benefits plan to a pharmacy provider for a generic drug or a brand-name drug that has at least one generic equivalent available. A carrier, or a pharmacy benefits manager under contract with a carrier, shall use the same maximum allowable cost list for each pharmacy provider.

b. A maximum allowable cost may be set for a prescription drug, or a prescription drug may be allowed to continue on a maximum allowable cost list, only if:

(1) The drug is listed as therapeutically and pharmaceutically equivalent or "A," "B," "NR," or "NA" rated in the Food and Drug Administration's most recent version of the Approved Drug Products with Therapeutic Equivalence Evaluations, commonly known as the "Orange Book;" and

(2) The drug is available for purchase without limitations by all pharmacies in the State from national or regional wholesalers and is not obsolete or temporarily unavailable.

c. A pharmacy benefits manager shall not penalize a pharmacist or pharmacy on audit if the pharmacist or pharmacy performs a generic substitution pursuant to the "Prescription Drug Price and Quality Stabilization Act," P.L.1977, c.240 (C.24:6E-1 et seq.).

d. A carrier, or a pharmacy benefits manager under contract with a carrier, shall use the average wholesale price to establish the maximum payment for a brand-name drug for which a generic equivalent is not available or a prescription drug not included on a maximum allowable cost list. In order to use the average wholesale price of a brand-name drug or prescription drug not included on a maximum allowable cost list, a carrier, or a pharmacy benefits manager under contract with a carrier, shall use only one national drug pricing source during a calendar year, unless the original drug pricing source is no longer available. A carrier, or a pharmacy benefits manager under contract with a carrier, shall use the same national drug pricing source for each pharmacy provider and identify on its publicly accessible website the name of the national drug pricing source used to determine the average wholesale price of a prescription drug not included on the maximum allowable cost list.

e. The amount paid by a carrier or a carrier's pharmacy benefits manager to a pharmacy provider under contract with the carrier or the carrier's pharmacy benefits manager for dispensing a prescription drug shall be the ingredient cost plus the dispensing fee less any cost-sharing amount paid by a covered person.

The ingredient cost shall not exceed the maximum allowable cost or average wholesale price, as applicable, and shall be disclosed by a carrier's pharmacy benefits manager to the carrier.

Only the pharmacy provider that dispensed the prescription drug shall retain the payment described in this subsection.

§ 17B:27F-3.1 Carrier duties, responsibilities.

3. a. A carrier shall:

(1) monitor all activities carried out on behalf of the carrier by a pharmacy benefits manager if the carrier contracts with a pharmacy benefits manager and is related to a carrier's prescription drug benefits; and

(2) ensure that all requirements of this section are met.

b. A carrier that contracts with a pharmacy benefits manager to perform any activities related to the carrier's prescription drug benefits shall ensure that, under the contract, the pharmacy benefits manager acts as the carrier's agent in good faith and fair dealing in the performance of all of its contractual duties. All funds received by the pharmacy benefits manager in relation to providing pharmacy benefits management services shall be used or distributed only pursuant to the pharmacy benefits manager's contract with the health benefits plan or carrier or applicable law; including any administrative fee or payment to the pharmacy benefits manager expressly provided for in the contract to compensate the pharmacy benefits manager for its services. Any funds received by the pharmacy benefits manager through spread pricing shall be subject to this subsection.

c. (1) A pharmacy benefits manager interacting with a covered person shall have the same duty to a covered person as the health benefits plan or carrier for whom it is performing pharmacy benefits management services.

(2) A pharmacy benefits manager shall have a duty of good faith and fair dealing with all parties, including but not limited to covered persons and pharmacies, with whom it interacts in the performance of pharmacy benefits management services.

d. A carrier or pharmacy benefits manager shall not require a covered person to make a payment at the point of sale for a covered prescription drug in an amount greater than the lesser of:

(1) the applicable cost-sharing amount for the prescription drug; or

(2) the amount a covered person would pay for the prescription medication if the covered person purchased the prescription medication without using a health benefits plan.

e. A carrier shall provide a reasonably adequate retail pharmacy network for the provision of prescription drugs for its covered persons.

f. For the purposes of this section, "health benefits plan" shall include the State Health Benefits Plan, the School Employees' Health Benefits Plan, the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or a self-insured health benefits plan governed by the provisions of the federal "Employee Retirement Income Security Act of 1974," 29 U.S.C., ss.1001 et seq.

§ 17B:27F-3.2 Compensation remitted, pharmaceutical manufacturer, developer, labeler, carrier, pharmacy benefits manager under contract; report.

6. a. Compensation remitted by or on behalf of a pharmaceutical manufacturer, developer or labeler, directly or indirectly, to a carrier or to a pharmacy benefits manager under contract with a carrier related to prescription drug benefits shall be:

(1) remitted directly to the covered person at the point of sale to reduce the out-of-pocket cost to the covered person associated with a particular prescription drug; or

(2) remitted to, and retained by, the carrier. Compensation remitted to the carrier shall be applied by the carrier in its plan design and in future plan years to offset the premium for covered persons.

b. Beginning on March 1 next following the effective date of P.L.2023, c.107 (C.17B:27F-1.1 et al.), and annually thereafter, a carrier shall file with the department a report explaining how the carrier has complied with the provisions of this section. The report shall be written in a manner and form determined by the department.

c. Nothing in this section shall preclude a carrier or pharmacy benefits manager under contract with a carrier from implementing a program designed to lower a covered person's out-of-pocket cost or decreasing a covered person's out-of-pocket cost by an amount greater than that required under subsection a. of this section.

d. As used in this section, "compensation" means any direct or indirect financial benefit, including, but not limited to, rebates, discounts, credits, fees, grants, chargebacks or other payments or benefits of any kind, that is attributed to, directly or indirectly, the utilization of a health benefits plan or enrollment in a health benefits plan, regardless of how the benefits are otherwise characterized by a pharmacy benefits manager and relevant third parties.

§ 17B:27F-3.3 Carrier, pharmacy benefits manager under contract, pharmacy and therapeutics committee, established, formulary system management.

7. a. A carrier, or a pharmacy benefits manager under contract with a carrier, shall establish a pharmacy and therapeutics committee responsible for managing the formulary system.

b. A carrier, or a pharmacy benefits manager under contract with a carrier, shall not allow a person with a conflict of interest to be a member of its pharmacy and therapeutics committee.

A carrier, or a pharmacy benefits manager under contract with a carrier, shall require that its pharmacy and therapeutics committee meet the requirements for conflict of interest as set by the Centers for Medicare and Medicaid Services or meets the accreditation standards of the National Committee for Quality Assurance or another independent accrediting organization.

§ 17B:27F-3.4 Carrier, use of pharmacy benefits manager, administer, manage, prescription drug benefits, claims, parameters.

9. a. If a carrier uses a pharmacy benefits manager to administer or manage the prescription drug benefits of covered persons, any pharmacy benefits manager compensation, for purposes of calculating a carrier's anticipated loss ratio or any loss ratio calculated as part of any applicable medical loss ratio filing or rate filing, shall:

(1) constitute an administrative cost incurred by the carrier in connection with a health benefits plan; and

(2) not constitute a benefit provided under a health benefits plan. A carrier shall claim only the amounts paid by the pharmacy benefits manager to a pharmacy or pharmacist as an incurred claim.

b. Any rate filing submitted by a carrier with respect to a health benefits plan that provides coverage for prescription drugs or pharmacy services and that is administered or managed by a pharmacy benefits manager shall include:

(1) a memorandum prepared by a qualified actuary describing the calculation of the pharmacy benefits manager compensation; and

(2) any records and supporting information as the department reasonably determines is necessary to confirm the calculation of the pharmacy benefits manager compensation.

c. Upon request, a carrier shall provide any records to the department that relate to the calculation of the pharmacy benefits manager and pharmacy services administrative organization compensation.

d. A pharmacy benefits manager and pharmacy services administrative organization shall provide any necessary documentation requested by a carrier that relates to pharmacy benefits manager compensation in order to comply with the requirements of this section.

§ 17B:27F-4 Process for appeals, investigation and dispute.

4. All contracts between a pharmacy benefits manager and a pharmacy services administrative organization, or its contracted pharmacies, and all contracts directly between a pharmacy benefits manager and a pharmacy shall include a process to appeal, investigate, and resolve disputes regarding brand andmultiple source generic drug pricing, including, if applicable, brand effective rate, generic effective rate, dispensing fee effective rate, and any other pricing formula for pharmacy reimbursement. The contract provision establishing the process shall include the following:

a. The right to appeal shall be limited to 14 calendar days following the initial claim;

b. The appeal shall be investigated and resolved by the pharmacy benefits manager through an internal process within 14 calendar days of receipt of the appeal by the pharmacy benefits manager;

c. A telephone number at which a pharmacy services administrative organization, or a pharmacy may contact the pharmacy benefits manager and speak with an individual who is involved in the appeals process; and

d. (1) If the appeal is denied, the pharmacy benefits manager shall:

(a) provide the reason for the denial to the pharmacy services administrative organization and its contracted pharmacies, and the pharmacy services administrative organization shall inform its contracted pharmacies of the availability, location and pricing of the appealed drug in the State;

(b) provide the reason for the denial directly to a pharmacy, if it contracts directly with a pharmacy benefits manager;

(c) identify the national drug code of a drug product that is available for purchase by the specific contracted pharmacy appealing the claim in this State from wholesalers registered pursuant to P.L.1961, c.52 (C.24:6B-1 et seq.) at a price which is available to the specific contracted pharmacy appealing the claim and which is equal to or less than the maximum allowable cost or the brand effective rate, generic effective rate or other pricing for the appealed drug as determined by the pharmacy benefits manager; and

(d) provide the name of wholesalers registered under P.L.1961, c.52 (C.24:6B-1 et seq.) from which the appealing pharmacy can obtain the brand or multiple source generic drug at or below the brand effective rate, generic effective rate, dispensing fee effective rate, maximum allowable cost or any other pricing formula for pharmacy reimbursement;

(2) If the appeal is approved, the pharmacy benefits manager shall make the price correction, permit the reporting pharmacy to reverse and rebill the appealed claim, and make the price correction effective for all similarly situated pharmacies from the date of the approved appeal.

e. A pharmacy benefits manager shall not terminate a pharmacy licensed in the State of New Jersey solely on the basis that the pharmacy offers and provides store direct delivery and mail prescriptions to an insured as an ancillary service.

§ 17B:27F-5 Rules, regulations.

5. The Commissioner of Banking and Insurance shall adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations, including any penalty provisions the commissioner deems to be necessary, to effectuate the purposes of this act.

§ 17B:27F-6 Regulations, pharmacy benefits managers.

1. a. A pharmacy benefits manager, in connection with any contract or arrangement with a private health insurer, prescription benefit plan, or the State Health Benefits Program or School Employees' Health Benefits Program, shall not require a covered person to make a payment at the point of sale for any amount for a deductible, coinsurance payment, or a copayment for a prescription drug benefit in an amount that exceeds the amount permitted pursuant to subsection d. of section 3 of P.L.2023, c.107 (C.17B:27F-3.1).

b. A pharmacy benefits manager shall not prohibit a network pharmacy from, and shall not apply a penalty or any other type of disincentive to a network pharmacy for:

(1) disclosing to a covered person lower cost prescription drug options, including those that are available to the covered person if the covered person purchases the prescription drug without using health insurance coverage;

(2) providing a covered person with the option of paying the pharmacy provider's cash price for the purchase of a prescription drug and not filing a claim with the covered person's health benefits plan if the cash price is less than the covered person's cost-sharing amount;

(3) providing information to a State or federal agency, law enforcement agency, or the department when such information is required by law; or

(4) applying a discounted price generated by a healthcare platform, as defined pursuant to section 2 of P.L.2003, c.280 (C.45:14-41), to the payment of a covered person with an account or membership to the healthcare platform for a prescription drug, even if the covered person maintains health insurance coverage.

c. Any provision of a contract that conflicts with the provisions of subsection b. of this section shall be void and unenforceable.

d. A violation of this section shall be an unlawful practice and a violation of P.L.1960, c.39 (C.56:8-1 et seq.), and shall also be subject to any enforcement action that the Commissioner of Banking and Insurance is authorized to take pursuant to section 5 of P.L.2015, c.179 (C.17B:27F-5).

§ 17B:27F-6.1 Requirements for pharmacy benefits managers.

4. a. The annual limitation on cost-sharing amounts provided for in section 1302 of the Patient Protection and Affordable Care Act, Pub.L.111-148 (42 U.S.C. s.18022) shall apply to all health care services covered under any health benefits plan offered or issued by a carrier in this State, including a health benefits plan administered by a pharmacy benefits manager. Nothing in this subsection shall be construed to limit or supersede the authority of the Department of Banking and Insurance to impose additional cost-sharing limits consistent with State law and regulations, including minimum standards established pursuant to N.J.A.C.11:22-5.1 et seq.

b. When calculating a covered person’s contribution to any applicable cost-sharing amount requirement, a pharmacy benefits manager shall give credit for the amount, or any portion thereof, of any cost-sharing amount paid by the covered person or on behalf of the covered person by another party. If a health benefits plan qualifies as a high-deductible health plan for which medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), this subsection shall apply to a high-deductible health plan with respect to the deductible after the covered person has satisfied the minimum deductible required under section 223, except for with respect to items or services that are preventive care pursuant to section 223(c)(2)(C) of the federal Internal Revenue Code (26 U.S.C. s.223), in which case the requirements of this subsection shall apply regardless of whether the minimum deductible under section 223 has been satisfied.

c. A pharmacy benefits manager shall not directly or indirectly set, alter, implement, or condition the terms of health benefits plan coverage, including the benefit design, based in part or entirely on information about the availability or amount of financial or product assistance available for a prescription drug.

d. By March 31 of each year, each pharmacy benefits manager authorized to conduct business in the State shall certify to the Commissioner of Banking and Insurance, in a form and manner as determined by the commissioner, that it has fully and completely complied with the requirements of this section throughout the prior calendar year. The certification shall be signed by the chief executive officer, chief financial officer, or designee, of the pharmacy benefits manager.

e. The Commissioner of Banking and Insurance, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations to effectuate the purposes of this section.

f. As used in this section:

“Cost-sharing amount” means any copayment, coinsurance, deductible, or other similar charges required of a covered person for a health care service covered by a health benefits plan, including a prescription drug benefits plan, and paid by or on behalf of the covered person.

“Health benefits plan” means a benefits plan which pays hospital or medical expense benefits for covered services, or prescription drug benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier or any other sponsor. For the purposes of P.L.2015, c.179 (C.17B:27F-1 et seq.), “health benefits plan” shall not include the following plans, policies or contracts: accident only; credit disability; long-term care; Medicare supplement coverage; TRICARE supplement coverage; coverage for Medicare services pursuant to a contract with the United States government; the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.); coverage arising out of a worker's compensation or similar law; the State Health Benefits Program; the School Employees' Health Benefits Program; or a self-insured health benefits plan governed by the provisions of the federal “Employee Retirement Income Security Act of 1974,” 29 U.S.C. s.1001 et seq.; coverage under a policy of private passenger automobile insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.); or hospital confinement indemnity coverage.

“Health care service” means an item or service furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or disability.

“Pharmacy benefits manager” means a corporation, business, or other entity, or unit within a corporation, business, or other entity, that, pursuant to a contract or under an employment relationship with a carrier, health benefits plan, self-insurance plan, or other third-party payer, either directly or through an intermediary, provides one or more pharmacy benefits management services on behalf of a carrier, health benefits plan, self-insurance plan, and or other third-party payer, and any agent, contractor, intermediary, affiliate, subsidiary, or related entity of a person who facilitates, provides, directs, or oversees the provision of the pharmacy benefits management services.

“Pharmacy benefits management services” means:

negotiating the price of prescription drugs, including negotiating and contracting for direct or indirect rebates, discounts, or other price concessions;

managing the aspects of a prescription drug benefit, including, but not limited to, the processing and payment of claims for prescription drugs; arranging alternative access to or funding for prescription drugs; the performance of drug utilization review; the processing of drug prior authorization requests; the adjudication of appeals or grievances related to the prescription drug benefit; contracting with network pharmacies; controlling the cost of covered prescription drugs; managing or providing data relating to the prescription drug benefit; or the provision of services related thereto;

performance of any administrative; managerial; clinical; pricing; financial; reimbursement; data administration or reporting; or billing service; and

other services as the Commissioner of Banking and Insurance may deem necessary.

§ 17B:27F-7 "Clean Claim" made by a pharmacy, actions of pharmaceutical benefits managers.

1. a. After the date of receipt of a clean claim for payment made by a pharmacy, a pharmacy benefits manager shall not retroactively reduce payment on the claim, either directly or indirectly, through aggregated effective rate, direct or indirect remuneration, quality assurance program, or otherwise,except if the claim is found not to be a clean claim during the course of a routine audit performed pursuant to an agreement between the pharmacy benefits manager and the pharmacy. When a pharmacy adjudicates a claim at the point of sale, the reimbursement amount provided to the pharmacy by the pharmacy benefits manager shall constitute a final reimbursement amount. Nothing in this section shall be construed to prohibit any retroactive increase in payment to a pharmacy pursuant to a contract between the pharmacy benefits manager, and the pharmacy services administration organization, or a pharmacy.

b. For the purpose of this section, "clean claim" means a claim that has no defect or impropriety, including a lack of any required substantiating documentation, or other circumstance requiring special treatment, including, but not limited to, those listed in subsection d. of this section, that prevents timely payment from being made on the claim.

c. A pharmacy benefit manager shall not recoup funds from a pharmacy in connection with claims for which the pharmacy has already been paid unless the recoupment is:

(1) otherwise permitted or required by law;

(2) the result of an audit, performed pursuant to a contract between the pharmacy benefits manager and the pharmacy; or

(3) the result of an audit, performed pursuant to a contract between the pharmacy benefits manager and the designated pharmacy services administrative organization.

d. The provisions of this section shall not apply to an investigative audit of pharmacy records when:

(1) fraud, waste, abuse or other intentional misconduct is indicated by physical review or review of claims data or statements; or

(2) other investigative methods indicate a pharmacy is or has been engaged in criminal wrongdoing, fraud or other intentional or willful misrepresentation.

§ 17B:27F-8 Commissioner review, approval.

5. The Commissioner of Banking and Insurance may review and approve the compensation program of a pharmacy benefits manager with a health benefits plan to ensure that the reimbursement for pharmacist services paid to a pharmacist or pharmacy is fair and reasonable to provide an adequate pharmacy benefits manager network for a health benefits plan.

§ 17B:27F-9 Applicability of C.17B:27F-1 et seq.

6. The licensing requirements of P.L.2015, c.179 (C.17B:27F-1 et seq.) shall apply to all pharmacy benefits managers operating in the State of New Jersey. Requirements imposed on carriers by the provisions of P.L.2015, c.179 (C.17B:27F-1 et seq.) shall not apply to an agreement by a pharmacy benefits manager to administer prescription drug benefits on behalf of the State Health Benefits Program, the School Employees Health Benefits Program, the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or a self-insured health benefits plan governed by the provisions of the federal "Employee Retirement Income Security Act of 1974," 29 U.S.C., ss.1001 et seq.

§ 17B:27F-9.1 Carrier, health benefits plan, access data, administration, provision, prescription drug benefits; penalties.

8. a. A carrier or health benefits plan, including the State Health Benefits Program, the School Employees' Health Benefits Program, the State Medicaid program, and a self-insured health benefits plan governed by the provisions of the federal "Employee Retirement Income Security Act of 1974," 29 U.S.C. s.1001 et seq., shall have the ability to access all data related to the administration and provision of prescription drug benefits administered by a pharmacy benefits manager under the health benefits plan, including, but not limited to:

(1) the names, addresses, member identification numbers, protected health information and other personal information of covered persons; and

(2) any contracts, documentation, and records, including transaction and pricing data and post point-of-sale information, related to the dispensing of prescription drugs to covered persons under the health benefits plan.

b. A sale or transaction involving the transfer of any records, information or data described in subsection a. of this section must comply with the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, and the federal Health Information Technology for Economic and Clinical Health Act, Pub. L. No. 111-5, and any regulations adopted pursuant to those laws.

c. A carrier or health benefits plan, including the State Health Benefits Program, the School Employees' Health Benefits Program, the State Medicaid program, or a self-insured health benefits plan may audit all transaction records related to the dispensing of prescription drugs to covered persons under a health benefits plan. A carrier or health benefits plan, including the State Health Benefits Program, the School Employees' Health Benefits Program, the State Medicaid program, or a self-insured health benefits plan may conduct audits at a location of its choosing and with an auditor of its choosing.

d. A carrier shall maintain all records, information and data described in subsection a. of this section and all audit records described in subsection c. of this section for a period of no less than five years.

e. (1) Upon request, a carrier or pharmacy benefits manager shall provide to the department any records, contracts, documents or data held by the carrier or the carrier's pharmacy benefits manager for inspection, examination or audit purposes. The department shall keep confidential all information submitted pursuant to this section and shall protect it from public disclosure. Any records, documents, or data provided to the department pursuant to this subsection shall not be considered a government record under P.L.1963, c.73 (C.47:1A-1 et seq.) or the common law concerning access to government records.

(2) A person who is authorized to access information submitted by a pharmacy benefits manager to the department who willfully discloses such information to any person or entity who is not authorized to access the information shall be subject to a civil penalty in an amount not to exceed $500.

A civil penalty imposed under this subsection shall be collected by the commissioner pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.).

f. A pharmacy benefits manager shall disclose in writing to a carrier or health benefits plan any activity, policy, practice, contract or arrangement of the pharmacy benefits manager that directly or indirectly presents any conflict of interest with the pharmacy benefits manager's relationship with or obligation to the carrier or plan.

§ 17B:27F-10 Violations, penalties.

7. a. A pharmacy benefits manager that violates any provision of P.L.2015, c.179 (C.17B:27F-1 et seq.) shall be subject to a penalty in an amount not exceeding the greater of:

(1) a penalty of $5,000 for a first violation and a penalty of $10,000 for each subsequent violation; or

(2) the aggregate gross receipts attributable to all violations.

b. In addition to any other penalties permitted by law, the Commissioner of Banking and Insurance may require a pharmacy benefits manager that violates the provisions of P.L.2015, c.179 (C.17B:27F-1 et seq.) to make restitution and pay compensatory damages, in an amount to be determined by the commissioner, to any person injured by the violation.

Chapter 28

§ 17B:28-1 Definition

When used in this chapter, the following terms shall have the following respective meanings: a. "Separate account contract" means any contract issued by an insurer under which amount (including without limitation proceeds applied under optional modes of settlement or under dividend options) are allocated by the insurer to one or more separate accounts; b. "Separate account" means any segregated portfolio of investments or designated account of an insurer established pursuant to this chapter; c. "Contract on a variable basis" means any separate account contract providing for the dollar amount of life insurance or annuity benefits or other contractual payments or values thereunder to vary so as to reflect investment results of one or more separate accounts in which amounts with respect to any such contracts shall have been placed; and d. "Variable contract account" means any such separate account.

§ 17B:28-2 Qualification of insurer

No present or future domestic insurer shall undertake the issuance of any contract on a variable basis, and no foreign or alien insurer heretofore or hereafter admitted to transact in this State any class or classes of insurance authorized by this code shall undertake the issuance or delivery of any contract on a variable basis within this State, unless said insurer shall have the authority to write life insurance or annuities or both and until said insurer has satisfied the commissioner that it has been engaged in transacting the business of life insurance for a period of at least 2 years and that its condition or methods of operation in connection with the issuance of such contracts on a variable basis will not be such as would render its operation hazardous to the public or its policyholders in this State. In determining the qualification of an insurer requesting authority to issue or deliver contracts on a variable basis within this State, the commissioner will consider, among other things, the history of the insurer; the character, responsibility and general fitness of the officers and directors of the insurer; and the regulation of such insurer by its jurisdiction of domicile. If the insurer is a subsidiary of an authorized insurer, or affiliated with such authorized insurer by common management or ownership, it may be deemed by the commissioner to have satisfied the aforementioned provisions if either it or such authorized insurer satisfies said provisions.

§ 17B:28-3 Certificate to sell

a. No agent or solicitor employed by an agent heretofore or hereafter licensed shall be authorized to sell or act or aid in any manner in the negotiation of a contract on a variable basis until he has received a certificate to sell contracts on a variable basis from the commissioner, which certificate shall not be issued by the commissioner until such agent or solicitor has qualified by personal examination, to the satisfaction of the commissioner, as to his trustworthiness and competence to act as such agent or solicitor.

b. Before a first-time applicant for a license to solicit and negotiate contracts on a variable basis shall be admitted to the examination, the applicant shall be required to concurrently hold an agent's license granting authority to solicit and negotiate contracts of life insurance in this State or hold a license to act as a solicitor for such an agent. Application for a license must be made on such forms as the commissioner may prescribe.

c. The examination fee shall be $25.00 for each examination scheduled and such examination fee shall not be returned for any reason. The licensee fee shall be $25.00. A renewal license shall be issued biennially subject to the payment of the renewal license fee as required by this section and upon request of the insurer. Licenses issued in accordance with this section shall expire on April 30 of each odd numbered year.

d. No written examination shall be required of:

(1) An applicant who is the holder of a valid agent's or solicitor's license issued pursuant to this section by the commissioner or an applicant for a renewal of such license, except in a case where the commissioner has good and sufficient cause to believe that the applicant for renewal has demonstrated incompetence in the conduct of his business as such agent or solicitor to the detriment of the public;

(2) An applicant whose license to do business as an agent or solicitor issued pursuant to this section has expired less than 3 years prior to the date of application. If the applicant has permitted his license to lapse for a period of more than 3 years he must submit to and pass an examination in the same manner as a new applicant, except where the applicant is a veteran who meets the requirements of subsection (4) hereunder, when no re-examination shall be required;

(3) An applicant whose previous license issued pursuant to this section has been revoked or suspended; provided this examination exemption is only at the discretion of the commissioner;

(4) An applicant who is a citizen of New Jersey and has served in the Armed Forces of the United States, including a citizen of New Jersey who served as a member of the American Merchant Marine during World War II and is declared by the United States Department of Defense to be eligible for federal veterans' benefits, and has been honorably discharged or released under conditions other than dishonorable and was the holder at any time of a license in New Jersey which authorized the applicant to solicit or negotiate contracts on a variable basis;

(5) Any individual seeking a variable license who, in the discretion of the commissioner, has satisfied the requirements and successfully passed all the examinations of the National Association of Securities Dealers, required to secure a registration to sell securities by the National Association of Securities Dealers in compliance and conformity with the rules and regulations promulgated by the Federal Securities and Exchange Commission.

e. The commissioner may issue a nonresident agent's or solicitor's license upon the application of a nonresident who is duly licensed under the law of the state of his residence or domicile to act as an agent or solicitor for contracts on a variable basis if said state does not prohibit residents of this State from acting as nonresident agents or solicitors therein, when:

(1) The applicant has shown by a statement from the proper official of the state in which he has his resident license that he is authorized to do business as an agent or solicitor in such state with authority for which the applicant is to be licensed under the New Jersey nonresident license.

(2) The applicant has paid the annual license fee as provided for in this section.

(3) The applicant has no place of business in this State.

(4) The commissioner may enter into reciprocal agreements with the appropriate supervisory insurance official of any other state waiving the written examination of any applicant resident in such other state, provided:

(a) A written examination is required of applicants for an agent's or solicitor's license in such other state.

(b) The appropriate supervisory insurance official of such other state certifies that the applicant holds a currently valid license as an agent or solicitor in such other state, and either,

(i) Passed a written examination,

(ii) Was the holder of an agent's or solicitor's license prior to the time a written examination was required, or

(iii) Was not required to take such examination by reason of provisions of the applicable agent's or solicitor's licensing law.

(c) That in such other state, a resident of this State is privileged to procure such an agent's or solicitor's license upon the foregoing conditions and without discrimination as to fees or otherwise in favor of residents of such other state. If the laws of another state require the sharing of commissions with resident agents or solicitors of that state on applications for contracts on a variable basis written by nonresident agent or solicitors, then the same provision shall apply when resident agents or solicitors of that state, licensed as nonresident agents or solicitors of New Jersey write applications for contracts on a variable basis in this State.

§ 17B:28-4 Required statements; procedure

Any contract on a variable basis delivered or issued for delivery in this State, and any certificate evidencing variable benefits issued pursuant to any such contract on a group basis, shall contain a statement of the essential features of the procedure to be followed by the insurer in determining the dollar amount of variable benefits or other contractual payments or values thereunder and shall state in clear terms that such amount may decrease or increase according to such procedure. Any such contract delivered or issued for delivery in this State, and any such certificate, shall contain on its first page, in a prominent position, a clear statement that the benefits or other contractual payments or values thereunder are on a variable basis.

§ 17B:28-5 Form of contract

(a) No contract on a variable basis shall be delivered or issued for delivery in this State by any insurer until a copy of the form (and, in the case of a contract on a group basis, the form of any certificate evidencing variable benefits issued pursuant thereto) and any form of application for such contract shall have been filed with the commissioner in accordance with the provisions of section 16 of P.L.1995, c.73 (C.17B:25-18.2). The commissioner shall disapprove or withdraw approval of any contract form, application or certificate if:

(i) The form contains provisions which are unjust, unfair, inequitable, ambiguous, misleading, likely to result in misrepresentation or contrary to law, or

(ii) Sales of contracts in such form are being solicited by any means of advertising, communication or dissemination of information which involves misleading or inadequate description of the provisions of the contract.

He shall notify the insurer, specifying particulars, of his disapproval. It shall be unlawful for such insurer thereafter to issue any contract or certificate thereunder or use any application in the form so disapproved unless it is resubmitted and approved in accordance with the provisions of subsections b., c., and d. of section 16 of P.L.1995, c.73 (C.17B:25-18.2). Such disapproval of the commissioner shall be subject to review in accordance with the procedure described in the "Administrative Procedure Act" P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder. Any such form which is filed by the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith.

(b) Illustrations of benefits payable under any contract on a variable basis shall not involve projections of past investment experience into the future and shall conform with reasonable regulations promulgated by the commissioner.

(c) No individual annuity contract on a variable basis shall be delivered or issued for delivery in this State unless it contains in substance the following provisions:

(i) That, in the event of default in the payment of any consideration beyond the period of grace allowed by the contract for the payment thereof, the insurer will make payment of the value of the contract, in accordance with a plan provided by the contract, commencing not later than the date contractual payments by the insurer were otherwise to have commenced in accordance with the contract;

(ii) That, upon request of the contract holder received by the insurer at least 4 months prior to the date contractual payments by the insurer were otherwise to have commenced, the insurer will make payment of the value of the contract in accordance with a plan provided by the contract and selected by the contract holder, commencing as of the first day of the first month which is at least 4 months after the date of receipt of such request, unless another date of commencement is requested by the contract holder and agreed to by the insurer;

(iii) That the insurer will mail to the contract holder at least once in each contract year after the first, at his last address known to the insurer, a report in a form approved by the commissioner, which shall include a statement of the number of units credited to such contract and the dollar value of a unit as of a date not more than 2 months previous to the date of mailing and a statement in a form and of a date approved by the commissioner of the investments held in the variable contract account designated in such contract.

(d) Any individual contract on a variable basis delivered or issued for delivery in this State shall stipulate the investment increment factors to be used in computing the dollar amount of variable benefits or other contractual payments or values thereunder, and shall guarantee that expense and mortality results shall not adversely affect such dollar amounts, except that such guarantee need not apply to any investment management fee which is subject to change with the approval by vote of the persons having beneficial interests in the variable contract account in which such contract participates. The mortality and investment increment factors used in computing the dollar amount of variable benefits or other contractual payments or values under an individual annuity contract on a variable basis shall not produce a larger initial payment than would be produced by the use of the mortality table or tables specified in N.J.S. 17B:19-8 (the Standard Valuation Law), as amended, and as such provision may be amended from time to time, as acceptable minimum mortality standards for the valuation of the reserve liabilities of individual annuity and pure endowment contracts, and an annual investment increment assumption of 5%.

Any group contract on a variable basis delivered or issued for delivery in the State shall stipulate the expense, mortality and investment increment factors to be used in computing the dollar amount payable with respect to a unit of variable benefits purchased thereunder and shall guarantee that expense and mortality results shall not adversely affect such dollar amounts, except that such guarantee need not apply to any investment management fee which is subject to change with the approval by vote of the persons having beneficial interests in the variable contract account in which such contract participates.

"Expense," as used in this subsection (d), may exclude some or all taxes, as stipulated in the contract.

(e) (Deleted by amendment).

§ 17B:28-6 Administration

Any insurer maintaining one or more separate accounts shall submit annually to the commissioner a report of the business of its separate accounts. Such report shall be made either by a separate annual statement for such business or by suitable additions to such insurer's regular annual statement, in either case on a form prescribed by the commissioner, and shall include details as to all of the income, disbursements, assets and liability items associated with the separate accounts.

The commissioner shall make a separate valuation of the assets of the separate accounts and a copy of such valuation shall be filed in the commissioner's office as a public document. Such valuation shall be in accordance with section 17B:28-10.

The commissioner shall further prescribe by regulation the steps to be taken by the insurer in disposing of those holdings which at any time subsequent to purchase fail to meet the standards and regulations for new investments.

§ 17B:28-7 Separate accounts; approval by commissioner

Any present or future domestic insurer shall have authority to establish and operate one or more separate accounts and to issue separate account contracts, whether or not contracts on a variable basis, with the approval of the commissioner, and the issuance or delivery of such contracts in this State by any foreign or alien insurer shall be subject to like approval. The commissioner, in granting or withholding any such approval, shall consider in addition to the matters referred to in N.J.S.17B:28-2, 17B:28-5, and 17B:28-15, if applicable, the following:

a. The type or types of contracts the funds from which will be placed in the separate accounts;

b. The extent to which, if any, the dollar amount of benefits or other contractual payments or values under such contracts will be guaranteed;

c. The investment limitations that will be applicable to the separate account;

d. The manner of valuing the assets of the account and the method or methods to be used to compute the liabilities arising from the contracts described in subsection a. of this section;

e. If such contracts are annuity contracts, whether or not they will be participating; and

f. Such other matters as the commissioner shall deem relevant.

Any such approval by the commissioner may be subject to such conditions as he may impose as being necessary for the protection of the public or of such insurer's policyholders. Any approval by the commissioner pursuant to this section may be granted with respect to a single separate account or a class of separate accounts having common characteristics.

For any separate account established and maintained solely for one or more employer group contracts sold to fund an employee benefit plan, which contracts constitute group contracts for the purposes of paragraph (v) of subsection a. of N.J.S.17B:28-9, an insurer may establish and maintain such account 45 days after filing its request for the commissioner's approval, unless within that time the commissioner shall have approved or disapproved the account, provided that neither the insurer nor any such contract shall provide a guaranty, including any index guaranty, of the dollar amount of benefits or other contractual payments or values under such contract. Any disapproval shall state in writing the grounds therefor in such detail as reasonable to inform the insurer thereof. The disapproval by the commissioner of any such account may be on the ground that the account is contrary to law or the public policy of this State. Any disapproval shall be subject to review in accordance with the procedure set forth in the "Administrative Procedure Act," P.L.1968, C.410 (C.52:14B-1 et seq.), and any rules or regulations adopted thereunder.

§ 17B:28-8 Amounts placed in account; liabilities

Except as may be otherwise specifically provided by the contract, all amounts with respect to any contract on a variable basis shall be placed in the variable contract account designated in such contract, and all liabilities on any such contract shall be set up in said account.

§ 17B:28-9 Investment of assets; eligibility; definition

a. The assets held in a separate account, or any part thereof, may be invested in:

(i) Common stock or shares of any investment company specified in the contract or contracts participating in such separate account, and registered under the Investment Company Act of 1940, whether or not such stock or shares satisfy the dividend or earnings history requirements now or hereafter contained in the provisions of this title that regulate investments by domestic insurers; provided that at the time of the first purchase of such stock or shares of any such investment company, the insurer which maintains such account, or a subsidiary or affiliate of such insurer, shall be the investment manager or investment adviser of such investment company and, as long as such insurer which maintains such account, or any subsidiary or affiliate of such insurer, shall continue as such investment manager or investment adviser, the investments acquired by such investment company shall be such as would be eligible for investment of separate account assets by domestic insurers under the provisions of this section excluding this paragraph (i);

(ii) Other investments made eligible for investment by domestic insurers by the provisions of this title that regulate investments by domestic insurers, except for investments made eligible by the provision of chapter 20 of this title which permits a domestic insurer to make loans or investments not otherwise expressly qualified or permitted up to 5% of total admitted assets, as such provision may be amended from time to time, or any similar or superseding provision corresponding in substance thereto;

(iii) Investments authorized, specifically or by classes or otherwise, by the commissioner as appropriate to the nature and purpose of such separate account; and

(iv) Investments not otherwise eligible under the preceding clauses of this subsection, provided that at the time of making any such investment, and immediately after giving effect thereto, the aggregate cost of all investments held in such separate account pursuant to this paragraph (iv) shall not exceed 5% of the aggregate market value of the assets held in such separate account;

provided that (A) any common stock or shares, other than common stock or shares referred to in paragraph (i) of this subsection issued by an open-end investment company, shall be (1) common stock or shares which are listed or admitted to trading on a securities exchange in the United States of America or Canada, or (2) common stock or shares which are included on the National Association of Securities Dealers' national price listings of "over-the-counter" securities, or (3) other common stock or shares which the commissioner shall have determined are publicly held and traded and as to which market quotations shall be available; (B) the quantitative investment limitations now or hereafter contained in this title regulating investments by domestic insurers shall not be applicable to investments for separate account, subject to the qualification that the provision contained in this title limiting the percentage of voting stock of any one corporation that may be purchased or acquired by a domestic insurer, as such provision may be amended from time to time, or any similar or superseding provision corresponding in substance thereto, shall apply (subject to the provisions of N.J.S.17B:20-3 as such provisions may be amended from time to time, or any similar or superseding provisions corresponding in substance thereto), with respect to the aggregate of the voting stock of any one corporation held in all accounts of such insurer, except for all such stock that may be voted at the direction of a person or persons, other than such insurer or any subsidiary or affiliate of such insurer; and provided further that, subject to the next succeeding paragraph of this subsection, no domestic insurer shall purchase for any separate account any security (other than common stock or shares referred to in paragraph (i) of this subsection issued by an open-end investment company) of any corporation, if after such purchase more than 10% of the market value of the assets of such separate account would be invested in the securities of such corporation.

(v) Notwithstanding the foregoing provisions of this section or any other provision of law, a domestic insurer may invest the assets, or any part thereof, held in a separate account established and maintained solely for one or more group contracts in any investment or investments authorized by the contract or contracts participating in such account, subject only to subparagraph (B) of paragraph (iv) of this subsection relating to the percentage of voting stock of any one corporation that may be purchased or acquired. For the purpose of this paragraph, a group contract shall not include, (1) a contract which provides benefits to individuals based upon the investment results of such an account unless such contract implements a plan (a) which covers at least 100 individuals at the time of execution of such contract and (b) under which, if the crediting to such an account of the contributions made by any individual would affect his benefits under the plan, no portion of his contributions in excess of 50% is so credited, unless he is offered an alternative to having such portion so credited or, (2) except with the consent of the commissioner, a contract the holder of which is an association of individuals or the representative thereof.

Except as otherwise provided in this subsection, the investments held in the separate accounts of any domestic insurer shall be disregarded in determining whether the other investments of such insurer comply with the provisions of this title that regulate investments by domestic insurers as such provisions may be amended from time to time, or any similar or superseding provisions corresponding in substance thereto.

b. Notwithstanding any other provision of law, a domestic insurer may, with respect to any separate account or any portion thereof

(i) Exercise any voting rights of any stock or shares in accordance with instructions from the person or persons specified in, or designated pursuant to, the contract or contracts participating in such account, or

(ii) Establish a committee for such account, the members of which may be directors or officers or other employees of such insurer, or persons having no such relationship to such insurer, or any combination thereof, who may be elected to such membership by the vote of the persons having the beneficial interests in such account ratably according to their respective interests in such account or in such other manner as the insurer shall deem appropriate. Such committee may have the power, which may be exercisable alone or in conjunction with others, or which may be delegated to such insurer or any other person, as investment manager or investment adviser, to authorize purchases and sales of investments for such account and to take such other action with respect to account investments as it shall deem appropriate, provided that as long as such insurer or any subsidiary or affiliate of such insurer shall be the investment manager or investment adviser of such account, the investments of such account shall be eligible under the provisions of subsection a. of this section. Such insurer may establish such a committee for only a portion of a separate account, and its members may be similarly elected. Any such committee for only a portion of a separate account may be given the further power to require the subdivision of such account into two accounts so that the portion with respect to which such committee shall be acting shall constitute a separate account. If such committee shall so require, the insurer shall segregate from the account being so subdivided a portion of the assets held with respect to the reserve liabilities of such account. Such portion shall be in the same proportion to the total of such asset as the reserve liability for the portion of the account with respect to which such committee is acting bears to the total reserve liability of such account; and notwithstanding any other provision of law, the assets so segregated shall be transferred to a separate account with respect to which such committee shall act.

c. The investments held in a separate account and the liabilities chargeable against it shall at all times be clearly identifiable and distinguishable from the other investments and liabilities of the insurer. To the extent provided in the applicable contract or contracts, assets held in a separate account shall not be chargeable with liabilities arising out of any other business of the corporation.

No sale, transfer or exchange of investments may be made between a separate account and any other investment account of the insurer, except with the prior consent of the commissioner, and no investments held in a separate account, other than an account of the kind described in paragraph (v) of subsection a. of this section, shall be pledged or transferred as collateral for a loan.

d. The term "Investment Company Act of 1940" as used in this section shall mean an act of Congress approved August 22, 1940 entitled "Investment Company Act of 1940" as amended from time to time, or any similar statute enacted in substitution therefor.

§ 17B:28-10 Valuation of assets

Except as the commissioner may require or permit a different basis of valuation, the valuation of separate account assets for all purposes, including annual reports of the insurer to the commissioner, shall be determined in accordance with the market value of such assets notwithstanding the application of other valuation methods to assets of the insurer other than the assets of separate accounts. If there shall be no readily available market for any such assets, their market value may be determined by reference to opinions or estimates based upon reasonably current transactions in similar investments with such adjustments, if any, as shall be deemed appropriate to take into account any dissimilarities in the investment being valued, or such other method as shall reflect what a willing buyer, under no pressure to buy, would pay a willing seller, under no pressure to sell, for such investment. The net asset value of common stock or shares of any investment company which is an open-end company shall be deemed to be the market value thereof. Such valuation may be made as of such valuation dates as the insurer shall establish from time to time, except as otherwise required for such annual reports to the commissioner.

§ 17B:28-11 Reserve liability

The reserve liability for contracts on a variable basis shall be established by the commissioner pursuant to the requirements of section 17B:19-8 (the Standard Valuation Law) in accordance with actuarial procedures that recognize the variable nature of the benefits provided.

§ 17B:28-12 Annuities

Any insurer which establishes one or more variable contract accounts and issues variable annuity contracts may in its discretion, but need not, require in any case the purchase of annuities which provide for benefits of predetermined dollar amount in specified proportions in combination with the purchase of annuities providing for benefits of variable dollar amount.

§ 17B:28-14 Regulation of separate account contracts, insurers issuing the same and sales agents

The commissioner shall have the sole and exclusive authority to regulate the issuance and sale of separate account contracts; and such contracts, the insurers which issue them and the agents, solicitors or other persons who sell them shall not be subject to the Uniform Securities Law (1967) (P.L.1967, c. 93) as amended or supplemented, in the issuance or sale of such contracts.

§ 17B:28-15 Application to separate accounts and separate account contracts of Title 17B; required provisions for variable life insurance contracts

Except for N.J.S. 17B:25-3, 17B:25-8, 17B:25-9, 17B:25-13, 17B:25-19 and 17B:27-11, in the case of a variable life insurance policy and except as otherwise provided in this act, all pertinent provisions of Title 17B of the New Jersey Statutes shall apply to separate accounts and contracts relating thereto. Any individual variable life insurance contract, delivered or issued for delivery in this State shall contain loan, grace, reinstatement and nonforfeiture provisions acceptable to the commissioner. Any group variable life insurance contract, delivered or issued for delivery in this State shall contain a grace provision appropriate to such a contract. The commissioner shall have the sole authority to issue such reasonable rules and regulations as may be appropriate to carry out the purposes and provisions of this act.

Chapter 28A

§ 17B:28A-1 Insurance against risk of loss in value of redeemable securities issued by investment company

A domestic insurer authorized to do the business specified in N.J.S. 17B:17-3 may issue and deliver individual and group policies insuring against the risk of loss in the value of (a) redeemable securities issued by an investment company regulated by the Investment Company Act of 1940 (15 U.S.C.A. s. 80a-1 et seq.) and whose redeemable securities are registered under the Securities Act of 1933 (15 U.S.C.A. s. 77a et seq.) or (b) redeemable securities issued by an investment company which shall include an investment fund, trust, or other similar investment entity, existing under the laws of a foreign country and not so regulated if such company or its securities are determined by the commissioner to be subject to regulation reasonably designed to provide adequate protection to investors in the redeemable securities issued by such company. Such insurance is herein termed investment return assurance. Investment return assurance does not include guarantees of benefits provided by separate account contracts issued by the insurer, which guarantees shall be subject to the provisions of chapter 28 of Title 17B of the New Jersey Statutes.

§ 17B:28A-2 Limitation on benefit and protection

Except with the approval of the commissioner and under such conditions as he may prescribe, the benefit provided by such insurance may not exceed the difference between the amount paid for such redeemable securities and the value of such redeemable securities at or after the end of a specified or determinable period of not less than 5 years from the date of the issuance of the policy or the certificate under a group policy, or at the date of death of the insured, if earlier. The protection provided by investment return assurance shall not extend beyond the coverage of shares of an investment company which are acquired or held during such time as the insurer, or a subsidiary or affiliate of the insurer, shall be the investment manager or investment adviser of such investment company; such a policy or certificate under a group policy shall not be extended or renewed beyond the end of the specified or determinable period if the insurer, or a subsidiary or affiliate of the insurer, ceases to be the investment manager or investment adviser.

§ 17B:28A-3 Undertaking or continuance; approval of commissioner; rules and regulations

No domestic insurer shall undertake or continue the issuance of any such insurance unless the commissioner is satisfied that the condition or methods of operation of such domestic insurer in connection with the issuance of policies of such insurance is not such as to render its operation hazardous to the public or its policyholders. The commissioner may adopt rules and regulations as may be reasonable and appropriate to carry out the purposes hereof, including the establishment of limitations on the amount of liabilities under such policies that might be assumed by the domestic insurer.

§ 17B:28A-4 Form of policy; submission to commissioner

No policy providing investment return assurance shall be issued or delivered in this State until a copy of the form thereof is submitted to the commissioner. The provisions of N.J.S. 17B:25-18, relating to the filing of forms of life insurance policies other than group, and N.J.S. 17B:27-25, relating to the filing of group life insurance forms, shall apply, respectively, to individual policies of investment return assurance and group policies of investment return assurance.

§ 17B:28A-5 Foreign or alien insurers; conditions for qualification to issue

No foreign or alien company shall deliver or issue for delivery within this State any policy of investment return assurance unless it is licensed to do life insurance business within this State, and the commissioner is satisfied that the applicable law and regulation of the company's state or country of domicile with respect to the issuance by it of policies of investment return assurance and its condition and methods of operation with respect to the issuance of such policies will not render its operation hazardous to the public or its policyholders in this State. The commissioner may adopt rules and regulations concerning limitations on foreign or alien companies similar to those applied to domestic insurers.

§ 17B:28A-6 Rules and regulations

The commissioner shall make appropriate further rules and regulations for the protection of policyholders and the public, including requirements for nonforfeiture benefits where appropriate, and regulations for valuation methods and minimum requirements for life insurance reserves which are set aside to mature or liquidate, as the case may be, future unaccrued claims under policies of investment return assurance, including specification of maximum assumed rates of interest and recognized minimum assumed mortality tables.

Chapter 29

§ 17B:29-1 Scope; differences in long-term and short-term indebtedness; rules and regulations

All life insurance and all health insurance in connection with loans or other credit transactions shall be subject to the provisions of this chapter, except where the issuance of such insurance is an isolated transaction on the part of the insurer not related to an agreement or a plan for insuring debtors of the creditor. The commissioner may, after notice and hearing, promulgate rules and regulations which will take account of the differences inherent in long-term and short-term indebtedness, including, but not limited to, differences in underwriting standards, the term of the loan, the nature of the risk, and the maximum amount of insurance purchased.

§ 17B:29-2 Definitions

a. "Credit life insurance" means insurance on the life of a debtor pursuant to or in connection with a specific loan or other credit transaction;

b. "Credit health insurance" means insurance on a debtor to provide indemnity for payments becoming due on a specific loan or other credit transaction while the debtor is disabled as defined in the policy;

c. "Creditor" means the lender of money or vendor or lessor of goods, services, property, rights or privileges, for which payment is arranged through a credit transaction, or any successor to the right, title or interest of any such lender, vendor, or lessor, and an affiliate, associate or subsidiary of any of them or any director, officer or employee of any of them or any other person in any way associated with any of them;

d. "Debtor" means a borrower of money or a purchaser or lessee of goods, services, property, rights of privileges for which payment is arranged through a credit transaction, and includes each partner who is jointly and severally liable for a partnership indebtedness. An officer of a corporation is not a debtor in connection with a corporate indebtedness, unless he is personally liable for such indebtedness as a codebtor. When more than one person is jointly obligated in connection with an indebtedness, credit insurance may be written either on an individual basis or, at the option of the insureds, on a joint basis, provided that the credit insurance has been approved by the Department of Insurance to be written on a joint basis in this State;

e. "Indebtedness" means the total amount payable by a debtor to a creditor in connection with a loan or other credit transaction.

§ 17B:29-3 Forms of credit life insurance and credit health insurance

Credit life insurance and credit health insurance shall be issued only in the following forms:

a. Individual policies of life insurance issued to debtors on the term plan;

b. Individual policies of health insurance issued to debtors on a term plan or disability benefit provisions in individual policies of credit life insurance;

c. Group policies of life insurance issued to creditors providing insurance upon the lives of debtors on the term plan;

d. Group policies of health insurance issued to creditors on a term plan insuring debtors or disability benefit provisions in group credit life insurance policies to provide such coverage.

§ 17B:29-3.1 Insurance offered with credit involuntary unemployment insurance

1. a. The individual and group coverages permitted by N.J.S.17B:29-3 may be offered in combination with credit involuntary unemployment insurance, credit personal property insurance, or both, under separate and distinct policies, provided that the total combined premium amount or rate to be charged to the debtor shall be reduced by five percent or by a greater percentage at the discretion of the insurer.

b. When credit involuntary unemployment insurance is included in the combined coverages and (1) the debtor notifies the insurer in writing that he is or has become ineligible for credit involuntary unemployment insurance coverage by reason of being or becoming voluntarily unemployed, or by reason of being or becoming self-employed, and states the date on which that ineligibility commenced; or (2) a claim is denied under the credit involuntary unemployment insurance coverage because the debtor became ineligible for that coverage, the insurer shall promptly remit a refund of the portion of the premium applicable to the credit involuntary unemployment insurance coverage during the period of ineligibility.

c. (1) Notwithstanding the provisions of N.J.S.17B:27-3 to the contrary, group life insurance coverage may be issued in combination with other coverages in accordance with this section.

(2) Insurers issuing insurance coverages combined in accordance with this section shall not be required to offer any of the coverages for separate purchase.

(3) The purchase of insurance coverages combined in accordance with this section shall be voluntary on the part of the debtor.

d. For the purpose of this section, "credit personal property insurance" means insurance covering direct or indirect damage or loss, by fire or other perils, including those of extended coverage, to the personal property of the debtor all or part of which is the security for the loan, which insurance shall be for an amount and term not to exceed the amount and term of the loan.

§ 17B:29-4 Amount of credit life insurance and credit health insurance

a. Credit Life Insurance

(1) The initial amount of credit life insurance shall not exceed the total amount repayable under the contract of indebtedness and, where an indebtedness is repayable in substantially equal installments, the amount of insurance shall at no time exceed the scheduled or actual amount of unpaid indebtedness, whichever is greater.

(2) Notwithstanding the provisions of the above paragraph, insurance on agricultural credit transaction commitments, not exceeding 18 months in duration, may be written up to the amount of the loan commitment, on a nondecreasing or level term plan.

(3) Notwithstanding the provisions of paragraph a. (1) of this or any other subsection, insurance on educational credit transaction commitments may be written for the amount of the portion of such commitment that has not been advanced by the creditor.

b. Credit Health Insurance

The total amount of periodic indemnity payable by credit health insurance in the event of disability, as defined in the policy, shall not exceed the aggregate of the periodic scheduled unpaid installments of the indebtedness; and the amount of each periodic indemnity payment shall not exceed the original indebtedness divided by the number of periodic installments.

§ 17B:29-5 Term of credit life insurance and credit health insurance

The term of any credit life insurance or credit health insurance shall, subject to acceptance by the insurer, commence on the date when the debtor becomes obligated to the creditor, except that, where a group policy provides coverage with respect to existing obligations, the insurance on a debtor with respect to such indebtedness shall commence on the effective date of the policy. Where evidence of insurability is required and such evidence is furnished more than 30 days after the date when the debtor becomes obligated to the creditor and such evidence is determined by the insurer to be satisfactory, the term of the insurance may commence on the date on which the evidence is furnished to the insurer and in such event there shall be an appropriate refund or adjustment of any charge to the debtor for insurance. The term of such insurance shall not extend more than 15 days beyond the scheduled maturity date of the indebtedness except when extended without additional cost to the debtor. If the indebtedness is discharged due to renewal or refinancing prior to the scheduled maturity date, the insurance in force shall be terminated before any new insurance may be issued in connection with the renewed or refinanced indebtedness. In all cases of termination prior to scheduled maturity, a refund shall be paid or credited as provided in section 17B:29-8.

§ 17B:29-6 Provisions of policies and certificates of insurance: disclosure to debtors

a. All credit life insurance and credit health insurance sold shall be evidenced by an individual policy, or in the case of group insurance by a certificate of insurance, which individual policy or group certificate of insurance shall be delivered to the debtor.

b. Each individual policy or group certificate of credit life insurance and each individual policy or group certificate of credit health insurance shall, in addition to other requirements of law, set forth the name and home office address of the insurer, the identity by name or otherwise of the person or persons insured, the rate of premium separately in connection with credit life insurance and credit health insurance if a payment therefor is collected from the debtor, a description of the coverage including any exceptions, limitations and restrictions, and shall state that the benefits shall be paid to the creditor to reduce or extinguish the unpaid indebtedness and, wherever the amount of insurance may exceed the unpaid indebtedness, that any such excess shall be payable to a beneficiary, other than the creditor, named by the debtor or to his estate. For the purpose of this section, a payment for such insurance is deemed to have been collected from the debtor if an amount therefor is separately stated or is included in a total charge for insurance and other services.

c. Said individual policy or group certificate of insurance shall be delivered to the insured debtor at the time the indebtedness is incurred except as hereinafter provided.

d. If said individual policy or group certificate of insurance is not delivered to the debtor at the time the indebtedness is incurred, a copy of the application for such policy or a notice of proposed insurance, signed by the debtor and setting forth the name and home office address of the insurer, the name or names of the debtor, the amount of payment, separately in connection with credit life insurance and credit health insurance coverage, and a brief description of the coverage provided shall be delivered to the debtor at the time such indebtedness is incurred. The copy of the application for, or notice of proposed insurance shall also refer exclusively to insurance coverage, and shall be separate and apart from the loan, sale or other credit statement of account, instrument or agreement, except that, when the information required by this subsection is adequately set forth therein, this requirement may be waived by the commissioner. Upon acceptance of the insurance and within 30 days of the date upon which the indebtedness is incurred, the insurer shall cause the individual policy or group certificate of insurance to be delivered to the debtor. Said application or notice of proposed insurance shall state that upon acceptance by the insurer, the insurance shall become effective as of the date the indebtedness is incurred.

e. Any policy, group certificate, copy of the application or notice of proposed insurance, as referred to in this section, may specify an age beyond which the insurance on a debtor will not become effective or on which a debtor's insurance will terminate; provided, however, that no charge shall be made to a debtor for coverage beyond the limiting age.

§ 17B:29-7 Filing of forms; premium rate schedules

a. All forms of policies, certificates of insurance, notice of proposed insurance, applications for insurance, endorsements and riders delivered or issued for delivery in this State and the schedules of premium rates pertaining thereto shall be filed with the commissioner in accordance with the provisions of subsection g. of this section.

b. (Deleted by amendment, P.L.1995, c.73.)

c. If a form or the schedule of premium rates pertaining thereto is disapproved by the commissioner during the 60-day period, the form may not be delivered or issued for delivery unless the form or schedule of premium rates is resubmitted in accordance with paragraphs (2), (3) and (4) of subsection g. of this section. A form or schedule of rates that is disapproved shall be subject to review in accordance with the procedure described in the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder. Any such form which is filed by the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith.

d. (Deleted by amendment, P.L.1995, c.73.)

e. The disapproval for filing or the withdrawal of the filing of any such form or schedule of premium rates may only be on one or both of the following grounds that may be applicable:

(1) the premium rates charged or to be charged are excessive in relation to benefits, or

(2) such form contains provisions which are unjust, unfair, inequitable, misleading, deceptive, or encourage misrepresentation of the coverage, or are contrary to any provision of this code or of any rule or regulation promulgated thereunder.

f. If a group policy of credit life insurance or credit health insurance

(1) has been delivered in this State before the effective date of this chapter, or

(2) has been or is delivered in another State before or after the effective date of this chapter,

the insurer shall be required to submit for filing only the group certificate and notice of proposed insurance delivered or issued for delivery in this State as specified in subsections b. and d. of N.J.S.17B:29-6 and such forms shall be filed by the commissioner if they conform with the requirements specified in said subsections and if the schedules of premium rates applicable to the insurance evidenced by such certificate or notice are not in excess of the insurer's schedules of premium rates filed with the commissioner.

g. (1) Any form or schedule of premium rates subject to the provisions of N.J.S.17B:29-1 et seq. shall be filed with the commissioner for approval as provided in this subsection. Any form, except those certified pursuant to section 17 of P.L.1995, c.73 (C.17B:25-18.3), and any schedule of premium rates pertaining thereto, shall be filed with the commissioner for approval pursuant to the provisions of this subsection.

(2) Any form or schedule of premium rates pertaining thereto filed with the commissioner for approval pursuant to this subsection shall be deemed approved upon the expiration of 60 days after the submission of the form or schedule of premium rates unless disapproved in writing by the commissioner within that time. Any such disapproval shall be based only on the specific provisions of applicable statutes, regulations adopted by the commissioner, or guidelines published by the commissioner as of the effective date of P.L.1995, c.73 (C.17:48-8.1 et al.) with regard to forms of that type or the schedules of premium rates pertaining thereto. A disapproved form or schedule of premium rates pertaining thereto may be resubmitted.

(3) Any form or schedule of premium rates submitted for approval pursuant to this subsection and disapproved by the commissioner before the expiration of 60 days after its submission, shall be deemed withdrawn at the expiration of 60 days after the transmittal of the commissioner's specific objections unless the filer submits a complete written response to all of the commissioner's objections regarding the submission within the 60 day period.

(4) A form or schedule of premium rates, resubmitted in response to the commissioner's objections pursuant to paragraph (2) of this subsection, shall be deemed approved upon the expiration of 30 days after its resubmission unless disapproved in writing by the commissioner within that time. No disapproval by the commissioner of a resubmission shall be based on any objection not specified by the commissioner in his initial disapproval of the filing, except that the commissioner may disapprove the form or schedule of premium rates based on any new provisions introduced in the resubmission or if in addressing the specified objections cited in the commissioner's disapproval transmission, the insurer changes or modifies any substantive provisions of the form or schedule of premium rates. Any form or schedule of premium rates resubmitted for approval pursuant to this subsection and disapproved by the commissioner before the expiration of 30 days after its submission, shall be deemed withdrawn at the expiration of 30 days after the transmittal of the commissioner's specific objections unless the filer submits a complete written response to all of the commissioner's objections regarding the submission within the 30 day period.

(5) With respect to all types of forms or schedules of premium rates to be filed pursuant to this subsection and currently on file with and approved by the commissioner upon enactment of P.L.1995, c.73 (C.17:48-8.1 et al.), the commissioner shall propose regulations which may be amended or modified by the commissioner from time to time after adoption, concerning any actuarial or form requirements consistent with applicable statutory provisions but not specified therein, not later than 180 days after enactment of P.L.1995, c.73 (C.17:48-8.1 et al.). Any such regulation shall be adopted not later than 180 days after it is proposed. With respect to any type of form or schedule of premium rates not then on file with the commissioner but filed subsequent to the enactment of P.L.1995, c.73 (C.17:48-8.1 et al.) the commissioner shall propose regulations, which may be amended or modified by the commissioner from time to time after adoption, concerning any actuarial or form requirements consistent with applicable statutory provisions but not specified therein, within 120 days after the form is approved or deemed approved by the commissioner pursuant to this subsection. Any such regulation shall be adopted not later than 180 days after it is proposed. The commissioner may issue bulletins which are interpretive of existing regulations consistent with statutory provisions, with respect to any type of policy form that may be certified pursuant to section 17 of P.L.1995, c.73 (C.17B:25-18.3). Nothing in this subsection shall preclude an insurer from filing a certifiable form or schedule of premium rates for approval by the commissioner.

(6) For purposes of this subsection, "days" means calendar days, except that when the last day of any specified time period is a Saturday, Sunday, or State holiday, then the time period shall end on the next following business day. With respect to any specified time period pertaining to correspondence between an insurer and the commissioner, the time period shall commence on the date that such correspondence is postmarked or submitted to a private delivery service.

h. For purposes of subsection b. of section 17 of P.L.1995, c.73 (C.17B:25-18.3), credit life and credit health insurance shall be considered a category of individual or group life or health insurance.

§ 17B:29-8 Premiums and refunds

a. Any insurer may revise its schedules of premium rates from time to time, and shall file such revised schedules with the commissioner. No insurer shall issue any credit life insurance policy or credit health insurance policy for which the premium rate exceeds that determined by the schedules of such insurer as then on file with the commissioner.

b. Each individual policy, or group certificate shall provide that in the event of termination of the insurance prior to the scheduled maturity date of the indebtedness, any refund of an amount paid by the debtor for insurance shall be paid or credited promptly to the person entitled thereto; provided, however, that the commissioner shall prescribe a minimum refund and no refund which would be less than such minimum need be made. The formula to be used in computing such refund shall be filed with and approved by the commissioner.

c. If a creditor requires a debtor to make any payment for credit life insurance or credit health insurance and an individual policy or group certificate of insurance is not issued, the creditor shall immediately give written notice to such debtor and shall promptly make an appropriate credit to the account.

d. The amount charged to a debtor for any credit life or credit health insurance shall not exceed the premiums charged by the insurer, as computed at the time the charge to the debtor is determined.

e. Nothing in this chapter shall be construed to legalize any charge now illegal under any statute or rule of law governing credit transactions.

§ 17B:29-9 Issuance of policies

All policies of credit life insurance and credit health insurance shall be delivered or issued for delivery in this State only by an insurer authorized to do an insurance business therein, and shall be issued only through holders of licenses or authorizations issued by the commissioner. The commissioner may require that a restricted license as referred to in section 17B:22-12d be obtained by a group policyholder.

§ 17B:29-10 Claims

a. All claims shall be promptly reported to the insurer or its designated claim representative, and the insurer shall maintain adequate claim files. All claims shall be settled as soon as possible and in accordance with the terms of the insurance contract.

b. All claims shall be paid either by draft drawn upon the insurer or by check of the insurer to the order of the claimant to whom payment of the claim is due pursuant to the policy provisions, or upon direction of such claimant to one specified.

c. No plan or arrangement shall be used whereby any person, firm or corporation other than the insurer or its designated claim representative shall be authorized to settle or adjust claims. The creditor shall not be designated as claim representative for the insurer in adjusting claims; provided, that a group policyholder may, by arrangement with the group insurer, draw drafts or checks in payment of claims due to the group policyholder subject to audit and review by the insurer.

§ 17B:29-11 Existing insurance--choice of insurer

When credit life insurance or credit health insurance is required as additional security for any indebtedness, the debtor shall, upon request to the creditor, have the option of furnishing the required amount of insurance through existing policies of insurance owned or controlled by him or of procuring and furnishing the required coverage through any insurer authorized to transact an insurance business within this State.

§ 17B:29-12 Enforcement

Whenever the commissioner finds that there has been a violation of this chapter or any rules or regulations issued pursuant thereto, and after written notice thereof and hearing given to the insurer or other person authorized or licensed by the commissioner, he shall set forth the details of his findings together with an order for compliance by a specified date. Such order shall be binding on the insurer and other person authorized or licensed by the commissioner on the date specified unless sooner withdrawn by the commissioner or a stay thereof has been ordered by a court of competent jurisdiction.

§ 17B:29-13 Judicial review

Any party to the proceeding affected by an order of the commissioner shall be entitled to judicial review by following the procedure set forth in the Administrative Procedure Act (P.L.1968, c. 410) and any rules adopted thereunder.

Chapter 30

§ 17B:30-1 Declaration of purpose

The principal purpose of chapter 30 is to regulate trade practices in the business of life insurance, health insurance and annuities in accordance with the intent of Congress as expressed in the Act of Congress of March 9, 1945 (Public Law 15, 79th Congress), by defining, or providing for the determination of, all such practices in this State which constitute unfair methods of competition or unfair or deceptive acts or practices and by prohibiting the trade practices so defined or determined.

§ 17B:30-2 Practices prohibited

No person shall engage in this State in any trade practice which is defined in this chapter as or determined pursuant to this chapter to be an unfair method of competition or an unfair or deceptive act or practice in the business of life insurance, health insurance or annuity. The practices described in sections 17B:30-3 to 17B:30-13 as modified by section 17B:30-14 are hereby defined to be such practices.

§ 17B:30-3 Misrepresentations and false advertising of policies or annuity contracts

No person shall make, issue, circulate or cause to be made, issued or circulated, any estimate, illustration, circular or statement misrepresenting the terms of any policy or annuity contract issued or to be issued or the benefits or advantages promised thereby or the dividends or share of the surplus to be received thereon, or make any false or misleading statement as to the dividends or share of surplus previously paid on similar policies or annuity contracts, or make any misleading representation or any misrepresentation as to the financial condition of any insurer, or as to the legal reserve system upon which any life insurer operates, or use any name or title of any policy or annuity contract or class of policies or annuity contracts misrepresenting the true nature thereof.

§ 17B:30-4 False information and advertising

No person shall make, publish, disseminate, circulate, or place before the public, or cause, directly or indirectly, to be made, published, disseminated, circulated, or placed before the public, in a newspaper, magazine or other publication, or in the form of a notice, circular, pamphlet, letter or poster, or over any radio or television station, or in any other way, an advertisement, announcement or statement containing any assertion, representation or statement with respect to the business of insurance and annuities or with respect to any person in the conduct of his insurance and annuity business, which is untrue, deceptive or misleading.

§ 17B:30-5 False financial statements

a. No person shall file with any supervisory or other public official, or make, publish, disseminate, circulate or deliver to any person, or place before the public, or cause directly or indirectly, to be made, published, disseminated, circulated, delivered to any person, or placed before the public, any false statement of financial condition of an insurer with intent to deceive.

b. No person shall make any false entry in any book, report or statement of any insurer with intent to deceive any agent or examiner lawfully appointed to examine into its condition or into any of its affairs, or any public official to whom such insurer is required by law to report, or who has authority by law to examine into its condition or into any of its affairs, or, with like intent, willfully omit to make a true entry of any material fact pertaining to the business of such insurer in any book, report or statement of such insurer.

§ 17B:30-6 "Twisting" prohibited

No person shall make any misleading representations or incomplete or fraudulent comparison of any insurance policies or annuity contracts or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, or convert any insurance policy or annuity contract, or to take out a policy of insurance or annuity contract in another insurer.

§ 17B:30-7 Defamation

No person shall make, publish, disseminate, or circulate, directly or indirectly, or aid, abet or encourage the making, publishing, disseminating or circulating of any oral or written statement or any pamphlet, circular, article or literature which is false or maliciously critical of or derogatory to the financial condition of an insurer and which is calculated to injure any person engaged in the business of insurance or annuity.

§ 17B:30-8 Boycott, coercion and intimidation

No person or persons shall enter into any agreement to commit, or by any concerted action commit, any act of boycott, coercion or intimidation resulting in or tending to result in unreasonable restraint of, or monopoly in, the business of insurance or annuity.

§ 17B:30-9 Stock operations and advisory board contracts

No person shall issue or deliver or permit agents, officers, or employees to issue or deliver, agency company stock or other capital stock, or benefit certificates or shares in any common-law corporation, or securities or any special or advisory board contracts or other contracts of any kind promising returns and profits as an inducement to insurance or annuity.

§ 17B:30-10 Stock acquisition, common management

No insurer shall retain, invest in or acquire the whole or any part of the capital stock of any other insurer or insurers, or have a common management with any other insurer or insurers which shall by reason of such retention, investment or acquisition of such capital stock, or common management, substantially lessen competition generally in the business of insurance or annuity or create a monopoly therein.

§ 17B:30-11 Interlocking directorate

No person shall be a director of 2 or more competing insurers so as to substantially lessen competition generally in the business of insurance or annuity or to create a monopoly therein.

§ 17B:30-12 Discrimination prohibited; terms defined.

a. No person shall discriminate against any person or group of persons because of race, creed, color, national origin or ancestry of such person or group of persons in the issuance, withholding, extension or renewal of any policy of life or health insurance or annuity or in the fixing of the rates, terms or conditions therefor, or in the issuance or acceptance of any application therefor.

b. No person shall use any form of policy of life or health insurance or contract of annuity which expresses, directly or indirectly, any limitation, or discrimination as to race, creed, color, national origin or ancestry or any intent to make any such limitation or discrimination.

c. No person shall make or permit any unfair discrimination between individuals of the same class and equal expectation of life in the rates charged for any policy of life insurance or contract of annuity or in the dividends or other benefits payable thereon, or in any other of the terms and conditions of such policy of life insurance or contract of annuity.

d. No person shall make or permit any unfair discrimination between individuals of the same class and of essentially the same hazard in the amount of premium, policy fees, or rates charged for any policy or contract of health insurance or in the benefits payable thereunder, or in any of the terms or conditions of such policy or contract, or in any other manner whatever.

e. (1) No person shall discriminate against any individual on the basis of genetic information or the refusal to submit to a genetic test or make available the results of a genetic test to the person in the issuance, withholding, extension or renewal of any hospital confinement or other supplemental limited benefit insurance, as defined by regulation of the commissioner, or in the fixing of the rates, terms or conditions therefor, or in the issuance or acceptance of any application therefor.

(2) As used in this subsection and subsection f. of this section:

"Genetic characteristic" means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with a statistically significant increased risk of development of a disease, disorder or syndrome.

"Genetic information" means the information about genes, gene products or inherited characteristics that may derive from an individual or family member.

"Genetic test" means a test for determining the presence or absence of an inherited genetic characteristic in an individual, including tests of nucleic acids such as DNA, RNA and mitochondrial DNA, chromosomes or proteins in order to identify a predisposing genetic characteristic.

f. No person shall make or permit any unfair discrimination against an individual in the application of the results of a genetic test or genetic information in the issuance, withholding, extension or renewal of a policy of life insurance, including credit life insurance, an annuity, disability income insurance contract or credit accident insurance coverage. If the commissioner has reason to believe that such unfair discrimination has occurred, including that application of the results of a genetic test is not reasonably related to anticipated claim experience, and that a proceeding by the commissioner would be in the interest of the public, the commissioner shall, in accordance with the provisions of N.J.S.17B:30-1 et seq., issue and serve upon the insurer a statement of the charges. Upon a determination that the practice or act of the insurer is in conflict with the provisions of this subsection, the commissioner shall issue an order requiring the insurer to cease and desist from engaging in the practice or act and may order payment of a penalty consistent with the provisions of N.J.S.17B:30-1 et seq.

If, in the issuance, withholding, extension or renewal of any policy of life insurance, including credit life insurance, an annuity, disability income insurance contract or credit accident insurance coverage, an insurer will use the results of a genetic test in compliance with this subsection, the insurer shall notify the individual who is the subject of the genetic test that such a test shall be required and shall obtain the individual's written informed consent for the test prior to the administration of the test, in accordance with the requirements of P.L.1985, c.179 (C.17:23A-1 et seq.). The insurer shall also provide that the physician or other health care professional designated by the individual shall promptly receive a copy of the results of the test and, if required, an interpretation of the test results by a qualified professional, and that the individual shall state in writing whether the individual elects to be informed of the results of the test.

g. No person shall make or permit any unfair discrimination against any individual on the basis of the individual's intent to engage in future lawful foreign travel in the issuance, extension or renewal of any policy of life insurance or in the fixing of the rates, terms or conditions therefor. For purposes of this subsection, "unfair discrimination" means any decision to issue, extend, or renew a policy of life insurance or the fixing of rates, terms, or conditions of a life insurance policy, on the basis of the individual's intent to engage in future lawful foreign travel, which is not based on sound actuarial principles or actual or reasonably anticipated experience.

h. Nothing contained in this section shall be construed to require any agent or company to take or receive the application for insurance or annuity of any person or to issue a policy of insurance or contract of annuity to any person.

i. No person shall decline or limit coverage under a policy of life or health insurance to any individual based solely on the status of the covered individual as a living organ donor; preclude an individual covered under a policy of life or health insurance from donating all or part of an organ as a condition of continuing to receive coverage; consider the status of a person as a living organ donor in determining the premium rate for coverage of the person under a policy of life or health insurance, provided that this shall not preclude consideration of other actuarial risks in determining premium rates for coverage; or otherwise discriminate in the offering, issuance, cancellation, amount of coverage, price, or other condition of coverage for an individual under a policy of life or health insurance based solely, and without any additional actuarial risks, on the status of the individual as a living organ donor.

As used in this subsection, "living organ donor" means a person who has donated all or part of an organ and is not deceased.

§ 17B:30-13 Rebates and special inducements

Except as otherwise expressly provided by law, no person shall knowingly make, permit to be made or offer to make any contract of life insurance, annuity or health insurance, or agreement as to such contract other than as plainly expressed in the contract issued thereon, or pay or allow, or give or offer to pay, allow, or give, directly or indirectly, as an inducement to such insurance, or annuity, any rebate of premiums or considerations payable on the contract or of any agent's, solicitor's or broker's commission relating thereto, or any special favor or advantage in the dividends or other benefits thereon, or any valuable consideration or inducement whatever not specified in the contract; or give, or sell, or purchase or offer to give, sell, or purchase as an inducement to such insurance or annuity or in connection therewith, any stocks, bonds, or other securities of any insurance company or other corporation, association, or partnership or any dividends or profits accrued thereon, or anything of value whatsoever not specified in the contract.

§ 17B:30-13.1 Unfair claim settlement practices

No person shall engage in unfair claim settlement practices in this State. Unfair claim settlement practices which shall be unfair practices as defined in N.J.S. 17B:30-2, shall include the following practices:

Committing or performing with such frequency as to indicate a general business practice any of the following:

a. Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue;

b. Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies;

c. Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies;

d. Refusing to pay claims without conducting a reasonable investigation based upon all available information;

e. Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed;

f. Not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear;

g. Compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insureds;

h. Attempting to settle a claim for less than the amount to which a reasonable man would have believed he was entitled by reference to written or printed advertising material accompanying or made part of an application;

i. Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of the insured;

j. Making claims payments to insureds or beneficiaries not accompanied by statement setting forth the coverage under which the payments are being made;

k. Making known to insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration;

l. Delaying the investigation or payment of claims by requiring an insured, claimant or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information;

m. Failing to promptly settle claims, where liability has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage;

n. Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement.

§ 17B:30-13.2 Record of complaints

Failure of any person to maintain a complete record of all the complaints which it has received since the date of its last examination shall be a practice prohibited by N.J.S. 17B:30-2. This record shall indicate the total number of complaints, their classification by line of insurance, the nature of each complaint, the disposition of these complaints, and the time it took to process each complaint. For purposes of this section "complaint" means any written communication primarily expressing a grievance.

§ 17B:30-14 Exceptions to discrimination and rebates

Nothing in sections 17B:30-12 or 17B:30-13 shall be construed as including within the definition of discrimination or rebates any of the following practices:

a. In the case of any contract of life or health insurance or annuity, paying bonuses to policyholders or contract holders or otherwise abating their premiums or considerations in whole or in part out of surplus accumulated from nonparticipating insurance or annuity, provided that any such bonuses or abatement of premiums or considerations shall be fair and equitable to policyholders and contract holders and for the best interests of the company and its policyholders and contract holders.

b. In the case of life insurance policies issued on the industrial debit plan, making allowance to policyholders who have continuously for a specified period made premium payments directly to an office of the insurer in an amount which fairly represents the saving in collection expense.

c. Readjustment of the rate of premium for a group insurance policy based on the loss or expense experience thereunder, at the end of the first or any subsequent policy year of insurance thereunder, which may be made retroactive only for such policy year.

d. Issuing life or health insurance policies or annuity contracts on a salary savings, bank draft, preauthorized check or payroll deduction plan or other similar plan at a rate which is lower than that charged when the policies are not issued on such plan or with special underwriting considerations, such rate or underwriting considerations being reasonably related to the savings made by the use of such plan.

e. Issuance of life, health insurance policies or annuity contracts at rates less than the usual rates of premiums or considerations for such policies or contracts or modification of premium or consideration based on amount of insurance or annuity; but any such issuance or modification shall not result in reduction of premium or consideration in excess of savings in administration and issuance expenses reasonably attributable to such policies or contracts.

§ 17B:30-15 Enumeration of acts not exclusive

The enumeration in this chapter of specific unfair methods of competition and unfair or deceptive acts and practices in the business of insurance or annuities is not exclusive or restrictive or intended to limit the powers of the commissioner or any court of review under the provisions of this code.

§ 17B:30-16 Commissioner's powers of investigation

The commissioner shall have power to examine and investigate into the affairs of every person acting as an insurer or engaged in the business of insurance in this State in order to determine whether such person has been or is engaged in any unfair method of competition or in any unfair or deceptive act or practice prohibited by this chapter.

§ 17B:30-17 Desist orders for prohibited practices; penalty

a. If the commissioner has reason to believe that any person has been engaged or is engaging in this State in any unfair method of competition, or any unfair or deceptive act or practice expressly prohibited in this chapter, and that a proceeding by him in respect thereto would be to the interest of the public, he shall issue and serve upon such person a statement of the charges in that respect and a notice of a hearing thereon as provided in the "Administrative Procedure Act" (P.L.1968, c. 410; c. 52:14B-1 et seq.) and any rules adopted thereunder.

b. If, after such hearing, the commissioner shall determine that the method of competition or the act or practice in question is defined in this chapter and that the person complained of has engaged in such method of competition, act or practice in violation of this chapter, he shall make his findings in writing and shall issue and cause to be served upon the person charged with the violation an order requiring such person to cease and desist from engaging in such method of competition, act or practice and the commissioner may order payment of a penalty not to exceed $1,000.00 for each and every act or violation unless the person knew or reasonably should have known he was in violation of this chapter, in which case the penalty shall be not more than $5,000.00 for every act or violation. The penalty shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with the "penalty enforcement law" (N.J.S. 2A:58-1 et seq.).

c. Until the expiration of the time limited for judicial review, if no proceeding for review has been instituted within such time or, if a proceeding for review has been instituted within such time, then until the transcript of the record in the proceeding has been filed in the Superior Court, as hereinafter provided, the commissioner may at any time, upon such notice and in such manner as he shall deem proper, modify or set aside in whole or in part any order issued by him under this section.

d. After the expiration of the time limited for judicial review if no such proceeding has been instituted within such time, the commissioner may at any time, after notice and opportunity for hearing, reopen and alter, modify or set aside, in whole or in part, any order issued by him under this section, whenever in his opinion the facts or the laws have so changed as to require such action or if the public interest shall so require.

e. No order or proceeding, or absence of such order or proceeding of the commissioner pursuant to this chapter or order of court to enforce such order, if made, shall in any way relieve or absolve any person affected thereby from any other liability, penalty or forfeiture provided by another law.

§ 17B:30-18 Procedures as to undefined practices

Whenever the commissioner shall have reason to believe that any person engaged in the business of insurance or annuities is engaging in this State in any method of competition or in any act or practice in the conduct of such business which is not defined in this chapter, and that such method of competition is unfair or that such act or practice is unfair or deceptive and that a proceeding by him in respect thereto would be to the interest of the public, he may issue and serve upon such person a statement of the charges in that respect and a notice of a hearing thereon as provided in the Administrative Procedure Act (P.L.1968, c. 410) and any rules adopted thereunder. Each such hearing shall be conducted in the same manner as the hearing provided for in the Administrative Procedure Act (P.L.1968, c. 410) and any rules adopted thereunder.

§ 17B:30-19 Appeal by intervenor

If the determination of the commissioner does not charge a violation of this chapter, then any intervenor in the proceedings before him may, within 30 days after the service of such determination, institute an action in the Superior Court to enjoin and restrain any method of competition, act or practice.

§ 17B:30-20 Violation of cease and desist order; penalty

Any person who violates a cease and desist order of the commissioner issued under this chapter shall be liable to a penalty not exceeding $5,000.00 for each violation, to be collected by the commissioner in the name of the State in a summary proceeding in accordance with the Penalty Enforcement Law (N.J.S. 2A:58-1 et seq.). The commissioner in his discretion may revoke or suspend the license or certificate of authority of any such person.

§ 17B:30-21 Provisions of chapter additional to existing laws

The powers vested in the commissioner by this chapter shall be additional to any other powers to enforce any penalties, fines or forfeitures authorized by law with respect to the methods, acts and practices hereby declared to be unfair or deceptive.

§ 17B:30-22 Immunity from prosecution

If any person shall ask to be excused from testifying or from producing any books, papers, records, correspondence or other documents at any hearing on the ground that the testimony or evidence required of him may tend to incriminate him or subject him to a penalty or forfeiture, and shall notwithstanding be directed to give such testimony or produce such evidence, he must nonetheless comply with such direction, but he shall not thereafter be prosecuted or subjected to any penalty or forfeiture for or on account of any transaction, matter or thing concerning which he may testify or produce evidence pursuant thereto, and no testimony so given or evidence produced shall be received against him upon any criminal action, investigation or proceeding; provided, however, that no such individual so testifying shall be exempt from prosecution or punishment for any perjury committed by him while so testifying and the testimony or evidence so given or produced shall be admissible against him upon any criminal action, investigation or proceeding concerning such perjury, nor shall he be exempt from the refusal, revocation or suspension of any license, permission or authority conferred, or to be conferred, pursuant to the insurance laws of this State. Any such person may execute, acknowledge and file in the office of the commissioner a statement expressly waiving such immunity or privilege in respect to any transaction, matter or thing specified in such statement and thereupon the testimony of such person or such evidence in relation to such transaction, matter or thing may be received or produced before any judge, court, tribunal, grand jury or other officer or body, and if so received or produced such person shall not be entitled to any immunity or privilege on account of any testimony or evidence he may so give or produce.

§ 17B:30-23 Timetable for implementation of electronic receipt, transmission of health care claim information; standard forms.

1. a. (1) The Commissioner of Banking and Insurance, in consultation with the Commissioner of Health, shall establish, by regulation, a timetable for implementation of the electronic receipt and transmission of health care claim information by each hospital, medical, and health service corporation, individual and group health insurer, health maintenance organization, dental service corporation, dental plan organization, and prepaid prescription service organization, respectively, and a subsidiary of such corporation, insurer, or organization that processes health care benefits claims as a third party administrator, authorized to do business in this State.

The Commissioner of Banking and Insurance shall establish the timetable within 90 days of the date the federal Department of Health and Human Services adopts rules establishing standards for health care transactions, including: health claims or equivalent encounter information, including institutional, professional, pharmacy, and dental health claims; enrollment and disenrollment in a health plan; eligibility for a health plan; health care payment and remittance advice; health care premium payments; first report of injury; health claim status; and referral certification and authorization, respectively, pursuant to section 262 of Pub.L.104-191 (42 U.S.C.s.1320d et seq.). The commissioner may adopt more than one timetable, if necessary, to conform the requirements of this section with the dates of adoption of the federal rules.

(2) The timetable for implementation adopted by the commissioner shall provide for extensions and waivers of the implementation requirement pursuant to paragraph (1) of this subsection in cases when it has been demonstrated to the commissioner's satisfaction that compliance with the timetable for implementation will result in an undue hardship to a hospital, medical or health service corporation, individual or group health insurer, health maintenance organization, dental service corporation, dental plan organization, or prepaid prescription service organization, respectively, or a subsidiary of such corporation, insurer, or organization that processes health care benefits claims as a third party administrator, authorized to do business in this State.

(3) The Commissioner of Banking and Insurance shall report to the Governor and the Legislature within one year of establishing the timetable pursuant to this subsection, on the number of extensions and waivers of the implementation requirement that he has granted pursuant to paragraph (2) of this subsection, and the reasons therefor.

b. The Commissioner of Banking and Insurance, in consultation with the Commissioner of Health, shall adopt, by regulation for each type of contract, as he deems appropriate, one set of standard health care enrollment and claim forms in paper and electronic formats to be used by each hospital, medical, or health service corporation, individual and group health insurer, health maintenance organization, dental service corporation, dental plan organization, and prepaid prescription service organization, and a subsidiary of such corporation, insurer, or organization that processes health care benefits claims as a third party administrator, authorized to do business in this State.

The Commissioner of Banking and Insurance shall establish the standard health care enrollment and claim forms within 90 days of the date the federal Department of Health and Human Services adopts rules establishing standards for the forms.

§ 17B:30-24 Regulations.

15. The Commissioner of Banking and Insurance, in consultation with the Commissioner of Health, shall adopt regulations to effectuate the purposes of sections 1 through 10 of this act, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). To the extent practicable, the regulations shall include any provisions the commissioner deems appropriate that seek to reduce the amount of, or to consolidate, the paper forms sent by hospital, medical, health, and dental service corporations, and commercial insurers, health maintenance organizations, dental plan organizations, and prepaid prescription service organizations to health care providers and covered persons.

§ 17B:30-25 Thomas A. Edison State College to study, monitor effectiveness of electronic data interchange technology, electronic health records.

16. Thomas A. Edison State College shall study and monitor the effectiveness of electronic data interchange technology and electronic health records in reducing administrative costs, identify means by which new electronic data interchange technology and electronic health records can be implemented to effect health care system cost savings, and determine the extent of electronic data interchange technology and electronic health records use in the State's health care system.

The Departments of Health and Banking and Insurance or any other department upon request shall cooperate with and provide assistance to the college in carrying out its study pursuant to this section.

The college shall report to the Legislature and the Governor from time to time on its findings and recommendations.

§ 17B:30-26 Definitions relative to payment of health and dental insurance plans.

1. As used in this act:

"Capitation payment" means a periodic payment to a health care provider for his services under the terms of a contract between the provider and a payer, under which the provider agrees to perform the health care services set forth in the contract for a specified period of time for a specified fee, but shall not include any payments made to the provider on a fee-for-service basis.

"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State and a dental service corporation or dental plan organization authorized to issue dental plans in this State.

"Commissioner" means the Commissioner of Banking and Insurance.

"Contract holder" means an employer or organization that purchases a contract for services.

"Covered person" means a person on whose behalf a carrier offering the plan is obligated to pay benefits or provide services pursuant to the health benefits or dental plan.

"Covered service" means a health care service provided to a covered person under a health benefits or dental plan for which the carrier is obligated to pay benefits or provide services.

"Dental plan" means a benefits plan which pays or provides dental expense benefits for covered services and is delivered or issued for delivery in this State by or through a dental service corporation or dental plan organization authorized to issue dental plans in this State.

"Eligible claim" or "claim for eligible services" means a claim for a covered service under a health benefits or dental plan, subject to any conditions imposed by the health benefits or dental plan.

"Eligible health care provider" means a health care provider whose services are reimbursable under a health benefits or dental plan.

"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier. Health benefits plan includes, but is not limited to, Medicare supplement coverage and risk contracts to the extent not otherwise prohibited by federal law. For the purposes of this act, health benefits plan shall not include the following plans, policies or contracts: accident only, credit, disability, long-term care, CHAMPUS supplement coverage, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.) or hospital confinement indemnity coverage.

"Health care provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service defined by the health benefits or dental plan. Health care provider includes, but is not limited to, a physician, dentist and other health care professionals licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes.

"Insured claim" or "claim" means a claim by a covered person for payment of benefits under an insured health benefits or dental plan.

"Insured health benefits or dental plan" means a health benefits or dental plan providing benefits for covered services to covered persons for which the contract holder pays a premium, which may include a deductible amount payable to a health care provider, and for which the financial obligation for the payment of claims under the plan rests upon the payer.

"Organized delivery system" means an organized delivery system that is either certified or licensed pursuant to P.L.1999, c.409 (C.17:48H-1 et seq.).

"Payer" means a carrier or any agent thereof or an organized delivery system or any agent thereof who is doing business in the State and is under a contractual obligation to pay insured claims.

§ 17B:30-27 Applicability.

2. The provisions of this act shall apply only to insured health benefits or dental plans and insured claims submitted to payers.

§ 17B:30-28 Provision of information.

3. A payer shall, at the request of a covered person, that person's agent, or an eligible health care provider, provide information as to the material required to be submitted to the payer with a claim for reimbursement, including any documentation which is to be submitted with the claim and information as to the proper coding, including the standard diagnosis and procedure codes used by the payer.

§ 17B:30-29 Provision of toll-free telephone number.

4. A payer shall provide covered persons and eligible health care providers with a toll-free telephone number for making inquiries regarding paid claims or pending claims. If the commissioner determines that the toll-free telephone numbers provided by the payer are not adequate, he may require separate toll-free numbers for covered persons and health care providers.

A payer shall respond to any covered person's or health care provider's claim inquiry no later than three business days after receipt of the inquiry.

§ 17B:30-30 Maintenance of claims records; audit required.

5. a. A payer shall maintain a record which shall be audited by a private auditing firm at the expense of the payer, to be submitted to the commissioner, Governor and the Legislature annually, in a form established by the commissioner by regulation, of the number of claims, by category:

(1) that are denied because they are for an ineligible service or the health care service was not rendered by an eligible health care provider under the health benefits or dental plan;

(2) that are rejected at their initial submission because of a lack of substantiating documentation;

(3) that are rejected at their initial submission because of incorrect coding or incorrect enrollment information;

(4) that are rejected at their initial submission because of the amount claimed;

(5) that are not paid in accordance with the time limit established by law because the payer deems the claim to require special treatment that prevents timely payments from being made;

(6) that are not paid in accordance with the time limits for payment established by law even though the claims meet the criteria established by law;

(7) upon which the 10% interest penalty established by law has been paid, and the aggregate amount of interest paid for the period covered by the report;

(8) that are denied or referred to the payer's fraud investigation unit, if applicable, or to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16) because the payer has reason to believe that the claim has been submitted fraudulently; and

(9) any other information the commissioner requires.

b. After reviewing an audit, the commissioner may, if he deems it necessary: require the implementation of a plan of remedial action by the payer; require that the payer's claims processing procedures be monitored by a private auditing firm for a time period he deems appropriate; or both.

If, following an audit, the implementation of a plan of remediation or the monitoring of the payer's claims processing procedures, the commissioner determines that:

(1) an unreasonably large or disproportionate number of eligible claims continue to be rejected, denied, or not paid in a timely fashion for the reasons set forth in paragraph (4), (5) or (6) of subsection a. of this section; or

(2) a payer has failed to pay interest as required pursuant to law, the commissioner shall impose a civil penalty of not more than $10,000 upon the payer, to be collected pursuant to "the penalty enforcement law," N.J.S.2A:58-1 et seq.

c. Every financial examination of a payer performed pursuant to section 11 of P.L.1938, c.366 (C.17:48-11), section 15 of P.L.1940, c.74 (C.17:48A-15), section 26 of P.L.1968, c.305 (C.17:48C-26), section 13 of P.L.1979, c.478 (C.17:48D-13), section 36 of P.L.1985, c.236 (C.17:48E-36), N.J.S.17B:21-1 et seq. or section 9 of P.L.1973, c.337 (C.26:2J-9), as applicable, shall include an examination of the payer's compliance with the provisions of this section.

§ 17B:30-31 Additional record of claims.

6. a. In addition to the annual audit required by section 5 of this act, the payer shall maintain and report to the commissioner on no less than a quarterly basis, a record of claims as provided in paragraphs (1) through (9) of subsection a. of section 5 of this act.

b. After reviewing a report, the commissioner may require an immediate audit of the payer by a private audit firm and after reviewing the audit, if he deems it necessary, may proceed with a remediation or monitoring procedure as provided by subsection b. of section 5 of this act.

§ 17B:30-32 Overdue capitation payment.

7. a. Payment of a capitation payment to a health care provider shall be deemed to be overdue if not remitted to the provider on the fifth business day following the due date of the payment in the contract, if: the health care provider is not in violation of the terms of the contract; and the health care provider has supplied such information to the insurer as may be required under the contract before payment is to be made.

b. An overdue payment shall bear simple interest at the rate of 10% per annum.

§ 17B:30-33 Regulations.

8. No later than 180 days following the date of enactment of this act, the commissioner shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to carry out the purposes of this act.

§ 17B:30-34 Inapplicability of act.

9. The provisions of this act shall not apply to any payer determined by the commissioner to be impaired, to be subject to the provisions of the "Life and Health Insurers Rehabilitation and Liquidation Act," P.L.1992, c.65 (C.17B:32-31 et seq.), or to any claims payable by the "New Jersey Life and Health Insurance Guaranty Association Act" pursuant to P.L.1991, c. 208 (C.17B:32A-1 et seq.).

§ 17B:30-34.1 Health care provider, carrier, more than one method of payment, reimbursement; definitions.

1. a. Any network agreement entered into, amended, or renewed on or after the effective date of this act between a carrier, or the carrier's contracted vendor, and a health care provider for the provision of health or dental care services to a covered person shall not mandate only one form of payment to the health care provider including, but not limited to, payment by credit card, electronic funds transfer, or check.

b. A carrier, or the carrier's contracted vendor, shall not restrict the method of payment to an out-of-network health care provider providing out-of-network covered services to only one form of payment including, but not limited to, payment by credit card, electronic funds transfer, or check.

c. If one of the available payment methods has a fee associated with it, a carrier, or the carrier's contracted vendor, shall, prior to initiating its first payment to an in-network, or out-of-network health care provider, or upon changing the payment methods available to a health care provider:

(1) notify the health care provider that there may be fees associated with a particular payment method, and that the carrier, or the carrier's contracted vendor, shall disclose any fees beyond what the health care provider would normally pay to process a payment using that particular payment method; and

(2) provide the health care provider with clear instructions on the carrier's, or the carrier's contracted vendor's, website, or through means other than the contract offered to the health care provider, as to how to select each payment method.

d. If a health care provider requests a change in the available payment method, a carrier, or the carrier's contracted vendor, shall implement the change to the payment method selected by the health care provider within 30 business days, subject to federal and State verification measures to prevent fraud and abuse.

e. A carrier shall be prohibited from using a health care provider's preferred method of payment as a factor when deciding whether to provide credentials to a health care provider.

f. The provisions of this act shall not be waived by contract, and any contractual clause in conflict with the provisions of this act or that purport to waive any requirements of this act after the effective date of this act are void.

g. Any violation of this act may be subject to enforcement by the Department of Banking and Insurance. The department shall provide the carrier notice and an opportunity to be heard, and upon a finding of a violation of the act, shall impose a civil penalty pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.), and shall order the carrier to reimburse a health care provider for any documented fees or charges reasonably incurred as a result of violation.

h. As used in this section:

"Carrier" means an insurance company; health service corporation; hospital service corporation; medical service corporation or health maintenance organization authorized to issue health benefit plans in this State, and a dental service corporation or dental plan organization authorized to issue dental plans in this State.

"Credit card" means a single-use or virtual credit card provided in an electronic, digital, facsimile, physical, or paper format.

"Health care provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service defined by the health benefits or dental plan. Health care provider includes, but is not limited to, a physician, dentist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes, and a hospital or other health care facility licensed pursuant to Title 26 of the Revised Statutes.

§ 17B:30-35 Definitions relative to standardized pharmacy identification cards

1. As used in this act:

"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State.

"Health benefits plan" means: a health benefits plan that is delivered or issued for delivery in this State by or through a carrier; a plan provided by a multiple employer welfare arrangement; or a plan provided by another benefit arrangement, to the extent permitted by the "Employee Retirement Income Security Act of 1974," Pub.L.93-406 (29 U.S.C. s.1001 et seq.), or by any waiver of or other exception to that act provided under federal law or regulation. "Health benefits plan" shall not include accident-only insurance; credit accident and health insurance; Medicare supplement insurance; Medicaid fee-for-service; disability income insurance; long-term care insurance; specified disease insurance; dental or vision care plan; hospital indemnity insurance; coverage issued as a supplement to liability insurance; medical payments under automobile or homeowners insurance; or insurance under which benefits are payable without regard to fault and that are statutorily required to be included in a liability policy or equivalent self-insurance program.

§ 17B:30-36 Issuance of standardized pharmacy identification information, card to primary insured

2. a. A carrier, multiple employer welfare arrangement or other health benefits plan provider, or its agents, contractors or administrators, including but not limited to a pharmacy benefits manager or third party administrator for a self-insured health benefits plan, that provides, administers or manages coverage for prescription drugs provided on an outpatient basis, shall issue or require the issuance to the primary insured of a card or other technology that includes standardized pharmacy identification information.

b. The card shall comply with the standards set forth in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide in effect at the time of card issuance, or, at a minimum, contain the following information:

(1) the name or identification number of the health benefits plan, when required for proper claims adjudication;

(2) the American National Standards Institute International Identification Number assigned to the administrator or pharmacy benefits manager of the health benefits plan, labeled as RxBIN, when required for proper claims adjudication;

(3) the processor control number, labeled as RxPCN, when required for proper claims adjudication;

(4) the insured's group number, labeled as RxGRP, when required for proper claims adjudication;

(5) the insured's identification number;

(6) the insured's name; except that, if a separate card is issued for another person included under the primary insured's coverage, the name of the covered person to whom the card is issued may be listed instead of the name of the primary insured;

(7) the telephone number that providers may call for pharmacy benefits assistance; and

(8) any other information necessary for proper claims adjudication, except for information provided on the prescription as required by law or regulation.

§ 17B:30-37 Exceptions for issuance of card

3. a. A carrier, multiple employer welfare arrangement or other health benefits plan provider shall not be required to issue a pharmacy identification card separate from another identification card issued to an insured under a health benefits plan if the identification card contains the information required pursuant to section 2 of this act.

b. A carrier, multiple employer welfare arrangement or other health benefits plan provider may use data elements that are required by State or federal regulations adopted pursuant to the "Health Insurance Portability and Accountability Act of 1996," Pub.L.104-191, in place of the information required pursuant to section 2 of this act.

§ 17B:30-38 Provision of new pharmacy identification card

4. A carrier, multiple employer welfare arrangement or other health benefits plan provider shall provide each primary insured with a new pharmacy identification card within a reasonable time, not to exceed 180 days, after a change in the insured's coverage that changes the information required to be on the card pursuant to section 2 of this act, if the issuance of a new card is required for proper claims adjudication. The carrier, multiple employer welfare arrangement or other health benefits plan provider shall not, however, be required to issue a new card more than once in a calendar year. Except as required by this section, a carrier, multiple employer welfare arrangement or other health benefits plan provider shall not be required to reissue a pharmacy identification card with any particular frequency.

§ 17B:30-39 Rules, regulations

5. The Commissioner of Banking and Insurance shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), to carry out the purposes of this act.

§ 17B:30-40 Definitions, construction, regulations on notice of premium increase to employers.

5. a. As used in this section:

"Carrier"means any entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Commissioner of Banking and Insurance, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurance company authorized to issue health insurance, a health maintenance organization, a hospital service corporation, medical service corporation and health service corporation, or any other entity providing a plan of health insurance, health benefits or health services. The term "carrier" shall not include a joint insurance fund established pursuant to State law.

"Health benefits plan" means a health benefits plan as defined in section 2 of P.L.1997, c.192 (C.26:2S-2).

b. For the renewal of a health benefits plan for which the premium rate will increase, a carrier shall provide, in writing, 60 days' prior notice of the amount of the increase, to the employer that purchased that plan.

c. The provisions of this section shall not be construed to diminish the right of a carrier to negotiate with an employer that purchased a health benefits plan over the amount of any proposed increase in the premium rate for the renewal of that plan.

d. The Commissioner of Banking and Insurance shall promulgate regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to effectuate the provisions of this section.

§ 17B:30-41 Findings, declarations relative to collection of unpaid hospital accounts.

1. The Legislature finds and declares that:

a. The rising cost of hospital-based health care in this State impedes the ability of the State and insurers to provide reasonably priced, comprehensive health insurance to the citizens of the State.

b. Hospitals located within the State report more than $1 billion annually in debts that they are unable to collect.

c. The cost of covering the unpaid care represented by the debt is spread among citizens, private insurers, hospitals and the State in the form of higher bills for hospital-based care.

d. A significant portion of the uncollected debt is related to copayments and deductibles that are difficult for hospitals to collect efficiently.

e. The State's Set off of Individual Liability (SOIL) program has proven to be an administratively efficient means of collecting debts owed to State agencies.

f. It is, therefore, in the public interest to create a system for using the State's SOIL program to collect valid hospital debts.

§ 17B:30-42 Definitions relative to collection of unpaid hospital accounts.

2. As used in this act:

"Coinsurance" means the percentage of a charge covered by a health plan that must be paid by a person covered under the health plan.

"Collection agency" means the Department of the Treasury and any company, agency, or law firm engaged in collecting debts that the Department of the Treasury may determine to engage to assist it in collecting debts.

"Debt" means money owed by a patient to a hospital, or by someone who is legally responsible for payment for a patient, and includes late payment penalties and interest thereon. It does not include monies owed to a hospital by a health plan for services provided by the hospital to a person with coverage under that plan, or amounts subject to dispute between a health plan and a hospital.

"Debtor" means an individual owing money to or having a delinquent account with a hospital, which obligation has not been adjudicated, satisfied by court order, set aside by court order, or discharged in bankruptcy.

"Deductible" means the amount of covered charges under a health plan that an individual must pay for services before a health plan begins to pay on a covered charge.

"Department" means the Department of Health.

"General Hospital" and "hospital" have the meanings set forth in N.J.A.C.8:43G-1.2.

"Health plan" means an individual or group health benefits plan that provides or pays the cost of hospital and medical expenses, dental or vision care, or prescription drugs, and is provided by or through an insurer, health maintenance organization, the Medicaid program, the Medicare program, a Medicare+Choice provider or Medicare supplemental insurer, an employer-sponsored group health benefits plan, government or church-sponsored health benefits plan or a multi-employer welfare arrangement.

"Medicaid" means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).

"Medicare" means the program established by Pub.L.89-97 (42 U.S.C. s.1395 et seq.) as amended, or its successor plan or plans.

"Patient" means a person who receives services in a hospital on an inpatient or outpatient basis.

§ 17B:30-44 "New Jersey Hospital Care Payment Fund."

4. a. There is established the "New Jersey Hospital Care Payment Fund" in the Department of the Treasury.

b. The fund shall be comprised of monies collected from debtors of hospitals pursuant to this act, and any other monies appropriated thereto to carry out the purposes of this act.

c. The fund shall be a nonlapsing fund, from which costs shall be paid in the following order, for each hospital participating:

(1) administrative costs of the department to implement the provisions of P.L.2003, c.112 (C.17B:30-41 et seq.);

(2) administrative fees to the collection agency;

(3) 50% of the remainder, but only from monies collected from debtors of hospitals pursuant to this act after paragraphs (1) and (2) of this subsection are paid, shall be payable to the hospital from which the debt originated within 90 days of receipt of monies related to discharge of the assigned debt into the fund; and

(4) the remainder, after paragraphs (1), (2) and (3) of this subsection are paid, shall be deposited into the General Fund.

§ 17B:30-45 Authority of department.

5. The department is authorized to:

a. Accept assignment of debts from hospitals which have followed the procedures outlined in section 7 of this act, or such other procedures as the department shall adopt.

b. Pursue collection of debts pursuant to this act. The department shall initiate the program in phases. The first phase may involve acceptance of assignment of debt that:

(1) derives from a limited number of hospitals;

(2) consists of coinsurance and deductibles that remain payable after adjudication by a health plan;

(3) is assigned by a general hospital;

(4) is less than two years old at the date of assignment to the department, as determined by the date of discharge for inpatient services and date of service for outpatient services;

(5) involves any of the above or any combination of the above, or includes such other limitations as the department determines are desirable to smooth implementation of the program created by this act.

After the first phase, the department may expand acceptance of assignments as it shall determine pursuant to this act.

c. Test assignment data received from the hospitals to determine whether the records are sufficient to make set-off practicable, and return records that do not pass the test to the hospitals.

d. Conduct such fact-finding, as is necessary, in preparation for making a determination as to the validity of debts.

e. Make final determinations as to the validity of debts.

f. Determine the payment to be collected from the debtor, based upon a "fairness formula" to be determined by the department. For debt processed by the department during the fiscal year starting on July 1, 2003, the fairness formula shall be based upon the department's report entitled "Net Patient Revenue to Charge Ratio," for the most recent year available. For debt processed by the department during the fiscal year starting on July 1, 2004 and thereafter, the fairness formula shall be based upon the most recent available "Net Patient Revenue to Charge Ratio" report, or such other measure as the department determines would most fairly reimburse hospitals for treatment.

g. Offset liability for the hospital debts against the New Jersey Gross Income Tax pursuant to N.J.S.54A:1-1 et seq., including an earned income tax credit provided as a refund pursuant to P.L.2000, c.80 (C.54A:4-6 et al.), or whenever any individual is eligible to receive an NJ SAVER rebate or a homestead rebate pursuant to P.L.1990, c.61 (C.54:4-8.57 et al.) or P.L.1999, c.63 (C.54:4-8.58a et al.), and if the rebate is not required to be paid over to the municipal tax collector under the provisions of section 8 of P.L.1990, c.61 (C.54:4-8.64), and including any other financial resource authorized as a source capable of offset for any reason by section 1 of P.L.1981, c.239 (C.54A:9-8.1 et seq.).

h. Adjudicate the validity of all set-off challenges pursuant to N.J.A.C.18:35-10.1 et seq.

i. Make such decisions as to compromise and waiver of interest, penalties, post-judgment interest and write-off as it shall deem prudent.

j. Refer assigned debts under section 7 of this act to a collection agency in the event that offsetting is not practical or is not successful in fully resolving the debt.

k. Create standards for settlement of debts through the collection agency process.

l. Determine to cease accepting debt from a hospital until such time as the hospital can demonstrate to the satisfaction of the department that its accuracy has improved to acceptable levels where the department determines that data forwarded by a hospital to the department has an unacceptable level of inaccuracies regarding validity or quality of the debt forwarded to the department.

m. Contract with other State agencies for services, including administrative services necessary to carry out the duties of the department.

n. Fund the cost of its operations from the fund created by section 4 of this act.

o. Adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to effectuate the purposes of this act; except that, notwithstanding any provision of P.L.1968, c.410 to the contrary, the department may adopt, immediately upon filing with the Office of Administrative Law, such regulations as the department deems necessary to implement the provisions of this act, which shall be effective for a period not to exceed six months and may thereafter be amended, adopted or readopted by the department in accordance with the requirements of P.L.1968, c.410.

§ 17B:30-46 Decisions of department constitute final agency action.

6. Decisions of the department, regarding the fairness formula, the validity of debts, the adequacy of data provided to the department by hospitals for use in the program, and other such matters as shall arise concerning the administration of the program, shall constitute final agency action.

§ 17B:30-47 Procedures for participating hospitals.

7. a. The following procedures shall apply for those hospitals that wish to participate in the voluntary assignment program created by this act.

b. The hospital shall file with the department a notice signifying its intent to participate voluntarily and certifying the following:

(1) the hospital has determined that the patient is not eligible for charity care under the New Jersey Hospital Care Payment Assistance Program established by the Department of Health pursuant to section 10 of P.L.1992, c.160 (C.26:2H-18.60);

(2) the hospital has submitted a "clean claim" pursuant to P.L.1999, c.154 (C.17B:30-23 et al.) and P.L.1999, c.155 (C.17B:30-26 et seq.) to the patient, a responsible party, Medicaid, Medicare or a health plan, as applicable, within a reasonable time following the patient's discharge, or in the case of outpatient service, the date of service;

(3) the claims have been fully adjudicated by a health plan, Medicare or Medicaid, where applicable, and a debt remains outstanding;

(4) the hospital has not initiated collection procedures against the patient or responsible party while a claim was pending adjudication with Medicare or a health plan, for which a debt remains outstanding;

(5) the hospital has notified the patient of the hospital's intention, if the account is not paid in full, or alternatively through a payment plan with the hospital, to proceed with legal action, or to turn the bill over to the department for collection. c. Nothing herein shall be deemed to create any new right to collection of hospital debts by hospitals beyond existing law; nor shall it be deemed to preclude any existing right to collection.

d. The department may determine the content of the notice required by paragraph (5) of subsection b. of this section to the patient concerning the likelihood that the account will be turned over to the department for collection.

e. The minimum amount of an unpaid bill that may be assigned to the department by a hospital is $100, or such other minimum as the department shall determine by regulation.

f. Upon receipt of the voluntary assignment, the Department of the Treasury shall send, on behalf of the department, a notice to the person named as a debtor of the hospital, notifying the person as to receipt of the assignment by the department, providing the person with 30 days to challenge the validity of the debt, and providing notice that in the absence of such challenge, a Certificate of Debt will be filed with the Superior Court of New Jersey. The notice shall also include a statement on the department's intention to take action to set off the liability against any refund of taxes pursuant to the "New Jersey Gross Income Tax Act" including an earned income tax credit, a NJ SAVER rebate or a homestead rebate, or other such funds as may be authorized by law.

g. If the person named as a debtor responds within the 30-day period, the person shall be provided with an opportunity to present, either in writing or in person, evidence as to why the person does not believe he is responsible for the debt. The department shall provide written notice to both the person and the hospital as to its determination regarding the validity of the debt, including the imposition of collection fees and interest, if applicable.

h. If the person fails to respond within 30 days to the department, the department may utilize the provisions of the Set off of Individual Liability (SOIL) program established pursuant to P.L.1981, c.239 (C.54A:9-8.1 et seq.), to collect any surcharge levied under this section that is unpaid on or after the effective date of this act.

As additional remedies, the department may utilize the services of a collection agency to settle the debt and may also issue a certificate to the Clerk of the Superior Court stating that the person identified in the certificate is indebted under this law in such amount as shall be stated in the certificate. The certificate shall reference this act. Thereupon the clerk to whom such certificate shall have been issued shall immediately enter upon the record of docketed judgments: the name of the person as debtor; the State as creditor; the address of the person, if shown in the certificate; the amount of the debt so certified; a reference to this act under which the debt is assessed; and the date of making the entries. The docketing of the entries shall have the same force and effect as a civil judgment docketed in the Superior Court, and the department shall have all the remedies and may take all of the proceedings for the collection thereof which may be had or taken upon the recovery of a judgment in an action, but without prejudice to any right of appeal. Upon entry by the clerk of the certificate in the record of docketed judgments in accordance with this provision, interest in the amount specified by the court rules for post-judgment interest shall accrue from the date of the docketing of the certificate; however, payment of the interest may be waived by the department.

i. Any collection efforts undertaken pursuant to this act shall be undertaken in accordance with the "Health Insurance Portability and Accountability Act of 1996," Pub.L.104-191 and 45 C.F.R. 160.101 to 164.534, or any other similar law. The department and any other entity performing collection activities pursuant to this act is authorized to enter into any agreements required to comply with such laws, including, but not limited to, entering into agreements with the hospitals and collection agencies to provide for appropriate safeguarding of information.

§ 17B:30-55 Violations, penalties; rules, regulations.

17. a. The Commissioner of Banking and Insurance shall enforce the provisions of sections 2 through 7 of P.L.2005, c.352 (C17B:30-49 through C.17B:30-54) and sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L.2005, c.352 (C.17B:30-48 et al.). A payer found in violation of those sections shall be liable for a civil penalty of not more than $10,000 for each day that the payer is in violation if reasonable notice in writing is given of the intent to levy the penalty and, at the discretion of the commissioner, the payer has 30 days, or such additional time as the commissioner shall determine to be reasonable, to remedy the condition which gave rise to the violation and fails to do so within the time allowed. The penalty shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.). The commissioner's determination shall be a final agency decision subject to review by the Appellate Division of the Superior Court.

b. If the Commissioner of Banking and Insurance has reason to believe that a person is engaging in a practice or activity, for the purpose of avoiding or circumventing the legislative intent of sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L.2005, c.352 (C. 17B:30-48 et al.), the Commissioner of Banking and Insurance is authorized to promulgate rules or regulations necessary to prohibit that practice or activity and levy a civil penalty of not more than $10,000 for each day that person is in violation of that rule or regulation.

c. For the purpose of administering the provisions of sections 2 through 7 of P.L.2005, c.352 (C.17B:30-49 through C.17B:30-54) and sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L.2005, c.352 (C.17B:30-48 et al.), 50% of the penalty monies collected pursuant to subsections a. and b. of this section shall be deposited into the General Fund. For the purpose of providing payments to hospitals in accordance with the formula used for the distribution of charity care subsidies that are provided pursuant to P.L.1992, c.160 (C.26:2H-18.51 et seq.), 50% of the penalty monies collected pursuant to subsections a. and b. of this section shall be deposited into the Health Care Subsidy Fund established pursuant to section 8 of P.L.1992, c.160 (C.26:2H-18.58).

d. A penalty levied pursuant to this section against a payer that does not reserve the right to change the premium shall be credited towards a penalty levied against the payer by the Department of Human Services for the same violation.

§ 17B:30-55.1 Short title.

2. This act shall be known and may be cited as the "Ensuring Transparency in Prior Authorization Act."

§ 17B:30-55.2 Findings, declarations.

3. The Legislature finds and declares that:

a. Prior authorization is a type of utilization management technique used by health plans and carriers to ensure safety and appropriateness of medical and pharmacy services, reduce low-value care, and control costs;

b. Providers and patients have raised concerns that the current process of prior authorization is burdensome and leads to care being delayed or abandoned;

c. In 2005, New Jersey enacted the "Health Claims Authorization, Processing and Payment Act" ("HCAPPA"), a groundbreaking law which established uniform procedures and guidelines for hospitals, physicians, and health insurance carriers to follow in communicating and following utilization management decisions and determinations on behalf of patients;

d. In the nearly two decades since HCAPPA was signed into law, the process has continued to be a source of abrasion and concern for providers and patients;

e. The Centers for Medicare and Medicaid Services have recently implemented additional controls on the prior authorization process, such as accelerated turnaround times for prior authorization requests from providers, and are currently considering, among other items, ways to improve efficiency in prior authorization, including the use of electronic submission of prior authorization requests;

f. When it is used, prior authorization should utilize an automated process to minimize the burden placed upon both physicians and health plans; and

g. Therefore, because it is fair and reasonable for hospitals and physicians to receive reimbursement for health care services delivered to covered persons under their health benefits plans and inefficiencies in any area of the health care delivery system reflect poorly on all aspects of the health care delivery system, and because those inefficiencies can harm patients, it is appropriate for the Legislature to update now the uniform procedures and guidelines for hospitals, physicians, and health insurance carriers to follow in communicating and following utilization management decisions and determinations on patients' behalf.

§ 17B:30-55.3 Definitions.

4. As used in sections 4 through 17 of P.L.2023, c.296 (C.17B:30-55.3 through 17B:30-55.16):

"Adverse determination" means a decision by a payer that the health care services furnished or proposed to be furnished to a covered person are not medically necessary, or are experimental or investigational; and benefit coverage is therefore denied, reduced, or terminated. A decision to deny, reduce, or terminate services which are not covered for reasons other than their medical necessity or experimental or investigational nature is not an "adverse determination" for the purposes of P.L.2023, c.296 (C.17B:30-55.1 et al.).

"Authorization" means a determination required under a health benefits plan that, based on the information provided, satisfies the requirements under the member's health benefits plan for medical necessity, and includes, but is not limited to, prior authorization.

"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State.

"Clinical criteria" means the written policies, written screening procedures, determination rules, determination abstracts, clinical protocols, practice guidelines, medical protocols, and any other criteria or rationale used for the purposes of utilization management to determine the necessity and appropriateness of covered services.

"Commissioner" means the Commissioner of Banking and Insurance.

"Covered person" means a person on whose behalf a carrier offering the plan is obligated to pay benefits or provide services pursuant to the health benefits plan.

"Covered service" means a health care service provided to a covered person under a health benefits plan for which the carrier is obligated to pay benefits or provide services, including, but not limited to, health care procedures, treatments, or services and the provision of pharmaceutical products or services or durable medical equipment.

"Emergency health care services" means health care services that are provided in an emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in: (1) placing the health of the patient in jeopardy; (2) serious impairment to bodily function; or (3) serious dysfunction of any bodily organ or part.

"Generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and specialty society recommendations, and the views of physicians practicing in relevant clinical areas.

"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services and is delivered or issued for delivery in this State by or through a carrier. For the purposes of sections 4 through 17 of P.L.2023, c.296 (C.17B:30-55.3 through 17B:30-55.16), health benefits plan shall not include the following plans, policies, or contracts: accident only; credit; disability; long-term care; Medicare Supplement; Medicare Advantage; Medicaid; Civilian Health and Medical Program for the Uniformed Services; CHAMPUS supplement coverage; coverage arising out of a workers' compensation or similar law; automobile medical payment insurance; personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.); or hospital confinement indemnity coverage.

"Health care provider" means a physician and other health care professionals licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes.

"Health care service" means health care procedures, treatments, or services provided by: (1) a health care facility licensed in New Jersey; or (2) a doctor of medicine, a doctor of osteopathy, or a health care provider performing within the scope of practice of the profession in which the provider is licensed in New Jersey. "Health care service" also includes the provision of pharmaceutical products or services or durable medical equipment.

"Hospital" means a general acute care facility licensed by the Commissioner of Health pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), including rehabilitation, psychiatric, and long-term acute facilities.

"Medical necessity" or "medically necessary" means or describes a health care service that a health care provider, exercising prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and that is: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the covered person's illness, injury, or disease; not primarily for the convenience of the covered person or the health care provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered person's illness, injury, or disease.

"NCPDP SCRIPT Standard" means the National Council for Prescription Drug Programs SCRIPT Standard Version 2017071, or the most recent standard adopted by the United States Department of Health and Human Services (HHS). Subsequently released versions of the NCPDP SCRIPT Standard may be used.

"Network provider" means a participating hospital or physician under contract or other agreement with a carrier to furnish health care services to covered persons.

"Payer" means a carrier which requires that utilization management be performed to authorize the approval of a health care service and includes an organized delivery system that is certified by the Commissioner of Banking and Insurance or licensed by the commissioner pursuant to P.L.1999, c.409 (C.17:48H-1 et seq.) and shall include a payer's agent.

"Payer's agent" means an intermediary contracted or affiliated with the payer to provide authorization or prior authorization for service or perform administrative functions including, but not limited to, the payment of claims or the receipt, processing, or transfer of claims or claim information.

"Prior authorization" means the process by which a payer determines the medical necessity of an otherwise covered service prior to the rendering of the service including, but not limited to, preadmission review, pretreatment review, utilization review, and case management. "Prior authorization" also includes a payer's requirement that a covered person or health care provider notify the carrier or payer prior to providing a health care service.

"Submission" means transmission of information by a health care provider or the authorized representative of a health care provider to a payer by any means (1) to which a network provider and health benefits plan have agreed to consider acceptable or (2) by a readily accessible secure communications mechanism identified by a payer or its agent on its public website.

"Urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determination may seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function or, in the opinion of a physician with knowledge of the medical condition of the covered person, subjects the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. In determining if a claim involves urgent care, a payer shall apply the judgement of a prudent layperson who possesses an average knowledge of health and medicine. However, if a physician with knowledge of the medical condition of the covered person determines that a claim involves urgent care, the claim shall be treated as an urgent care claim.

"Utilization management" means a system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines, in order to recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be reimbursed, covered, paid for, or otherwise provided under the health benefits plan. The system may include, but shall not be limited to: preadmission certification, the application of practice guidelines, continued stay review, discharge planning, prior authorization of ambulatory care procedures, and retrospective review.

§ 17B:30-55.4 Payer, information, utilization management, processing, payment of claims.

5. a. A payer shall provide the following information concerning utilization management and the processing and payment of claims in a clear and conspicuous manner, described in detail but also in easily understandable language, to covered persons, health care providers, and the general public, through an Internet website no later than 30 calendar days before the information or policies or any changes in the information or policies take effect:

(1) a description of the source of all commercially produced clinical criteria guidelines and a copy of all internally produced clinical criteria guidelines used by the payer or its agent to determine the medical necessity of health care services;

(2) a list of the material, documents, or other information required to be submitted to the payer with a claim for payment for health care services;

(3) a description of the type of claims for which the submission of additional documentation or information is required for the adjudication of a claim fitting that description;

(4) the payer's policy or procedure for reducing the payment for a duplicate or subsequent service provided by a health care provider on the same date of service;

(5) prescription drug formularies; and

(6) any other information the commissioner deems necessary.

b. Any changes in the information or policies required to be provided pursuant to subsection a. of this section shall be clearly noted on the Internet website.

c. A payer shall, for health care services as defined pursuant to section 4 of P.L.2023, c.296 (C.17B:30-55.3) but excluding the provision of pharmaceutical products:

(1) provide impacted contracted in-network health care providers with written notice of any new or materially adverse amended requirement or restriction no less than 90 days before the requirement or restriction is implemented;

(2) ensure that any new or amended requirement is not implemented unless the payer's Internet website has been updated to reflect the new or amended requirement or restriction; and

(3) withhold implementation of any new materially adverse requirement or restriction until and unless 90 days have passed since written notice was provided to an impacted contracted in-network health care provider.

§ 17B:30-55.5 Payer, respond, hospital, health care provider request, prior authorization.

6. A payer shall respond to a hospital or health care provider request for prior authorization of health care services by either approving or denying the request based on the covered person's health benefits plan upon submission of all necessary information.

§ 17B:30-55.6 Carrier, respond, prior authorization requests, medication coverage submitted, NCPDP SCRIPT Standard for ePA transactions.

7. a. A carrier shall respond to prior authorization requests for medication coverage submitted using the NCPDP SCRIPT Standard for ePA (electronic prior authorization) transactions, under the pharmacy benefit part of a health benefits plan, within 24 hours for urgent requests and 72 hours for non-urgent requests after obtaining all necessary information to make the approval or adverse determination.

b. Beginning January 1, 2027, a carrier shall only accept and respond to prior authorization requests for medication coverage, under the pharmacy benefit part of a health benefits plan submitted through a secure electronic transmission using the NCPDP SCRIPT Standard for ePA transactions.

§ 17B:30-55.7 Prior authorization, chronic, long-term care condition, validity, exception, timeline.

8. Except where shorter time frames are necessary to monitor patient safety or treatment effectiveness and with notice to the treating provider, if a payer requires prior authorization for a health care service for the treatment of a chronic or long-term care condition, the prior authorization shall remain valid for 180 days and the payer shall not require the covered person to obtain a prior authorization again for the health care service within the 180-day period.

§ 17B:30-55.8 Prior authorization, denial, limitation imposed by payer, physician, scope of actions.

9. Any denial of a request for prior authorization or limitation imposed by a payer on a requested service on the basis of utilization management determination shall be made by a physician who shall:

a. make the adverse determination under the clinical direction of a medical director of the payer who shall:

(1) be licensed in this State; and

(2) strictly follow a medical policy that has been developed and made available in accordance with P.L.2023, c.296 (C.17B:30-55.1 et al.) and the "New Jersey Health Care Quality Act," P.L.1997, c.192 (C.26:2S-1 et seq.);

b. not be compensated by a payer based on the approval or denial rate of the reviewing physician; and

c. not be provided preferential treatment by a payer in the requests for prior authorization of the reviewing physician if that physician is also a network provider for the payer.

§ 17B:30-55.9 Prior authorization, defined number, discrete services, set time frame, validity, exception.

10. Except where shorter time frames are necessary to monitor patient safety or treatment effectiveness and with notice to the treating provider, prior authorization for a service which includes a defined number of discrete services within a set time frame shall be valid for purposes of authorizing the health care provider to provide care for a period of 180 days from the date the provider receives the prior authorization and a payer shall not revoke, limit, condition or restrict a prior authorization within that period if (1) the covered person continues to be eligible for coverage; (2) the clinical information provided at the time the prior authorization request was made has not been misrepresented by the treating physician or covered person; and (3) there has not been a material change in the clinical circumstances or condition of the covered person.

§ 17B:30-55.10 Payer to honor prior authorization granted to covered person by previous payer, initial coverage, upon receipt of documentation.

11. a. On receipt of information documenting a prior authorization from the covered person or the health care provider of the covered person, a payer shall honor a prior authorization granted to a covered person by a previous payer for at least the initial 60 days of coverage under a new health plan of the covered person, if that prior authorization was based on information provided in good faith by a provider.

b. During the initial 60 days described in subsection a. of this section, a payer may perform its own review to grant a prior authorization.

c. If there is a change in coverage or approval criteria for a previously prior authorized covered service by the health benefits plan issuing the change, the change in coverage or approval criteria shall not affect a covered person who received prior authorization before the effective date of the change for the remainder of the plan year of the covered person, unless the prior authorization previously issued for a covered service was issued based on materially inaccurate medical information or fraudulent information.

d. A payer shall continue to honor a prior authorization it has granted to a covered person when the covered person changes products under the same payer, provided the service for which prior authorization was issued remains a covered benefit under the terms and conditions of the replacement health benefits plan.

§ 17B:30-55.11 Denial of prior authorization, communicated via written communication agreed to by payer, hospital, health care provider.

12. a. A denial of prior authorization shall be communicated to the hospital or health care provider by facsimile, e-mail, or any other means of written communication agreed to by the payer and hospital or health care provider as follows:

(1) in the case of a request for prior authorization for a covered person who will be receiving inpatient hospital services, the payer shall communicate the denial of the request or the limitation imposed on the requested service to the hospital or health care provider within a time frame appropriate to the medical exigencies of the case but no later than 12 days if the request is submitted in paper, or nine days if submitted through an electronic portal provided by the payer, following the time the request was made;

(2) in the case of a request for prior authorization for a covered person who is currently receiving inpatient hospital services or care rendered in the emergency department of a hospital, the payer shall communicate the denial of the request or the limitation imposed on the requested service to the hospital or health care provider within a time frame appropriate to the medical exigencies of the case but no later than 24 hours;

(3) in the case of a request for prior authorization for a covered person who will be receiving health care services in an outpatient or other setting, including, but not limited to, a clinic, rehabilitation facility, or nursing home, the payer shall communicate the denial of the request or the limitation imposed on the requested service to the hospital or health care provider within a time frame appropriate to the medical exigencies of the case but no later than 12 days if the request is submitted in paper, or nine days if submitted through an electronic portal provided by the payer, following the time the request was made;

(4) in the case of a claim involving urgent care, the payer shall notify the hospital or health care provider of the carrier's benefit determination as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim by the carrier, unless the hospital or health care provider fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the plan. In the case of such a failure, the carrier shall notify the hospital or health care provider as soon as possible, but not later than 24 hours after receipt of the claim by the payer, of the specific information necessary to complete the claim. The hospital or health care provider shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. The payer shall notify the hospital or health care provider of the carrier's benefit determination as soon as possible, but in no case later than 48 hours after the carrier's receipt of the specified information; and

(5) if the payer requires additional information to approve or make an adverse determination with regard to a request for prior authorization, the payer shall so notify the hospital or health care provider by facsimile, e-mail, or any other means of written communication agreed to by the payer and hospital or health care provider within the applicable time frame set forth in paragraph (1), (2), or (3) of this subsection and shall identify the specific information needed to approve or make the adverse determination with regard to the request for authorization.

b. If the payer is unable to approve or make an adverse determination with regard to a request for authorization within the applicable time frame set forth in paragraph (1), (2), (3), or (4) of this subsection because of the need for this additional information, the payer shall have an additional period within which to approve or make an adverse determination with regard to the request, as follows:

(1) in the case of a request for prior or concurrent authorization for a covered person who will be receiving inpatient hospital services, within a time frame appropriate to the medical exigencies of the case but no later than 12 calendar days beyond the time of receipt by the payer from the hospital or health care provider of the additional information that the payer has identified as needed to approve or made an adverse determination with regard to the request for authorization. For requests made through an electronic portal provided by the payer, this time frame shall be within nine calendar days;

(2) in the case of a request for prior or concurrent authorization for a covered person who is currently receiving inpatient hospital services or care rendered in the emergency department of a hospital, no more than 24 hours beyond the time of receipt by the payer from the hospital or health care provider of the additional information that the payer has identified as needed to approve or make an adverse determination with regard to the request for prior or concurrent authorization; and

(3) in the case of a request for prior or concurrent authorization for a covered person who will be receiving health care services in another setting, within a time frame appropriate to the medical exigencies of the case but no more than 12 calendar days beyond the time of receipt by the payer from the hospital or health care provider of the additional information that the payer has identified as needed to approve or make an adverse determination with regard to the request for authorization. For requests made through an electronic portal provided by the payer, this time frame shall be within nine calendar days.

c. Payers and hospitals shall have appropriate staff available between the hours of 9 a.m. and 5 p.m., seven days a week, to respond to authorization requests within the time frames established pursuant to subsection a. of this section.

d. If a payer fails to respond to an authorization request within the time frames established pursuant to subsection a. or b. of this section, the hospital or health care provider's claim for the service shall not be denied on the basis of a failure to secure prior or concurrent authorization for the service.

e. If a hospital or health care provider fails to respond to a payer's request for additional information necessary to render an authorization decision within 72 hours, the hospital or health care provider's request for authorization shall be deemed withdrawn.

§ 17B:30-55.12 Adverse determinations, appeal, reviewed by physician.

13. A payer shall ensure that any adverse determinations of any appeal are reviewed by a physician. The physician shall:

a. be board-certified in a same or similar specialty that has experience treating the condition or service under review or has experience treating the condition within the last five years;

b. not be paid by a payer based on the reviewing physician's denial or approval rate;

c. not have been directly involved in making an initial adverse determination for the same claim;

d. consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the payer by the health care provider of the covered person, any relevant records provided to the payer by a health care facility, and any medical literature provided to the payer by the health care service provider of the covered person;

e. not be provided preferential treatment by the payer in the reviewing physician's own requests for prior authorization if the reviewing physician is also a network provider; and

f. when requested by the treating provider, engage in a telephonic conversation with the treating provider to discuss the need for the prescribed medication or service.

§ 17B:30-55.13 Payer shall not deny reimbursement, hospital, health care provider in compliance, circumstances,

14. a. When a hospital or health care provider complies with the provisions set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.), no payer shall deny reimbursement to a hospital or health care provider for covered services rendered to a covered person on grounds of failure to secure prior or concurrent authorization in the absence of fraud or misrepresentation if the hospital or health care provider:

(1) requested authorization from the payer and received approval for the health care services delivered prior to rendering the service;

(2) requested authorization from the payer for the health care services prior to rendering the services and the payer failed to respond to the hospital or health care provider within the time frames established pursuant to P.L.2023, c.296 (C.17B:30-55.1 et al.); or

(3) received authorization for the covered service for a patient who is no longer eligible to receive coverage from that payer and it is determined that the patient is covered by another payer, in which case the subsequent payer, based on the subsequent payer's benefits plan, shall accept the authorization and reimburse the hospital or health care provider.

b. If the hospital is a network provider of the payer, health care services shall be reimbursed at the contracted rate for the services provided.

c. No payer shall amend a claim by changing the diagnostic code assigned to the services rendered by a hospital or health care provider without providing written justification.

§ 17B:30-55.14 Payer, reimbursement according to provider contract, medically necessary emergency, urgent care covered under plan.

15. a. A payer shall reimburse a hospital or health care provider according to the provider contract for all medically necessary emergency and urgent care health care services that are covered under the health benefits plan, including all tests necessary to determine the nature of an illness or injury, pre-hospital transportation, or the provision of emergency health care services.

b. A payer shall allow a covered person and the covered person's health care provider a minimum of 24 hours following an emergency admission or provision of emergency health care services for the covered person or health care provider to notify the payer of the admission or provision of covered services. If the admission or covered service occurs on a holiday or weekend, a payer shall not require notification until the next business day after the admission or provision of the covered service.

c. A payer shall approve coverage for emergency health care services necessary to screen and stabilize a covered person without requiring any prior authorization. Admission on an in-patient basis may be subject to concurrent review.

d. A payer shall not determine medical necessity or appropriateness of emergency health care services based on whether or not those services are provided by participating or nonparticipating providers. A payer shall ensure that restrictions on coverage of emergency health care services provided by nonparticipating providers shall not be greater than restrictions that apply when those services are provided by participating providers.

e. If a covered person receives an emergency health care service that requires immediate post-evaluation or post-stabilization services, a payer shall make an authorization determination within 150 minutes of receiving a request. If the authorization determination is not made within 150 minutes, those services shall be deemed approved.

§ 17B:30-55.15 Failure by payer to comply with deadline, health care services subject to review, automatic authorization.

16. a. In addition to the protections afforded to a health care provider or patient by the requirements of P.L.2023, c.296 (C.17B:30-55.1 et al.), any failure by a payer to comply with a deadline shall result in any health care services subject to review being automatically deemed authorized.

b. Notwithstanding any health care services being automatically deemed authorized pursuant to the terms of P.L.2023, c.296 (C.17B:30-55.1 et al.), the Commissioner of Banking and Insurance shall enforce the provisions of sections 3 through 15 of P.L.2023, c.296 (C.17B:30-55.2 through 17B:30-55.14) and sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L.2023, c.296 (C.17B:30-55.1 et al.). A payer found in violation of those sections shall be liable for a civil penalty of not more than $10,000 for each day that the payer is in violation if reasonable notice in writing is given of the intent to levy the penalty and, at the discretion of the commissioner, the payer has 30 days, or such additional time as the commissioner shall determine to be reasonable, to remedy the condition which gave rise to the violation and fails to do so within the time allowed. The penalty shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.). The commissioner's determination shall be a final agency decision subject to review by the Appellate Division of the Superior Court.

c. If the Commissioner of Banking and Insurance has reason to believe that a person is engaging in a practice or activity, for the purpose of avoiding or circumventing the legislative intent of sections 4 through 17 of P.L.2023, c.296 (C.17B:30-55.3 through 17B:30-55.16) and sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L.2023, c.296 (C.17B:30-55.1 et al.), the Commissioner of Banking and Insurance is authorized to promulgate rules or regulations necessary to prohibit that practice or activity and levy a civil penalty of not more than $10,000 for each day that person is in violation of that rule or regulation.

d. For the purpose of administering the provisions of sections 3 through 15 of P.L.2023, c.296 (C.17B:30-55.2 through 17B:30-55.14) and sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L.2023, c.296 (C.17B:30-55.1 et al.), 50 percent of the penalty monies collected pursuant to subsections b. and c. of this section shall be deposited into the General Fund. For the purpose of providing payments to hospitals in accordance with the formula used for the distribution of charity care subsidies that are provided pursuant to P.L.1992, c.160 (C.26:2H-18.51 et seq.), 50 percent of the penalty monies collected pursuant to subsections b. and c. of this section shall be deposited into the Health Care Subsidy Fund established pursuant to section 8 of P.L.1992, c.160 (C.26:2H-18.58).

e. A penalty levied pursuant to this section against a payer that does not reserve the right to change the premium shall be credited towards a penalty levied against the payer by the Department of Human Services for the same violation.

§ 17B:30-55.16 Statistics available regarding prior authorization approvals, denials, website.

17. A payer shall make statistics available regarding prior authorization approvals and denials on its Internet website in a readily accessible format, as determined by the commissioner. Payers shall include categories for:

a. health care provider specialty;

b. medication or diagnostic tests and procedures;

c. indication offered;

d. reason for denial;

e. whether prior authorization determinations were:

(1) appealed; or

(2) approved or denied on appeal;

f. the time between submission of prior authorization requests and the determination;

g. the average median time elapsed between a request for clinical records from the requesting health care provider and receipt of adequate clinical records to complete the prior authorization; and

h. the number of appeals generated for cases denied in which there was inadequate or no prior clinical information.

§ 17B:30-55.17 Liberal construction.

27. P.L.2023, c.296 (C.17B:30-55.1 et al.) shall be liberally construed to effectuate the legislative purposes thereof.

§ 17B:30-56 Rules, regulations.

20. The Commissioner of Banking and Insurance shall promulgate rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to carry out the purposes of P.L.2023, c.296 (C.17B:30-55.1 et al.).

§ 17B:30-57 Liberal construction.

21. This act shall be liberally construed to effectuate the legislative purposes of the act.

§ 17B:30-58 Definitions relative to reimbursement for certain ambulance services.

1. As used in this act:

"Ambulance service" means the provision of emergency health care services, basic life support services, advanced life support services, critical care services, mobile intensive care services, or emergency medical transportation in a vehicle that is licensed, equipped, and staffed in accordance with the requirements set forth by the Commissioner of Health.

"Assignment of benefits" means any written instrument executed by the covered person or his authorized representative which assigns a service provider the covered person's right to receive reimbursement for a covered service rendered to the covered person.

"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State.

"Claim" means a claim by a covered person for payment of benefits under a health benefits plan.

"Commissioner" means the Commissioner of Banking and Insurance.

"Covered person" means a person on whose behalf a carrier offering the health benefits plan is obligated to pay benefits or provide services pursuant to the health benefits plan.

"Covered service" means an ambulance service provided to a covered person under a health benefits plan for which the carrier is obligated to pay benefits or provide services.

"Health benefits plan" means a hospital and medical expense insurance policy; health service corporation contract; hospital service corporation contract; medical service corporation contract; health maintenance organization subscriber contract; or other plan for medical care delivered or issued for delivery in this State. For purposes of this act, health benefits plan shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; stop loss or excess risk insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; coverage for Medicaid services pursuant to a contract with the State; and any other similar insurance coverage, as specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefits plans shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in federal regulations. Health benefits plan shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.

"Payer" means a carrier or any agent thereof who is doing business in the State and is under a contractual obligation to pay claims.

"Service provider" means any person, public or private institution, agency, or business concern lawfully providing an ambulance service.

§ 17B:30-59 Assignment of benefits to service provider of right to receive reimbursement for ambulance service.

2. a. Notwithstanding any provision of law to the contrary, a covered person may, through an assignment of benefits, assign to a service provider his right to receive reimbursement for any ambulance service rendered by the service provider, regardless of whether the service provider is under contract with the carrier to provide services to the covered person.

b. A service provider provided an assignment of benefits by a covered person, pursuant to subsection a. of this section, shall submit a copy of that assignment of benefits, or provide other notice of that assignment of benefits acceptable to the commissioner pursuant to regulation, to the payer with any claim for payment for any ambulance service rendered to the covered person.

c. The payer, based upon the claim and notice of the assignment of benefits submitted by the service provider, shall remit payment of the claim directly to the service provider within the timeframe established by P.L.1999, c.154 (C.17B:30-23 et al.) for remitting payment on a claim submitted by electronic means, or by other than electronic means, as applicable, and provide written notice, within the same applicable timeframe, of the payment to the covered person.

d. If a covered person executes an assignment of benefits, and the service provider submits notice of that assignment of benefits with its claim for payment pursuant to subsection b. of this section, but the payer remits payment of the claim to the covered person, rather than the service provider, the claim shall not be considered paid. The payer shall, notwithstanding the incorrect payment of the claim to the covered person, remain liable for remitting payment of the claim to the service provider pursuant to the assignment of benefits.

e. Any overdue payment on the claim to the service provider pursuant to the assignment of benefits shall accrue interest at the rate established by P.L.1999, c.154 (C.17B:30-23 et al.) for an overdue payment.

§ 17B:30-60 Definitions relative to certain dental provider networks.

1. As used in this act:

"Contracting entity" means any person or entity that enters into direct contracts with providers for the delivery of dental services in the ordinary course of business, including a third party administrator as defined by section 1 of P.L.2001, c.267 (C.17B:27B-1) and a dental carrier.

"Covered person" means an individual who is covered under a dental benefits or health benefits plan for dental services.

"Dental benefits plan" means a benefits plan which pays or provides dental expense benefits for covered dental services and is delivered or issued for delivery in this State by or through a dental carrier on a stand-alone basis.

"Dental carrier" means a dental insurance company, dental service corporation, or dental plan organization authorized to provide a dental benefits plan in New Jersey or a health benefits plan in New Jersey that includes coverage for dental services.

"Dental services" means services for the diagnosis, prevention, treatment, or cure of a dental condition, illness, injury, or disease. Dental services shall not include those services delivered by a provider under a health benefits plan that are billed as medical services under that plan.

"Health benefits plan" means any hospital and medical expense incurred policy, health maintenance organization subscriber contract, or any other health care plan or arrangement that pays for or furnishes medical, dental, or health care services, whether by insurance or otherwise. Health benefits plan shall include a dental benefits plan. "Health benefits plan" shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and private passenger automobile insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; coverage similar to the foregoing as specified in federal regulations issued pursuant to the federal "Health Insurance Portability and Accountability Act of 1996," P.L.104-191, under which benefits for medical care are secondary or incidental to other insurance benefits; benefits for long-term care, nursing home care, home health care, or community-based care; specified disease or illness coverage, hospital indemnity or other fixed indemnity insurance, or such other similar, limited benefits as are specified in regulations; Medicare supplemental health insurance as defined under section 1882(g)(1) of the federal Social Security Act (42 U.S.C. s.1395ss(g)(1)); coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code (10 U.S.C. s.1071 et seq.); or other similar limited benefit supplemental coverages.

"Provider" means an individual or entity which, acting within the scope of its licensure or certification, provides dental services or supplies defined by the health benefits or dental benefits plan. Provider includes, but is not limited to, a dentist, physician or other health care professionals licensed pursuant to Title 45 of the Revised Statutes acting within the scope of his or her licensure. "Provider" shall not include a physician organization or physician hospital organization that leases or rents the physician organization's or physician hospital organization's network to a third party.

"Provider network contract" means a contract between a contracting entity and a provider specifying the rights and responsibilities of the contracting entity and providing for the delivery of and payment for dental services to covered persons.

"Third party" means a person or entity that enters into a contract with a contracting entity or with another third party to gain access to the dental services or contractual discounts of a provider network contract. "Third party" shall not include any employer or other group for whom the contracting entity or dental carrier provides administrative services, including at least the payment of claims.

§ 17B:30-61 Third party access.

2. a. A contracting entity shall not grant to a third party access to a provider network contract, or a provider's dental services or contractual discounts, or both, pursuant to a provider network contract, unless the contracting entity meets the requirements of subsections b. and c. of this section.

b. A dental carrier may grant access to its provider network contract to a third party if, at the time the contract is entered into, and at any time the contract is renewed, the dental carrier allows any provider which is part of the carrier's provider network to choose not to participate in third party access to the contract. The third party access provision of any provider contract shall be clearly identified in the provider contract. A dental carrier shall not grant third party access to the contract of any provider that does not participate in third party access.

c. A contracting entity may grant a third party access to a provider network contract, or services or discounts pursuant to a provider network contract, if:

(1) The contract specifically states that the contracting entity may enter into an agreement with third parties allowing the third parties to obtain the contracting entity's rights and responsibilities as if the third party were the contracting entity, and when the contracting entity is a dental carrier, the provider chose to participate in third party access at the time the provider network contract was entered into or renewed;

(2) The third party accessing the contract agrees to comply with all of the contract's terms;

(3) The contracting entity identifies, in writing or electronic form to the provider, all third parties in existence as of the date the contract is entered into or renewed;

(4) The contracting entity includes on its website a listing, updated no less frequently than every 90 days, identifying all third parties;

(5) The contracting entity requires each third party to identify the source of the discount on all remittance advices or explanations of payment under which a discount is taken , except this requirement shall not apply to electronic transactions mandated under the "Health Insurance Portability and Accountability Act of 1996," Pub.L.104-191;

(6) The contracting entity notifies the third party of the termination of a provider network contract no later than 30 days from the termination date with the contracting entity;

(7) A third party ceases its right to a provider's discounted rate as of the date of termination of the provider's contract with the contracting entity; and

(8) The contracting entity delivers to participating providers a copy of the provider network contract relied on in the adjudication of a claim within 30 days after the date of a request from the provider.

d. No provider shall be bound by or required to perform dental treatment or services under a provider network contract that has been granted to a third party in violation of this act.

§ 17B:30-62 Inapplicability.

3. This act shall not apply to:

a. a provider network contract for dental services provided to beneficiaries of the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), the Medicare program established pursuant to the federal Social Security Act, (42 U.S.C. s.1395 et seq.), the State Health Benefits Program, the School Employees' Health Benefits Program, or the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.); and

b. situations in which access to a provider network contract is granted to a contracting entity or dental carrier operating under the same brand licensee program as the contracting entity or to an entity that is an affiliate of the contracting entity. A listing of all affiliates of the contracting entity shall be made available to the provider, in writing or electronic form, prior to access being granted as provided in subsection b. of section 2 of this act.

§ 17B:30-63 Rules, regulations.

4. The Commissioner of Banking and Insurance shall, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), adopt rules and regulations necessary to effectuate the purpose of this act. The commissioner shall ensure the rules and regulations for this act include penalty provisions for contracting entities and dental carriers that violate the provisions of this act.

Chapter 30B

§ 17B:30B-1 Short title.

1. This act shall be known and may be cited as the "Viatical Settlements Act."

§ 17B:30B-2 Definitions relative to viatical settlements.

2. As used in this act:

"Advertising" means any written, electronic or printed communication or any communication by means of recorded telephone messages or transmitted on radio, television, the Internet or similar communications media, including film strips, motion pictures and videos, published, disseminated, circulated or placed before the public, directly or indirectly, for the purpose of creating an interest in or inducing a person to sell a life insurance policy pursuant to a viatical settlement contract.

"Business of viatical settlements" means an activity involved in, but not limited to, the offering, solicitation, negotiation, procurement, effectuation, financing, monitoring, tracking, underwriting, selling, transferring, assigning, pledging, hypothecating of, or in any other manner involving, viatical settlement contracts.

"Chronically ill" means:

(1) Being unable to perform at least two activities of daily living, including, but not limited, to eating, toileting, transferring, bathing, dressing or continence;

(2) Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment; or

(3) Having a level of disability similar to that described in paragraph (1) of this subsection as determined by the United States Secretary of Health and Human Services.

"Commissioner" means the Commissioner of Banking and Insurance.

"Department" means the Department of Banking and Insurance.

"Financing entity" means:

(1) an underwriter, placement agent, lender, purchaser of securities, purchaser of a policy from a viatical settlement provider, credit enhancer, or any entity that has a direct ownership in a policy that is the subject of a viatical settlement contract but:

(a) whose principal activity related to the transaction is providing funds to effect the viatical settlement contract or purchase of one or more viaticated policies; and

(b) who has an agreement in writing with one or more licensed viatical settlement providers to finance the acquisition of viatical settlement contracts.

(2) "Financing entity" does not include a non-accredited investor or purchaser of a policy from a viatical settlement provider.

"Fraudulent viatical settlement act" means and includes:

(1) Acts or omissions committed by any person who, knowingly or with intent to defraud, for the purpose of depriving another of property or for pecuniary gain, commits, or permits its employees or its agents to engage in acts including:

(a) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by a viatical settlement provider, life insurance producer, financing entity, insurer or any other person, false material information, or concealing material information, as part of, in support of or concerning a fact material to one or more of the following:

(i) An application for the issuance of a viatical settlement contract or insurance policy;

(ii) The underwriting of a viatical settlement contract or insurance policy;

(iii) A claim for payment or benefit pursuant to a viatical settlement contract or insurance policy;

(iv) Premiums paid on an insurance policy;

(v) Payments and changes in ownership or beneficiary made in accordance with the terms of a viatical settlement contract or insurance policy;

(vi) The reinstatement or conversion of an insurance policy;

(vii) The solicitation, offer, effectuation or sale of a settlement contract or insurance policy;

(viii) The issuance of written evidence of a viatical settlement contract or insurance; or

(ix) A financing transaction;

(b) Employing any device, scheme, or artifice to defraud related to viaticated policies;

(2) In the furtherance of a fraud or to prevent the detection of a fraud any person commits or permits its employees or its agents to:

(a) Remove, conceal, alter, destroy or sequester from the commissioner the assets or records of a viatical settlement provider licensee or other person engaged in the business of viatical settlements;

(b) Misrepresent or conceal the financial condition of a licensee, financing entity, insurer or other person;

(c) Transact the business of viatical settlements in violation of laws requiring a license, certificate of authority or other legal authority for the transaction of the business of viatical settlements; or

(d) File with the commissioner or the chief insurance regulatory official of another jurisdiction a document containing false information or otherwise concealing information about a material fact from the commissioner;

(3) Embezzlement, theft, misappropriation or conversion of monies, funds, premiums, credits or other property of a viatical settlement provider, insurer, insured, viator, insurance policy owner or any other person engaged in the business of viatical settlements or insurance;

(4) Recklessly entering into, brokering or otherwise dealing in a viatical settlement contract, the subject of which is a life insurance policy that was obtained by presenting false information concerning any fact material to the policy or by concealing, for the purpose of misleading another, information concerning any fact material to the policy, where the viator or the viator's agent intended to defraud the policy's issuer. For the purposes of this paragraph, "recklessly" means engaging in the conduct in conscious and clearly unjustifiable disregard of a substantial likelihood of the existence of the relevant facts or risks, such disregard involving a gross deviation from acceptable standards of conduct; or

(5) Attempting to commit, assisting, aiding or abetting in the commission of, or conspiracy to commit the acts or omissions specified in this subsection.

"Life insurance producer" means any person licensed as a resident or nonresident insurance producer with a life insurance line of authority pursuant to the "New Jersey Insurance Producer Licensing Act of 2001," P.L.2001, c.210 (C.17:22A-26 et seq.).

"Person" means a natural person or a legal entity, including, but not limited to, an individual, partnership, limited liability partnership, limited liability company, association, trust or corporation.

"Policy" means an individual or group policy, group certificate, contract or arrangement of life insurance affecting the rights of a resident of this State or bearing a reasonable relation to this State, regardless of whether delivered or issued for delivery in this State.

"Related provider trust" means a titling trust or other trust established by a licensed viatical settlement provider or a financing entity for the sole purpose of holding the ownership or beneficial interest in viaticated policies in connection with a financing transaction. The trust shall have a written agreement with the licensed viatical settlement provider under which the licensed viatical settlement provider is responsible for ensuring compliance with all statutory and regulatory requirements and under which the trust agrees to make all records and files related to viatical settlement transactions available to the commissioner as if those records and files were maintained directly by the licensed viatical settlement provider.

"Special purpose entity" means a corporation, partnership, trust, limited liability company or other similar entity formed solely to provide, either directly or indirectly, access to institutional capital markets for a financing entity or licensed viatical settlement provider.

"Terminally ill" means having an illness or sickness that can reasonably be expected to result in death in 24 months or less.

"Viatical settlement contract" means a written agreement establishing the terms under which compensation or anything of value will be paid, which compensation or value is less than the expected death benefit of the policy, in return for the viator's assignment, transfer, sale, devise or bequest of the death benefit or ownership of any portion of the policy. A viatical settlement contract also includes a contract for a loan or other financing transaction with a viator secured primarily by an individual or group life insurance policy, other than a loan by a life insurance company pursuant to the terms of the life insurance contract, or a loan secured by the cash value of a policy. A viatical settlement contract includes an agreement with a viator to transfer ownership or change the beneficiary designation at a later date regardless of the date that compensation is paid to the viator. A viatical settlement contract does not mean or include a written agreement between a viator and a person having an insurable interest in the insured's life. A viatical settlement contract shall not include any accelerated benefit pursuant to the terms of a life insurance policy issued in accordance with Title 17B of the New Jersey Statutes.

"Viatical settlement provider" means a person, other than a viator, that enters into or effectuates a viatical settlement contract. Viatical settlement provider does not include:

(1) A bank, savings bank, savings and loan association, credit union or other licensed lending institution that takes an assignment of a life insurance policy as collateral for a loan;

(2) The issuer of a life insurance policy providing accelerated benefits pursuant to regulations prescribed by the commissioner and pursuant to the policy;

(3) An authorized or eligible insurer that provides stop loss coverage to a viatical settlement provider, financing entity, special purpose entity or related provider trust;

(4) A natural person who enters into or effectuates no more than one agreement in a calendar year for the transfer of life insurance policies for any value less than the expected death benefit;

(5) A financing entity;

(6) A special purpose entity;

(7) A related provider trust; or

(8) An accredited investor or qualified institutional buyer as defined respectively in Regulation D, Rule 501 (17 C.F.R. 230.501 through 230.508) or Rule 144A (17 C.F.R. 230.144A) of the federal "Securities Act of 1933" (15 U.S.C. s.77a et seq.) as amended, and who purchases a viaticated policy from a viatical settlement provider.

"Viaticated policy" means a life insurance policy or certificate that has been acquired by a viatical settlement provider pursuant to a viatical settlement contract.

"Viator" means the owner of a policy who enters or seeks to enter into a viatical settlement contract. For the purposes of this act, a viator shall not be limited to an owner of a policy insuring the life of an individual with a terminal or chronic illness or condition except where specifically addressed. If there is more than one viator on a single policy and the viators are residents of different states, the transaction shall be governed by the law of the state in which the viator having the largest percentage ownership resides or, if the viators hold equal ownership, the state of residence of one viator agreed upon in writing by all viators. Viator shall not include:

(1) A viatical settlement provider licensed under this act;

(2) An accredited investor or qualified institutional buyer as defined respectively in Regulation D, Rule 501 (17 C.F.R. 230.501 through 230.508) or Rule 144A (17 C.F.R. 230.144A) of the federal "Securities Act of 1933" (15 U.S.C. s.77a et seq.), as amended;

(3) A financing entity;

(4) A special purpose entity; or

(5) A related provider trust.

§ 17B:30B-3 License to operate as viatical settlement provider.

3. a. A person shall not operate as a viatical settlement provider without first obtaining a license from the commissioner of the state of residence of the viator.

b. (1) No person shall act on behalf of a viator residing in this State, or otherwise negotiate, as that term is defined in section 3 of P.L.2001, c.210 (C.17:22A-28), viatical settlement contracts between a viator residing in this State and one or more viatical settlement providers unless that person is licensed as a life insurance producer pursuant to the "New Jersey Insurance Producer Licensing Act of 2001," P.L.2001, c.210 (C.17:22A-26 et seq.) and has been licensed as a resident insurance producer in his home state for not less than one year.

(2) Irrespective of the manner in which the life insurance producer is compensated, a life insurance producer is deemed to represent only the viator and not the viatical settlement provider or any insurer, and owes a fiduciary duty to the viator to act according to the viator's instructions and in the best interest of the viator.

(3) Not later than 30 days from the first day of negotiating a viatical settlement contract on behalf of a viator, such producer shall notify the commissioner of that activity on a form or in a manner that may be prescribed by, and shall pay any applicable fees determined by, the commissioner by regulation. The notification shall include an acknowledgment by the producer that he will operate in accordance with the provisions of this act.

(4) Notwithstanding paragraph (1) of this subsection, a person licensed as an attorney, or a certified public accountant, representing a viator, and whose compensation is not paid directly or indirectly by the viatical settlement provider, may negotiate a viatical settlement contract without a license as a life insurance producer.

c. Application for a viatical settlement provider license pursuant to subsection a. of this section shall be made to the commissioner by the applicant on a form prescribed by the commissioner, and the application shall be accompanied by a fee, the amount of which shall be set by the commissioner by regulation, provided, however, that the license and renewal fees for a viatical settlement license shall not exceed that established by law or regulation for a domestic stock life insurance company.

d. A viatical settlement provider license may be renewed from year to year on the anniversary date upon payment of the annual renewal fee in an amount set by the commissioner by regulation. Failure to pay the fee by the renewal date shall result in expiration of the license.

e. The applicant for a license pursuant to subsection a. of this section shall provide information on forms required by the commissioner. The commissioner shall have the authority, at any time, to require the applicant to fully disclose the identity of all stockholders except those owning fewer than five percent of the shares of an applicant whose shares are publicly traded, partners, officers, members and employees, and the commissioner may, in his discretion, refuse to issue a license in the name of a legal entity if not satisfied that any officer, employee, stockholder, partner or member thereof who may materially influence the applicant's conduct meets the standards of this act.

f. A license pursuant to subsection a. of this section issued to a legal entity authorizes all partners, officers, members and designated employees to act as viatical settlement providers, under the license, and all those persons shall be named in the application and any supplements to the application.

g. Upon the filing of an application and the payment of the license fee, the commissioner shall make an investigation of each applicant and issue a license if the commissioner finds that the applicant:

(1) Has provided a detailed plan of operation;

(2) Is competent and trustworthy and intends to act in good faith in the capacity involved by the license applied for;

(3) Has a good business reputation and has had experience, training or education so as to be qualified in the business for which the license is applied for;

(4) If a legal entity, provides a certificate of good standing from the state of its domicile; and

(5) Has provided an anti-fraud plan that meets the requirements of section 12 of this act.

h. The commissioner shall not issue a license to a nonresident applicant unless a written designation of an agent for service of process is filed and maintained with the commissioner, or the applicant has filed with the commissioner, the applicant's written irrevocable consent that any action against the applicant may be commenced against the applicant by service of process on the commissioner.

i. A viatical settlement provider shall provide to the commissioner any new or revised information about officers, stockholders holding 10% or more of the outstanding shares, partners, directors, members or designated employees within 30 days of the change.

§ 17B:30B-4 Refusal to issue, suspension, revocation, refusal to renew license.

4. a. The commissioner may refuse to issue, suspend, revoke or refuse to renew the license of a viatical settlement provider, if the commissioner finds that:

(1) There was any material misrepresentation in the application for the license;

(2) The licensee or any officer, partner, member or key management personnel has been convicted of fraudulent or dishonest practices, is subject to a final administrative action or is otherwise shown to be untrustworthy or incompetent to act as a licensee;

(3) The licensee demonstrates a pattern of unreasonable payments to viators;

(4) The licensee or any officer, partner, member or key management personnel has been found guilty of, or has pleaded guilty or nolo contendere to, any felony, or to a misdemeanor involving fraud or moral turpitude, regardless of whether a judgment of conviction has been entered by the court;

(5) The licensee has entered into any settlement contract that has not been approved pursuant to this act;

(6) The licensee has failed to honor contractual obligations set out in a viatical settlement contract;

(7) The licensee no longer meets the requirements for initial licensure;

(8) The licensee has assigned, transferred or pledged a viaticated policy to a person other than a viatical settlement provider licensed in this State, an accredited investor or qualified institutional buyer as defined respectively in Regulation D, Rule 501 (17 C.F.R. 230.501 through 230.508) or Rule 144A (17 C.F.R. 230.144A) of the federal "Securities Act of 1933" (15 U.S.C. s.77a et seq.), as amended, financing entity, special purpose entity or related provider trust; or

(9) The licensee or any officer, partner, member or key management personnel has violated any provision of this act.

b. The commissioner may suspend, revoke or refuse to renew the license of a life insurance producer if the commissioner finds that the life insurance producer has violated the provisions of this act.

c. Before the commissioner denies a license application or suspends, revokes or refuses to renew the license of a viatical settlement provider or suspends, revokes or refuses to renew the license of a life insurance producer pursuant to this act, the commissioner shall conduct a hearing in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

§ 17B:30B-5 Approval of viatical settlement forms by commissioner.

5. A person shall not use a viatical settlement contract form or provide a disclosure statement or application form to a viator in this State unless it has been filed with and approved by the commissioner. The commissioner shall disapprove a viatical settlement contract form or disclosure statement form if, in the commissioner's opinion, the contract form, disclosure form, or provisions contained therein are unreasonable, contrary to the interests of the public, or otherwise misleading or unfair to the viator. The commissioner may require the submission of advertising material used in connection with a viatical settlement contract.

§ 17B:30B-6 Filing of annual statement.

6. a. Each viatical settlement provider licensee shall file with the commissioner on or before March 1 of each year an annual statement containing that information which the commissioner by regulation may prescribe. This information is limited to only those transactions in which the viator is a resident of this State and shall not include individual transaction data or data which compromises the privacy of personal, financial, and health information of the viator or insured.

b. Except as otherwise allowed or required by law, a viatical settlement provider, insurance company, life insurance producer, information bureau, rating agency or company, or any other person with actual knowledge of the identity of the insured, shall not disclose that identity, or the insured's financial or medical information, to any other person unless the disclosure:

(1) Is necessary to effect a viatical settlement contract between the viator and a viatical settlement provider and the viator and insured have provided prior written consent to the disclosure;

(2) Is provided in response to an investigation or examination by the commissioner or any other governmental officer or agency or pursuant to the requirements of subsection e. of section 12 of this act;

(3) Is a term of or condition to the transfer of a policy by one viatical settlement provider to another viatical settlement provider;

(4) Is necessary to permit a financing entity, related provider trust or special purpose entity to finance the purchase of policies by a viatical settlement provider and the viator and insured have provided prior written consent to the disclosure;

(5) Is necessary to allow the viatical settlement provider or its authorized representative to make contacts for the purpose of determining health status; or

(6) Is required to purchase stop loss coverage.

c. In addition to the information required in this section, the commissioner may require that either or both viatical settlement providers and life insurance producers provide to the commissioner that information the commissioner determines by regulation, regarding the amount and method of compensation paid to life insurance producers for negotiating a viatical settlement contract pursuant to this act.

§ 17B:30B-7 Examinations of licensees by commissioner.

7. a. (1) The commissioner may conduct an examination of a licensee under this act as often as the commissioner, in his sole discretion, deems appropriate.

(2) For purposes of completing an examination of a licensee under this act, the commissioner may examine or investigate any person, or the business of any person, insofar as the examination or investigation is, in the sole discretion of the commissioner, necessary or material to the examination of the licensee.

(3) In lieu of an examination under this act of any foreign or alien licensee licensed in this State, the commissioner may, at the commissioner's discretion, accept an examination report on the licensee as prepared by the commissioner or other regulator for the licensee's state of domicile or port-of-entry state.

b. (1) A person required to be licensed by this act shall for five years retain copies of all:

(a) Proposed, offered or executed viatical settlement contracts, underwriting documents, policy forms and applications from the date of the proposal, offer, or execution of the viatical settlement contract, whichever is later;

(b) All checks, drafts or other evidence and documentation related to the payment, transfer, deposit or release of funds from the date of the transaction; and

(c) All other records and documents related to the requirements of this act.

(2) This subsection shall not relieve a person of the obligation to produce these documents to the commissioner after the retention period has expired if that person has retained the documents.

(3) Records required to be retained pursuant to this subsection shall be legible and complete and may be retained in paper, photograph, microprocess, magnetic, mechanical or electronic media, or by any process that accurately reproduces or forms a durable medium for the reproduction of a record.

c. (1) Upon determining that an examination should be conducted, the commissioner shall issue an examination warrant appointing one or more examiners to perform the examination and instructing them as to the scope of the examination. In conducting the examination, the examiner shall observe those guidelines and procedures set forth in the Examiners' Handbook adopted by the National Association of Insurance Commissioners (NAIC). The commissioner may also employ other guidelines or procedures as the commissioner deems appropriate.

(2) Every licensee or person from whom information is sought, its officers, directors and agents shall provide to the examiners timely, convenient and free access at all reasonable hours at its offices to all books, records, accounts, papers, documents, assets and computer or other recordings relating to the property, assets, business and affairs of the licensee being examined. The officers, directors, employees and agents of the licensee or person shall facilitate the examination and aid in the examination so far as it is in their power to do so. The refusal of a licensee, by its officers, directors, employees or agents, to submit to examination or to comply with any reasonable written request of the commissioner shall be grounds for suspension or refusal of, or nonrenewal of any license or authority held by the licensee to engage in the business of viatical settlements or other business subject to the commissioner's jurisdiction. Any proceedings for suspension, revocation or refusal of any license or authority shall be conducted pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

(3) The commissioner shall have the power to issue subpoenas, to administer oaths and to examine under oath any person as to any matter pertinent to the examination. Upon the failure or refusal of a person to obey a subpoena, the commissioner may petition a court of competent jurisdiction, and upon proper showing, the court may enter an order compelling the witness to appear and testify or produce documentary evidence. Failure to obey the court order shall be punishable as contempt of court.

(4) When making an examination under this act, the commissioner may retain attorneys, appraisers, independent actuaries, independent certified public accountants or other professionals and specialists as examiners, the reasonable cost of which shall be borne by the licensee that is the subject of the examination.

(5) Nothing contained in this act shall be construed to limit the commissioner's authority to terminate or suspend an examination in order to pursue other legal or regulatory action pursuant to the insurance laws of this State. Findings of fact and conclusions made pursuant to any examination shall be prima facie evidence in any legal or regulatory action.

(6) Nothing contained in this act shall be construed to limit the commissioner's authority to use and, if appropriate, to make public any final or preliminary examination report, any examiner or licensee work papers or other documents, or any other information discovered or developed during the course of any examination in the furtherance of any legal or regulatory action which the commissioner may, in his or her sole discretion, deem appropriate.

d. (1) Examination reports shall be comprised of only facts appearing upon the books, records or other documents of the licensee, its agents or other persons examined, or as ascertained from the testimony of its officers or agents or other persons examined concerning its affairs, and such conclusions and recommendations as the examiners find reasonably warranted from the facts.

(2) No later than 60 days following completion of the examination, the examiner in charge shall file with the commissioner a verified written report of examination under oath. Upon receipt of the verified report, the commissioner shall transmit the report to the licensee examined, together with a notice that shall afford the licensee examined a reasonable opportunity of not more than 30 days to make a written submission or rebuttal with respect to any matters contained in the examination report.

(3) Within 30 days of the end of the period allowed for the receipt of written submissions or rebuttals, the commissioner shall fully consider and review the report, together with any written submissions or rebuttals, and any relevant portions of the examiner's workpapers and either:

(a) Adopt the examination as filed or with modification or corrections. If the examination report reveals that the company is operating in violation of any law, regulation or prior order of the commissioner, the commissioner may order the company to take any action the commissioner considers necessary and appropriate to cure the violation; or

(b) Reject the examination report with directions to the examiners to reopen the examination for purposes of obtaining additional data, documentation or information, and refiling pursuant to paragraph (1) of this subsection; or

(c) Call for an investigatory hearing with no less than 20 days' notice to the company for purposes of obtaining additional documentation, data, information and testimony.

(4) (a) All determinations made pursuant to subparagraph (a) of paragraph (3) of this subsection shall be accompanied by findings and conclusions resulting from the commissioner's consideration and review of the examination report, relevant examiner workpapers and any written submissions or rebuttals. Any such determination shall be served upon the company, together with a copy of the adopted examination report. Within 30 days of the issuance of the adopted report, the company shall file affidavits executed by each of its directors stating under oath that they have received a copy of the adopted report and related orders.

(b) Any hearing under subparagraph (c) of paragraph (3) of this subsection shall be conducted by the commissioner or an authorized representative of the commissioner as a nonadversarial, confidential investigatory proceeding, as necessary for the resolution of any inconsistencies, discrepancies or disputed issues apparent upon the face of the filed examination report or raised by or as a result of the commissioner's review of relevant workpapers or by the written submission or rebuttal of the company. Within 20 days of the conclusion of any such hearing, the commissioner shall make a determination pursuant to subparagraph (a) of paragraph (3) of this subsection.

(i) The hearing shall proceed expeditiously with discovery by the company limited to the examiner's workpapers which tend to substantiate any assertions set forth in any written submission or rebuttal. The commissioner or his representative may issue subpoenas for the attendance of any witnesses or the production of any documents relevant to the investigation whether under the control of the department, the company or other persons. Nothing contained in this section shall require the department to disclose any information or records which would indicate or show the existence or content of any investigation or activity of a criminal justice agency.

(ii) The hearing shall proceed with the commissioner or his representative posing questions to the persons subpoenaed. Thereafter the company and the department may present testimony relevant to the investigation. Cross-examination shall be conducted only by the commissioner or his representative. The company and the department shall be permitted to make closing statements and may be represented by counsel of their choice.

(5) Upon the adoption of the examination report under subparagraph (a) of paragraph (3) of this subsection, the commissioner may continue to hold the content of the examination report as private and confidential information for a period of 90 days except to the extent provided in paragraph (6) of subsection c. of this section.

(6) If the commissioner determines that regulatory action is appropriate as a result of an examination, the commissioner may initiate any proceedings or actions provided by law.

e. (1) Names and individual identification data for all viators shall be considered private and confidential information and shall not be disclosed by the commissioner, unless required by law.

(2) Except as otherwise provided in this act, all examination reports, working papers, recorded information, documents and copies thereof produced by, obtained by or disclosed to the commissioner or any other person in the course of an examination made under this act, or in the course of analysis or investigation by the commissioner of the financial condition or market conduct of a licensee shall be confidential by law and privileged, shall not be subject to any State or federal freedom of information law, shall not be subject to subpoena, and shall not be subject to discovery or admissible in evidence in any private civil action. The commissioner is authorized to use the documents, materials or other information in the furtherance of any regulatory or legal action brought as part of the commissioner's official duties.

(3) Documents, materials or other information, including, but not limited to, all working papers, and copies thereof, in the possession or control of the NAIC and its affiliates and subsidiaries shall be confidential by law and privileged, shall not be subject to subpoena, and shall not be subject to discovery or admissible in evidence in any private civil action if they are:

(a) Created, produced or obtained by or disclosed to the NAIC and its affiliates and subsidiaries in the course of assisting an examination made under this act, or assisting the commissioner in the analysis or investigation of the financial condition or market conduct of a licensee; or

(b) Disclosed to the NAIC and its affiliates and subsidiaries under paragraph (4) of this subsection by the commissioner.

(c) For the purposes of paragraph (2) of this subsection, "act" includes the law of another state or jurisdiction that is substantially similar to this act.

(4) Neither the commissioner nor any person that received the documents, material or other information while acting under the authority of the commissioner, including the NAIC and its affiliates and subsidiaries, shall be permitted to testify in any private civil action concerning any confidential documents, materials or information subject to paragraph (1) of this subsection.

(5) In order to assist in the performance of the commissioner's duties, the commissioner:

(a) May share documents, materials or other information, including the confidential and privileged documents, materials or information subject to paragraph (1) of this subsection, with other state, federal and international regulatory agencies, with the NAIC and its affiliates and subsidiaries, and with state, federal and international law enforcement authorities, provided that the recipient agrees to maintain the confidentiality and privileged status of the document, material, communication or other information; and

(b) May receive documents, materials, communications or information, including otherwise confidential and privileged documents, materials or information, from the NAIC and its affiliates and subsidiaries, and from regulatory and law enforcement officials of other foreign or domestic jurisdictions, and shall maintain as confidential or privileged any document, material or information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the document, material or information.

(6) No waiver of any applicable privilege or claim of confidentiality in the documents, materials or information shall occur as a result of disclosure to the commissioner under this section or as a result of sharing as authorized in paragraph (5) of this subsection.

(7) A privilege established under the law of any state or jurisdiction that is substantially similar to the privilege established under this subsection shall be available and enforced in any proceeding in, and in any court of, this State.

(8) Nothing contained in this act shall prevent or be construed as prohibiting the commissioner from disclosing the content of an examination report, preliminary examination report or results, or any matter relating thereto, to the commissioner of any other state or country, or to law enforcement officials of this or any other state or agency of the federal government at any time or to the NAIC, so long as that agency or office receiving the report or matters relating thereto agrees in writing to hold it confidential and in a manner consistent with this act.

f. (1) An examiner may not be appointed by the commissioner if the examiner, either directly or indirectly, has a conflict of interest or is affiliated with the management of or owns a pecuniary interest in any person subject to examination under this act. This subsection shall not be construed to automatically preclude an examiner from being:

(a) A viator;

(b) An insured in a viaticated insurance policy; or

(c) A beneficiary in an insurance policy that is proposed to be viaticated.

(2) Notwithstanding the requirements of this subsection, the commissioner may retain from time to time, on an individual basis, qualified actuaries, certified public accountants, or other similar individuals who are independently practicing their professions, even though these persons may from time to time be similarly employed or retained by persons subject to examination under this act.

g. (1) No cause of action shall arise nor shall any liability be imposed against the commissioner, the commissioner's authorized representatives or any examiner appointed by the commissioner for any statements made or conduct performed in good faith while carrying out the provisions of this act.

(2) No cause of action shall arise nor shall any liability be imposed against any person for the act of communicating or delivering information or data to the commissioner or the commissioner's authorized representative or examiner pursuant to an examination made under this act, if the act of communication or delivery was performed in good faith and without fraudulent intent or the intent to deceive. This paragraph shall not abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person identified in paragraph (1) of this subsection.

(3) A person identified in paragraph (1) or (2) of this subsection shall be entitled to an award of attorney's fees and costs if that person is the prevailing party in a civil cause of action for libel, slander or any other relevant tort arising out of activities in carrying out the provisions of this act and the party bringing the action was not substantially justified in doing so. For purposes of this section, a proceeding is "substantially justified" if it had a reasonable basis in law or fact at the time that it was initiated.

h. The commissioner may investigate suspected fraudulent viatical settlement acts and persons engaged in the business of viatical settlements.

§ 17B:30B-8 Disclosures to viator, procedure.

8. a. With each application for a viatical settlement, a viatical settlement provider or life insurance producer shall provide the viator with at least the following disclosures no later than the time the application for the viatical settlement contract is signed by all parties. The disclosures shall be provided in a separate document that is signed by the viator and the viatical settlement provider, and shall provide the following information:

(1) There are possible alternatives to viatical settlement contracts, including any accelerated death benefits or policy loans offered under the viator's life insurance policy;

(2) Some or all of the proceeds of the viatical settlement contract may be taxable under federal income tax and state franchise and income taxes, and assistance should be sought from a professional tax advisor;

(3) Proceeds of the viatical settlement contract could be subject to the claims of creditors;

(4) Receipt of the proceeds of a viatical settlement contract may adversely affect the viator's eligibility for Medicaid or other government benefits or entitlements, and advice should be obtained from the appropriate government agencies;

(5) The viator has the right to rescind a viatical settlement contract before the earlier of 30 calendar days after the date upon which the settlement contract is executed by all parties or 15 calendar days after the receipt of the viatical settlement proceeds by the viator, as provided in subsection c. of section 9 of this act. If exercised by the viator, rescission is effective only if both notice of the rescission is given and repayment of all proceeds and any premiums, loans and loan interest to the settlement provider is made within the rescission period. If the insured dies during the rescission period, the viatical settlement contract shall be deemed to have been rescinded, subject to repayment of all viatical settlement proceeds and any premiums, loans and loan interest to the viatical settlement provider;

(6) Funds will be sent to the viator within three business days after the viatical settlement provider has received the insurer or group administrator's acknowledgment that ownership of the policy has been transferred and the beneficiary has been designated pursuant to the viatical settlement contract;

(7) Entering into a viatical settlement contract may cause other rights or benefits, including conversion rights and waiver of premium benefits that may exist under the policy, to be forfeited by the viator and that assistance should be sought from a financial adviser;

(8) Disclosure to a viator shall include distribution of a brochure, describing the process of viatical settlements approved by the commissioner. The National Association of Insurance Commissioners (NAIC) form for the brochure shall be used unless one is developed by the commissioner;

(9) The disclosure document shall contain the following language:

"All medical, financial or personal information solicited or obtained by a viatical settlement provider or life insurance producer about an insured, including the insured's identity or the identity of family members, a spouse or a significant other, may be disclosed as necessary to effect the viatical settlement between the viator and the viatical settlement provider. If you are asked to provide this information, you will be asked to consent to the disclosure. The information may be provided to someone who buys the policy or provides funds for the purchase. You may be asked to renew your permission to share information every two years."; and

(10) The insured may be contacted by the viatical settlement provider or its authorized representative for the purpose of determining the insured's health status. This contact shall be limited to once every three months if the insured has a life expectancy of more than one year, and no more than once per month if the insured has a life expectancy of one year or less.

b. A viatical settlement provider shall provide the viator with at least the following disclosures no later than the date the viatical settlement contract is signed by all parties. The disclosures shall be conspicuously displayed in the viatical settlement contract or in a separate document signed by the viator and the viatical settlement provider and provide the following information:

(1) State the affiliation, if any, between the viatical settlement provider and the issuer of the insurance policy to be acquired pursuant to a viatical settlement contract;

(2) The document shall include the name, address and telephone number of the viatical settlement provider;

(3) If the policy to be acquired pursuant to a viatical settlement contract has been issued as a joint policy or involves family riders or any coverage of a life other than the insured under the policy to be acquired pursuant to a viatical settlement contract, the viator shall be informed of the possible loss of coverage on the other lives;

(4) State the dollar amount of the current death benefit payable to the viatical settlement provider under the policy. The viatical settlement provider shall, if known, also disclose the availability of any additional guaranteed insurance benefits, the dollar amount of any accidental death and dismemberment benefits under the policy and the viatical settlement provider's interest in those benefits; and

(5) State the name, business address and telephone number of the independent third party escrow agent, and the fact that the viator or owner may inspect or receive copies of the relevant escrow or trust agreements or documents.

c. If the viatical settlement provider transfers ownership or changes the beneficiary of the policy, the viatical settlement provider shall communicate the change in ownership or beneficiary to the insured within 20 days after the change.

§ 17B:30B-9 Material required prior to entering into viatical settlement contract.

9. a. (1) A viatical settlement provider entering into a viatical settlement contract shall first obtain:

(a) If the viator is the insured, a written statement from a licensed attending physician that the viator is of sound mind and under no constraint or undue influence to enter into a viatical settlement contract; and

(b) A document in which the insured consents to the release of his medical records to a viatical settlement provider, life insurance producer and, if the policy was issued less than two years from the date of application for a viatical settlement contract, to the insurance company that issued the policy covering the life of the insured.

(2) The insurer shall respond to a request for verification of coverage submitted by a viatical settlement provider not later than 30 calendar days after the date the request is received. The request for verification of coverage shall be made on a form approved by the commissioner. The insurer shall complete and issue the verification of coverage or indicate in which respects it is unable to respond. In its response, the insurer shall indicate whether, based on the medical evidence and documents provided, the insurer intends to pursue an investigation at that time regarding the validity of the insurance contract.

(3) Prior to or at the time of execution of the viatical settlement contract, the viatical settlement provider shall obtain a witnessed document in which the viator consents to the viatical settlement contract, represents that the viator has a full and complete understanding of the viatical settlement contract, that the viator has a full and complete understanding of the benefits of the life insurance policy, acknowledges that the viator is entering into the viatical settlement contract freely and voluntarily and, for persons with a terminal or chronic illness or condition, acknowledges that the insured has a terminal or chronic illness and that the terminal or chronic illness was diagnosed after the life insurance policy was issued.

(4) If a life insurance producer performs any of the activities required of the viatical settlement provider, the viatical settlement provider is deemed to have fulfilled the requirements of this section.

b. All medical information solicited or obtained by any licensee shall be subject to the applicable provisions of State law relating to confidentiality of medical information.

c. All viatical settlement contracts entered into in this State shall provide the viator with an unconditional right to rescind the contract before the earlier of 30 calendar days after the date upon which the settlement contract is executed by all parties or 15 calendar days after the receipt of the viatical settlement proceeds by the viator. If exercised by the viator, rescission is effective only if both notice of the rescission is given and a full repayment of all proceeds and any premiums, loans and loan interest to the settlement provider is made within the rescission period. If the insured dies during the rescission period, the viatical settlement contract shall be deemed to have been rescinded, subject to repayment to the viatical settlement provider or purchaser of all viatical settlement proceeds, and any premiums, loans and loan interest that have been paid by the settlement provider.

d. The viatical settlement provider shall instruct the viator to send the executed documents required to effect the change in ownership, assignment or change in beneficiary directly to the independent escrow agent. Within three business days after the date the escrow agent receives the documents (or from the date the viatical settlement provider receives the documents, if the viator erroneously provides the documents directly to the provider), the provider shall pay or transfer the proceeds of the viatical settlement into an escrow or trust account maintained in a State or federally-chartered financial institution whose deposits are insured by the Federal Deposit Insurance Corporation (FDIC). Upon payment of the settlement proceeds into the escrow account, the escrow agent shall deliver the original change in ownership, assignment or change in beneficiary forms to the viatical settlement provider or related provider trust. Upon the escrow agent's receipt of the acknowledgment of the properly completed transfer of ownership or designation of beneficiary from the insurance company, the escrow agent shall pay the viatical settlement proceeds to the viator.

e. Failure to tender consideration to the viator for the viatical settlement contract within the time disclosed pursuant to paragraph (6) of subsection a. of section 8 of this act renders the viatical settlement contract voidable by the viator for lack of consideration until the time consideration is tendered to and accepted by the viator.

f. Contacts with the insured for the purpose of determining the health status of the insured by the viatical settlement provider after the viatical settlement has occurred shall only be made by the settlement provider licensed in this State or its authorized representatives and shall be limited to once every three months for insureds with a life expectancy of more than one year, and to no more than once per month for insureds with a life expectancy of one year or less. The provider shall explain to the insured the procedure for these contacts at the time the viatical settlement contract is entered into. The limitations set forth in this subsection shall not apply to any contacts with an insured for reasons other than determining the insured's health status. Viatical settlement providers shall be responsible for the actions of their authorized representatives.

g. If the insured is not terminally or chronically ill, viatical settlement providers shall pay an amount greater than the cash surrender value or accelerated death benefit then available.

§ 17B:30B-10 Two-year period required between issuance of policy and viatical settlement; exceptions.

10. a. It is a violation of this act for any person to enter into a viatical settlement contract within a two-year period commencing with the date of issuance of the insurance policy unless the viator certifies to the viatical settlement provider that one or more of the following conditions have been met within the two-year period:

(1) The policy was issued upon the viator's exercise of conversion rights arising out of a group or individual life insurance policy, so long as the total amount of time covered under the conversion policy plus the time covered under the prior policy is at least 24 months. The time covered under a group policy shall be calculated without regard to any change in insurance carriers, provided the coverage has been continuous and under the same group sponsorship;

(2) The viator submits independent evidence to the viatical settlement provider that within the two-year period: (a) the viator or insured was terminally ill or chronically ill; or (b) the viator or insured disposed of his ownership interests in a closely held corporation pursuant to a buyout or other similar agreement in effect at the time the insurance policy was initially issued; or (c) both.

b. Copies of the independent evidence described in paragraph (2) of subsection a. of this section and documents required by subsection a. of section 9 of this act shall be submitted to the insurer when the viatical settlement provider submits a request to the insurer for verification of coverage. The copies shall be accompanied by a letter of attestation from the viatical settlement provider that the copies are true and correct copies of the documents received by the viatical settlement provider.

c. If the viatical settlement provider submits to the insurer a copy of the owner or insured's certification described in subsection a. of this section when the provider submits a request to the insurer to effect the transfer of the policy to the viatical settlement provider, the copy shall be deemed to conclusively establish that the viatical settlement contract satisfies the requirements of this section and the insurer shall timely respond to the request.

§ 17B:30B-11 Advertisement of viatical settlement contracts; guidelines, standards.

11. The purpose of this section is to provide prospective viators with clear and unambiguous statements in the advertisement of viatical settlement contracts and to assure the clear, truthful and adequate disclosure of the benefits, risks, limitations and exclusions of any viatical settlement contract. This purpose is intended to be accomplished by the establishment of guidelines and standards of permissible and impermissible conduct in the advertising of viatical settlement contracts to assure that product descriptions are presented in a manner that prevents unfair, deceptive or misleading advertising and is conducive to accurate presentation and description of viatical settlements through the advertising media and material used by licensees under this act.

a. This section shall apply to any advertising of viatical settlement contracts or related products or services intended for dissemination in this State, including Internet advertising viewed by persons located in this State. Where disclosure requirements are established pursuant to federal regulation, this section shall be interpreted so as to minimize or eliminate conflict with federal regulation wherever possible.

b. Every viatical settlement provider licensee shall establish and at all times maintain a system of control over the content, form and method of dissemination of all advertisements of its contracts, products and services. All advertisements, regardless of by whom written, created, designed or presented, shall be the responsibility of the viatical settlement provider licensee, as well as the individual who created or presented the advertisement. A system of control shall include regular, routine notification, at least once a year, to life insurance producers and others authorized by the viatical settlement provider who disseminates advertisements, of the requirements and procedures for approval prior to the use of any advertisements not furnished by the viatical settlement provider.

c. Advertisements shall be truthful and not misleading in fact or by implication. The form and content of an advertisement of a viatical settlement contract, product or service shall be sufficiently complete and clear so as to avoid deception. It shall not have the capacity or tendency to mislead or deceive. Whether an advertisement has the capacity or tendency to mislead or deceive shall be determined by the commissioner from the overall impression that the advertisement may be reasonably expected to create upon a person of average education or intelligence within the segment of the public to which it is directed.

d. Certain advertisements are deemed false and misleading on their face and are prohibited. False and misleading advertisements include, but are not limited to, the following representations:

(1) "Guaranteed," "fully secured," "100 percent secured," "fully insured," "secure," "safe," "backed by rated insurance companies," "backed by federal law," "backed by state law," or "state guaranty funds," or similar representations;

(2) "No risk," "minimal risk," "low risk," "no speculation," "no fluctuation," or similar representations;

(3) "Qualified or approved for individual retirement accounts (IRAs), Roth IRAs, 401(k) plans, simplified employee pensions (SEP), 403(b), Keogh plans, TSA, other retirement account rollovers," "tax deferred," or similar representations;

(4) Utilization of the word "guaranteed" to describe the fixed return, annual return, principal, earnings, profits, investment, or similar representations;

(5) "No sales charges or fees" or similar representations; and

(6) "High yield," "superior return," "excellent return," "high return," "quick profit," or similar representations;

(7) Purported favorable representations or testimonials about the benefits of viatical settlement contracts taken out of context from newspapers, trade papers, journals, radio and television programs, and all other forms of print and electronic media.

e. The information required to be disclosed under this section shall not be minimized, rendered obscure, or presented in an ambiguous fashion or intermingled with the text of the advertisement so as to be confusing or misleading.

(1) An advertisement shall not omit material information or use words, phrases, statements, references or illustrations if the omission or use has the capacity, tendency or effect of misleading or deceiving viators as to the nature or extent of any benefit, loss covered, premium payable, or state or federal tax consequence. The fact that the viatical settlement contract offered is made available for inspection prior to consummation of the sale, or an offer is made to refund the payment if the viator is not satisfied or that the viatical settlement contract includes a "free look" period that satisfies or exceeds legal requirements, does not remedy misleading statements.

(2) An advertisement shall not use the name or title of a life insurance company or a life insurance policy unless the advertisement has been approved by the insurer.

(3) An advertisement shall not represent that premium payments will not be required to be paid on the life insurance policy that is the subject of a viatical settlement contract in order to maintain that policy, unless that is the fact.

(4) An advertisement shall not state or imply that interest charged on an accelerated death benefit or a policy loan is unfair, inequitable or in any manner an incorrect or improper practice.

(5) The words "free," "no cost," "without cost," "no additional cost," "at no extra cost," or words of similar import shall not be used with respect to any benefit or service unless true. An advertisement may specify the charge for a benefit or a service or may state that a charge is included in the payment or use other appropriate language.

(6) Testimonials, appraisals or analysis used in advertisements must be genuine; represent the current opinion of the author; be applicable to the viatical settlement contract, product or service advertised, if any, and be accurately reproduced with sufficient completeness to avoid misleading or deceiving prospective viators as to the nature or scope of the testimonials, appraisal, analysis or endorsement. In using testimonials, appraisals or analysis, the viatical settlement provider licensee makes as its own all the statements contained therein, and the statements are subject to all the provisions of this section.

(a) If the individual making a testimonial, appraisal, analysis or an endorsement has a financial interest in the viatical settlement provider or related entity as a stockholder, director, officer, employee or otherwise, or receives any benefit directly or indirectly other than required union scale wages, that fact shall be prominently disclosed in the advertisement.

(b) An advertisement shall not state or imply that a viatical settlement contract, benefit or service has been approved or endorsed by a group of individuals, society, association or other organization unless that is the fact and unless any relationship between an organization and the licensee is disclosed. If the entity making the endorsement or testimonial is owned, controlled or managed by the licensee, or receives any payment or other consideration from the licensee for making an endorsement or testimonial, that fact shall be disclosed in the advertisement.

(c) When an endorsement refers to benefits received under a viatical settlement contract all pertinent information shall be retained for a period of five years after its use.

f. An advertisement shall not contain statistical information unless it accurately reflects recent and relevant facts. The source of all statistics used in an advertisement shall be identified.

g. An advertisement shall not disparage insurers, viatical settlement providers, life insurance producers, policies, services or methods of marketing.

h. The name of the licensee shall be clearly identified in all advertisements about the licensee or its viatical settlement contract, products or services, and if any specific viatical settlement contract is advertised, the viatical settlement contract shall be identified either by form number or some other appropriate description. If an application is part of the advertisement, the name of the viatical settlement provider shall be shown on the application.

i. An advertisement shall not use a trade name, group designation, name of the parent company of a licensee, name of a particular division of the licensee, service mark, slogan, symbol or other device or reference without disclosing the name of the licensee, if the advertisement would have the capacity or tendency to mislead or deceive as to the true identity of the licensee, or to create the impression that a company other than the licensee would have any responsibility for the financial obligation under a viatical settlement contract.

j. An advertisement shall not use any combination of words, symbols or physical materials that by their content, phraseology, shape, color or other characteristics are so similar to a combination of words, symbols or physical materials used by a government program or agency or otherwise appear to be of such a nature that they tend to mislead prospective viators into believing that the solicitation is in some manner connected with a government program or agency.

k. An advertisement may state that a licensee is licensed in the state where the advertisement appears so long as it does not exaggerate that fact or suggest or imply that competing licensees may not be so licensed. The advertisement may ask the audience to consult the licensee's website or contact the department to find out if the state requires licensing and, if so, whether the viatical settlement provider, or life insurance producer is licensed.

l. An advertisement shall not create the impression that the viatical settlement provider, its financial condition or status, the payment of its claims or the merits, desirability, or advisability of its viatical settlement contracts forms are recommended or endorsed by any government entity.

m. The name of the actual licensee shall be stated in all of its advertisements. An advertisement shall not use a trade name, any group designation, name of any affiliate or controlling entity of the licensee, service mark, slogan, symbol or other device in a manner that would have the capacity or tendency to mislead or deceive as to the true identity of the actual licensee or create the false impression that an affiliate or controlling entity would have any responsibility for the financial obligation of the licensee.

n. An advertisement shall not directly or indirectly create the impression that any division or agency of the State or of the federal government endorses, approves or favors:

(1) Any viatical settlement provider licensee or its business practices or methods of operation;

(2) The merits, desirability or advisability of any viatical settlement contract;

(3) Any viatical settlement contract; or

(4) Any life insurance policy or life insurance company.

o. If the advertiser emphasizes the speed with which the viatication will occur, the advertising shall disclose the average time from the date of the completed application to the date of offer and from acceptance of the offer to receipt of the funds by the viator.

p. If the advertising emphasizes the dollar amounts available to viators, the advertising shall disclose the average purchase price as a percent of face value obtained by viators contracting with the licensee during the past six months.

§ 17B:30B-12 Fraudulent viatical settlement acts, prohibited, reporting, investigation, prosecution.

12. a. A person shall not commit a fraudulent viatical settlement act as defined in section 2 of this act.

b. A person shall not knowingly or intentionally interfere with the enforcement of the provisions of this act or investigations of suspected or actual violations of this act.

c. A person in the business of viatical settlements shall not knowingly or intentionally permit any person convicted of a felony involving dishonesty or breach of trust to participate in the business of viatical settlements.

d. (1) Viatical settlement contracts and applications for viatical settlement contracts, regardless of the form of transmission, shall contain the following statement or a substantially similar statement: "Any person who knowingly presents false information in an application for insurance or viatical settlement contract is guilty of a crime and may be subject to fines and confinement in prison."

(2) The lack of a statement as required in paragraph (1) of this subsection does not constitute a defense in any prosecution for a fraudulent viatical settlement act.

e. (1) Any person engaged in the business of viatical settlements having knowledge or a reasonable belief that a fraudulent viatical settlement act is being, will be or has been committed shall provide to the commissioner the information required by, and in a manner prescribed by, the commissioner.

(2) Any other person having knowledge or a reasonable belief that a fraudulent viatical settlement act is being, will be or has been committed may provide to the commissioner the information required by, and in a manner prescribed by, the commissioner.

f. (1) No civil liability shall be imposed on and no cause of action shall arise from the furnishing of information concerning suspected, anticipated or completed fraudulent viatical settlement acts or suspected or completed fraudulent insurance acts, if the information is provided to or received from:

(a) The commissioner or the commissioner's employees, agents or representatives;

(b) Federal, state or local law enforcement or regulatory officials or their employees, agents or representatives;

(c) A person involved in the prevention and detection of fraudulent viatical settlement acts or that person's agents, employees or representatives;

(d) The National Association of Insurance Commissioners (NAIC), National Association of Securities Dealers (NASD), the North American Securities Administration Association or their employees, agents or representatives, or other regulatory body overseeing life insurance, viatical settlements, securities or investment fraud; or

(e) The life insurer, including its agents and employees, that issued the life insurance policy covering the life of the insured.

(2) Paragraph (1) of this subsection shall not apply to statements made with actual malice. In an action brought against a person for filing a report or furnishing other information concerning a fraudulent viatical settlement act or a fraudulent insurance act, the party bringing the action shall plead specifically any allegation that paragraph (1) does not apply because the person filing the report or furnishing the information did so with actual malice.

(3) A person identified in paragraph (1) of this subsection shall be entitled to an award of attorney's fees and costs if he is the prevailing party in a civil cause of action for libel, slander or any other relevant tort arising out of activities in carrying out the provisions of this act and the party bringing the action was not substantially justified in doing so. For purposes of this section a proceeding is "substantially justified" if it had a reasonable basis in law or fact at the time that it was initiated.

(4) This section does not abrogate or modify common law or statutory privileges or immunities enjoyed by a person described in paragraph (1) of this subsection.

g. (1) The documents and evidence provided pursuant to subsection e. of this section or obtained by the commissioner in an investigation of suspected or actual fraudulent viatical settlement acts shall be privileged and confidential and shall not be a public record and shall not be subject to discovery or subpoena in a civil or criminal action.

(2) The provisions of paragraph (1) of this subsection shall not prohibit release by the commissioner of documents and evidence obtained in an investigation of suspected or actual fraudulent viatical settlement acts:

(a) In administrative or judicial proceedings to enforce laws administered by the commissioner;

(b) To federal, state or local law enforcement or regulatory agencies, to an organization established for the purpose of detecting and preventing fraudulent viatical settlement acts or to the National Association of Insurance Commissioners (NAIC); or

(c) At the discretion of the commissioner, to a person in the business of viatical settlements or the business of life insurance that is aggrieved by a fraudulent viatical settlement act.

(3) Release of documents and evidence under paragraph (2) of this subsection shall not abrogate or modify the privilege granted in paragraph (1) of this subsection.

h. This act shall not:

(1) Preempt the authority or relieve the duty of other law enforcement or regulatory agencies to investigate, examine and prosecute suspected violations of law;

(2) Prevent or prohibit a person from disclosing voluntarily information concerning a fraudulent viatical settlement act to a law enforcement or regulatory agency other than the department; or

(3) Limit the powers granted elsewhere by the laws of this State to the commissioner or the Insurance Fraud Prosecutor to investigate and examine possible violations of law and to take appropriate action against wrongdoers.

i. Viatical settlement providers shall have in place antifraud initiatives reasonably calculated to detect, prosecute and prevent fraudulent viatical settlement acts. At the discretion of the commissioner, the commissioner may order, or a licensee may request and the commissioner may grant, modifications of the following required initiatives as necessary to ensure an effective antifraud program. The modifications may be more or less restrictive than the required initiatives so long as the modifications may reasonably be expected to accomplish the purpose of this section. Antifraud initiatives shall include:

(1) Fraud investigators, who may be viatical settlement provider employees or independent contractors; and

(2) An antifraud plan, which shall be submitted to the commissioner. The antifraud plan shall include, but not be limited to:

(a) A description of the procedures for detecting and investigating possible fraudulent viatical settlement acts and procedures for resolving material inconsistencies between medical records and insurance applications;

(b) A description of the procedures for reporting possible fraudulent viatical settlement acts to the commissioner;

(c) A description of the plan for antifraud education and training of underwriters and other personnel; and

(d) A description or chart outlining the organizational arrangement of the antifraud personnel who are responsible for the investigation and reporting of possible fraudulent viatical settlement acts and investigating unresolved material inconsistencies between medical records and insurance applications.

(3) Antifraud plans submitted to the commissioner shall be privileged and confidential and shall not be a public record and shall not be subject to discovery or subpoena in a civil or criminal action.

(4) The commissioner may refer suspected fraudulent viatical settlement acts to the Department of Law and Public Safety, Office of Insurance Fraud Prosecutor, for investigation, prosecution or other action or disposition involving such suspected fraudulent viatical settlement acts.

§ 17B:30B-13 Injunction in addition to penalties, enforcement provisions.

13. a. In addition to the penalties and other enforcement provisions of this act, if any person violates this act or any regulation implementing this act, the commissioner may seek an injunction in a court of competent jurisdiction and may apply for temporary and permanent orders that the commissioner determines are necessary to restrain the person from committing the violation.

b. Any person damaged by the acts of a person in violation of this act may bring a civil action against the person committing the violation in a court of competent jurisdiction.

c. The commissioner may issue, in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), a cease and desist order upon a person that violates any provision of this act, any regulation or order adopted by the commissioner, or any written agreement entered into with the commissioner.

d. When the commissioner finds that an activity in violation of this act presents an immediate danger to the public that requires an immediate final order, the commissioner may issue an emergency cease and desist order reciting with particularity the facts underlying the findings. The emergency cease and desist order is effective immediately upon service of a copy of the order on the respondent and remains effective for 90 days. If the commissioner begins non-emergency cease and desist proceedings, the emergency cease and desist order remains effective, absent an order by a court of competent jurisdiction pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

e. In addition to the penalties and other enforcement provisions of this act, any person who violates this act shall be subject to civil penalties of up to $10,000 per violation which may be collected in a summary proceeding pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.). The commissioner's order may require a person found to be in violation of this act to make restitution to persons aggrieved by violations of this act.

f. A person convicted of a violation of this act shall be ordered to pay restitution to persons aggrieved by the violation of this act. Restitution shall be ordered in addition to a fine or imprisonment, but not in lieu of a fine or imprisonment.

g. A person convicted of a violation of this act may be sentenced in accordance with paragraph (1), (2), (3) or (4) of this subsection based on the greater of: the value of property, services, or other benefit wrongfully obtained or attempted to be obtained; or the aggregate economic loss suffered by any person as a result of the violation. A person convicted of a fraudulent viatical settlement act shall be ordered to pay restitution to persons aggrieved by the fraudulent viatical settlement act. Restitution shall be ordered in addition to a fine or imprisonment but not in lieu of a fine or imprisonment.

(1) Imprisonment for not more than 20 years or payment of a fine of not more than $100,000, or both, if the value of the viatical settlement contract is more than $35,000;

(2) Imprisonment for not more than 10 years or payment of a fine of not more than $20,000, or both, if the value of the viatical settlement contract is more than $2,500 but not more than $35,000;

(3) Imprisonment for not more than five years or payment of a fine of not more than $10,000, or both, if the value of the viatical settlement contract is more than $500 but not more than $2,500; or

(4) Imprisonment for not more than one year or payment of a fine of not more than $3,000, or both, if the value of the viatical settlement contract is $500 or less.

h. In any prosecution under paragraphs (1), (2), (3) and (4) of subsection g. of this section the value of the viatical settlement contracts within any six-month period may be aggregated and the defendant charged accordingly in applying the provisions of this section; provided that, when two or more offenses are committed by the same person in two or more counties, the accused may be prosecuted in any county in which one of the offenses was committed for all of the offenses aggregated under this section. The applicable statute of limitations provision shall not begin to run until the insurance company or law enforcement agency is aware of the fraud, but in no event may the prosecution be commenced later than seven years after the act has occurred.

§ 17B:30B-14 Violation considered unfair trade practice; penalties.

14. A violation of this act shall be considered an unfair trade practice pursuant to N.J.S.17B:30-1 et seq. and shall be subject to the penalties contained in N.J.S.17B:30-17.

§ 17B:30B-15 Regulations, authority of commissioner.

15. The commissioner shall have the authority to promulgate regulations implementing the provisions of this act pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) including, but not limited to, the following:

a. Establishing standards for evaluating reasonableness of payments under viatical settlement contracts for persons terminally or chronically ill;

b. Establishing appropriate licensing requirements, fees and standards for continued licensure for viatical settlement providers;

c. Requiring a bond or other mechanism for financial accountability for viatical settlement providers; and

d. Governing the relationship and responsibilities of insurers, viatical settlement providers, life insurance producers and others in the business of viatical settlements during the period of consideration or effectuation of a viatical settlement contract.

§ 17B:30B-16 Construction of act with Uniform Securities Law.

16. Nothing in this act shall be construed to preempt or otherwise limit the provisions of the "Uniform Securities Law (1967)," P.L.1967, c.93 (C.49:3-47 et seq.) or any regulations, orders, policy statements, notices, bulletins, or other interpretations issued by or through the Attorney General or his designee acting pursuant thereto. Compliance with the provisions of this act does not constitute compliance with any applicable provisions of the "Uniform Securities Law (1967)."

§ 17B:30B-17 Continuation of negotiating viatical settlements, certain circumstances prior to act.

17. a. Notwithstanding the provisions of sections 1 through 16 of this act, a person who has lawfully negotiated viatical settlement contracts between a viator and one or more viatical settlement providers for at least one year immediately prior to the effective date of this act may continue to negotiate viatical settlements in this State for a period of one year from the effective date of this act, provided that person registers with the department on a form prescribed by the department. The registration form shall be published by the department not later than 30 days from the effective date of this act and shall require a person registering to evidence that he has lawfully negotiated viatical settlement contracts and include an acknowledgment by that person that he will operate in accordance with and comply with this act.

b. A viatical settlement provider that is either licensed or is lawfully transacting business in this State immediately prior to the effective date of this act may continue to do so pending approval or disapproval of the viatical settlement provider's application for a license pursuant to this act.

§ 17B:30B-18 Engaging in stranger-originated life insurance prohibited.

1. a. No person shall directly or indirectly engage in any act, practice or arrangement that constitutes stranger-originated life insurance.

b. A contract, agreement, arrangement, or transaction, including, but not limited to, a financing agreement or any other arrangement or understanding entered into, whether written or verbal, for the furtherance or aid of a stranger-originated life insurance policy or practice shall be void and unenforceable at the outset.

c. A trust that is created to give the appearance of an insurable interest and that is used to initiate or procure policies for investors shall be in violation of the insurable interest laws of this State and the prohibition against wagering on life.

d. Notwithstanding the provisions of N.J.S.17B:25-4, a life insurer may contest a life insurance policy on the grounds that it was obtained by a stranger-originated life insurance practice, as defined in this section, at any time.

e. (1) As used in this section, "stranger-originated life insurance" or "STOLI" means an act, practice or arrangement to initiate or procure the issuance of a policy in this State for the benefit of a third-party investor who, at the time of policy inception has no insurable interest under the laws of this State in the life of the insured.

(2) STOLI practices shall include, but shall not be limited to, cases in which: (a) a policy is purchased with resources or guarantees from or through a person or entity who, at the time of policy inception, could not lawfully initiate or procure the policy himself, herself, or itself; and (b) at the time of policy inception, there exists an arrangement or agreement, to transfer, directly or indirectly, the ownership of that policy or the policy benefits to a third party.

f. A STOLI arrangement shall not include an otherwise lawful viatical settlement contract as permitted by the "Viatical Settlements Act," P.L.2005, c.229 (C.17B:30B-1 et seq.).

§ 17B:30B-19 Violations, remedies, penalties.

2. a. The Commissioner of Banking and Insurance may seek an injunction in a court of competent jurisdiction and may apply for temporary and permanent orders that the commissioner determines are necessary to restrain the person from committing a violation of this act.

b. Any person damaged by the acts of a person in violation of this act may bring a civil action against the person committing the violation in a court of competent jurisdiction.

c. The commissioner may issue, in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), a cease and desist order upon a person that violates any provision of this act, any regulation or order adopted by the commissioner, or any written agreement entered into with the commissioner.

d. When the commissioner finds that an activity in violation of this act presents an immediate danger to the public that requires an immediate final order, the commissioner may issue an emergency cease and desist order reciting with particularity the facts underlying the findings. The emergency cease and desist order shall be effective immediately upon service of a copy of the order on the respondent and shall remain effective for 90 days. If the commissioner begins non-emergency cease and desist proceedings, the emergency cease and desist order shall remain effective, absent an order by a court of competent jurisdiction pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

e. In addition to the penalties and other enforcement provisions of this act, any person who violates this act shall be subject to civil penalties of up to $10,000 per violation which may be collected in a summary proceeding pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.). The commissioner's order may require a person found to be in violation of this act to make restitution to persons aggrieved by violations of this act.

f. A violation of this act shall be considered an unfair trade practice pursuant to N.J.S.17B:30-1 et seq. and shall be subject to the penalties contained in N.J.S.17B:30-17.

§ 17B:30B-20 Regulations.

3. The Commissioner of Banking and Insurance shall promulgate regulations implementing the provisions of this act pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

Chapter 32

§ 17B:32-31 Short title, purpose of act

1. a. This act shall be known and may be cited as the "Life and Health Insurers Rehabilitation and Liquidation Act."

b. The purpose of this act is the protection of the interests of insureds, claimants, creditors and the public generally through:

(1) Early detection of any potentially dangerous condition in an insurer, and prompt application of appropriate corrective measures;

(2) Improved methods for rehabilitating insurers, involving the cooperation and management expertise of the life and health insurance industry;

(3) Enhanced efficiency and economy of liquidation, through clarification of the law, to minimize legal uncertainty and litigation;

(4) Equitable apportionment of any unavoidable loss;

(5) Lessening the problems of interstate rehabilitation and liquidation by facilitating cooperation between states in the liquidation process, and by extending the scope of personal jurisdiction over debtors of the insurer outside this State;

(6) Regulation of the insurance industry by the impact of the law relating to delinquency procedures and substantive rules on the entire life and health insurance industry; and

(7) Providing for a comprehensive scheme for the rehabilitation and liquidation of life and health insurers and others subject to this act as part of the regulation of the business of insurance, insurance industry and insurers in this State. Proceedings in cases of insurer insolvency and delinquency are deemed an integral aspect of the business of insurance and are of vital public interest and concern.

§ 17B:32-32 Application of authorized proceedings

2. The proceedings authorized by this act shall be applied to:

a. All insurers who are doing, or have done, insurance business in this State, and against whom claims arising from that business may exist now or in the future.

b. All insurers who purport to do insurance business in this State.

c. All insurers who have insureds residing in this State.

d. All other persons organized or in the process of organizing with the intent to do life or health insurance or annuity business in this State.

§ 17B:32-33 Definitions

3. For the purposes of this act:

"Advance" shall have the same meaning as that term is defined at 12 C.F.R. s.1266.1.

"Ancillary state" means any state other than a domiciliary state.

"Commissioner" means the Commissioner of Insurance of this State.

"Creditor" is a person having any claim against the insurer, whether matured or unmatured, liquidated or unliquidated, secured or unsecured, absolute, fixed or contingent.

"Delinquency proceeding" means any proceeding instituted against an insurer for the purpose of liquidating, rehabilitating, reorganizing or conserving that insurer, and any summary proceeding under section 9 of this act. "Formal delinquency proceeding" means any liquidation or rehabilitation proceeding.

"Department" means the Department of Insurance.

"Doing business" includes any of the following acts, whether effected by mail or otherwise:

(1) The issuance or delivery of contracts of life or health insurance or annuity to persons residing in this State;

(2) The solicitation of applications for those contracts, or other negotiations preliminary to the execution of those contracts;

(3) The collection of premiums, membership fees, assessments or other consideration for those contracts;

(4) The transaction of matters subsequent to execution of those contracts and arising out of them; or

(5) Operating under a license or certificate of authority, as an insurer, issued by the department.

"Domiciliary state" means the state in which an insurer is incorporated or organized; or, in the case of an alien insurer, its state of entry.

"Fair consideration" is given for property or obligation:

(1) When in exchange for that property or obligation, as a fair equivalent therefor, and in good faith, property is conveyed or services are rendered or an obligation is incurred or an antecedent debt is satisfied; or

(2) When that property or obligation is received in good faith to secure a present advance or antecedent debt in an amount not disproportionately small as compared to the value of the property or obligation obtained.

"Federal home loan bank" means a bank as defined in 12 U.S.C. s.1422(1)(A).

"Foreign country" means any other jurisdiction not in any state.

"General assets" means all property, real, personal or otherwise, not specifically mortgaged, pledged, deposited or otherwise encumbered for the security or benefit of specified persons or classes of persons. As to specifically encumbered property, "general assets" includes all such property or its proceeds in excess of the amount necessary to discharge the sum or sums secured thereby. Assets held in trust and on deposit for the security or benefit of all policyholders or all policyholders and creditors, in more than a single state, shall be treated as general assets.

"Guaranty association" means the New Jersey Life and Health Insurance Guaranty Association created in subsection a. of section 5 of P.L.1991, c.208 (C.17B:32A-5) and any other similar entity now or hereafter created by any other law of this State for the payment of claims of insolvent insurers. "Foreign guaranty association" means any similar entities now in existence in, or hereafter created by, any law of any other state.

"Insolvency" or "insolvent" means:

(1) That an insurer: (a) is unable to pay its obligations when they are due, or (b) its admitted assets do not exceed its liabilities plus the greater of:

(i) Any capital and surplus required by law for its organization; or

(ii) The total par or stated value of its authorized and issued capital stock.

(2) As to any insurer licensed to do business in this State, as of the effective date of this act, which does not meet the standard established under paragraph (1) of this definition, the term "insolvency" or "insolvent" shall mean, for a period not to exceed three years from the effective date of this act, that it is unable to pay its obligations when they are due or that its admitted assets do not exceed its liabilities plus any required capital contribution ordered by the commissioner under provisions of the insurance law.

(3) For purposes of the definition of "insolvency" or "insolvent," "liabilities" shall include, but not be limited to, reserves required by law or by regulations of the department or specific requirements imposed by the commissioner upon an insurer at the time of admission or subsequent thereto.

"Insurer" includes every person engaged as indemnitor or contractor in the business of life insurance, health insurance or of annuities and every such person subject to the supervisory authority of, or to liquidation, rehabilitation, reorganization or conservation by, the commissioner or the equivalent insurance regulator of another state; every person purporting to be engaged as indemnitor or contractor in the business of life insurance, health insurance or of annuities in this State; every person in the process of organization to become engaged as indemnitor or contractor in the business of life insurance, health insurance or of annuities; and every fraternal benefit society established pursuant to P.L.1959, c.167 (C.17:44A-1 et seq.); every mutual benefit association established pursuant to R.S.17:45-1 et seq.; every hospital service corporation established pursuant to P.L.1938, c.366 (C.17:48-1 et seq.); every health service corporation established pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.); every medical service corporation established pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.); every dental service corporation established pursuant to P.L.1968, c.305 (C.17:48C-1 et seq.); every dental plan organization established pursuant to P.L.1979, c.478 (C.17:48D-1 et seq.); and every health maintenance organization established pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.).

"Insurer-member" means an insurer that is a member of a federal home loan bank.

"Preferred claim" means any claim which is accorded priority of payment from the general assets of the insurer pursuant to the provisions of this act.

"Receiver" means receiver, liquidator, rehabilitator or conservator as the context requires.

"Reciprocal state" means any state, other than this State, in which in substance and effect, subsection a. of section 17 and sections 51, 52 and 54 through 56 of this act are in force, and in which provisions are in force requiring the commissioner or equivalent official to be the receiver of a delinquent insurer, and in which some provision exists for the avoidance of fraudulent conveyances and preferential transfers.

"Secured claim" means any claim secured by mortgage, trust deed, pledge, deposit as security, escrow, or otherwise; but not including special deposit claims or claims against general assets. The term also includes claims which have become liens upon specific assets by reason of judicial process.

"Special deposit claim" means any claim secured by a deposit made pursuant to law for the security or benefit of a limited class or classes of persons, but not including any claim secured by general assets.

"State" means any state, district, or territory of the United States and the Panama Canal Zone.

"Transfer" shall include the sale and every other and different mode, direct or indirect, of disposing of or of parting with, property or with an interest therein, or with the possession thereof, or of fixing a lien upon property or upon an interest therein, absolutely or conditionally, voluntarily, by or without judicial proceedings. The retention of a security title to property delivered to a debtor shall be deemed a transfer suffered by the debtor.

§ 17B:32-34 Jurisdiction over delinquency proceedings

4. a. No delinquency proceeding shall be commenced under this act by anyone other than the commissioner and no court shall have jurisdiction to entertain, hear or determine any proceeding commenced by any other person.

b. No court of this State shall have jurisdiction to entertain, hear or determine any complaint praying for the dissolution, liquidation, rehabilitation, sequestration, conservation or receivership of any insurer; or praying for an injunction or restraining order or other relief preliminary to, incidental to or relating to such proceedings other than in accordance with this act.

c. In addition to other grounds for jurisdiction provided by the law of this State, a court of this State having jurisdiction of the subject matter has jurisdiction over a person served pursuant to the Rules Governing the Courts of the State of New Jersey or other applicable provisions of law in an action brought by the receiver of a domestic insurer or an alien insurer domiciled in this State:

(1) If the person served is an agent, broker or other person who has at any time written policies of insurance for, or has acted in any manner whatsoever on behalf of, an insurer against which a delinquency proceeding has been instituted, in any action resulting from or incident to such a relationship with the insurer;

(2) If the person served is a reinsurer who has at any time entered into a contract of reinsurance with an insurer against which a delinquency proceeding has been instituted, or is an agent or broker of or for the reinsurer, in any action on or incident to the reinsurance contract;

(3) If the person served is or has been an officer, director, manager, trustee, organizer, promoter or other person in a position of comparable authority or influence over an insurer against which a delinquency proceeding has been instituted, in any action resulting from or incident to such a relationship with the insurer;

(4) If the person served is or was at the time of the institution of the delinquency proceeding against the insurer holding assets in which the receiver claims an interest on behalf of the insurer, in any action concerning the assets; or

(5) If the person served is obligated to the insurer in any way whatsoever, in any action on or incident to the obligation.

d. If the court on motion of any party finds that any action should as a matter of substantial justice be tried in a forum outside this State, the court may enter an appropriate order to stay further proceedings on the action in this State.

e. All actions authorized pursuant to this section shall be brought in the Superior Court.

§ 17B:32-35 Restraining orders, injunctions

5. a. Any receiver appointed in a proceeding under this act may at any time apply for, and the Superior Court may grant, such restraining orders, preliminary and permanent injunctions, and other orders as may be deemed necessary and proper to prevent:

(1) The transaction of further business;

(2) The transfer of property;

(3) Interference with the receiver or with a proceeding under this act;

(4) Waste of the insurer's assets;

(5) Dissipation and transfer of bank accounts;

(6) The institution or further prosecution of any actions or proceedings;

(7) The obtaining of preferences, judgments, attachments, garnishments or liens against the insurer, its assets or its policyholders;

(8) The levying of execution against the insurer, its assets or its policyholders;

(9) The making of any sale or deed for nonpayment of taxes or assessments that would lessen the value of the assets of the insurer;

(10) The withholding from the receiver of books, accounts, documents or other records relating to the business of the insurer; or

(11) Any other threatened or contemplated action that might lessen the value of the insurer's assets or prejudice the rights of policyholders, creditors or shareholders, or the administration of any proceeding under this act.

b. The receiver may apply to any court outside of this State for the relief described in subsection a. of this section.

c. Notwithstanding any provision of law to the contrary, the commencement of a delinquency proceeding with respect to an insurer-member shall not operate as a stay, injunction, or prohibition of exercise by a federal home loan bank of its rights regarding collateral pledged by that insurer-member.

§ 17B:32-36 Cooperation with commissioner in proceedings

6. a. Any officer, manager, director, trustee, owner, employee or agent of any insurer, or any other person with authority over or in charge of any segment of the insurer's affairs, including any person who exercises control directly or indirectly over activities of the insurer through any holding company or other affiliate of the insurer, shall cooperate with the commissioner in any proceeding under this act or any investigation preliminary to the proceeding. The term "cooperate" shall include, but shall not be limited to, the following:

(1) Replying promptly in writing to any inquiry from the commissioner requesting such a reply; and

(2) Making available to the commissioner any books, accounts, documents, or other records or information or property of or pertaining to the insurer and in his possession, custody or control.

b. No person shall obstruct or interfere with the commissioner in the conduct of any delinquency proceeding or any investigation preliminary or incidental thereto.

c. This section shall not be construed to abridge any other existing legal rights, including the right to resist a petition for liquidation or other delinquency proceedings, or other orders.

d. Any person who fails to cooperate with the commissioner pursuant to subsection a. of this section, or who obstructs or interferes with the commissioner pursuant to subsection b. of this section, or who violates any order the commissioner issued validly under this act shall:

(1) Be subject to a civil penalty of not more than $10,000 or to imprisonment for not more than one year, or both; or

(2) After a hearing, be subject to an administrative penalty imposed by the commissioner of not more than $10,000 and to the revocation or suspension of any insurance licenses issued by the commissioner.

§ 17B:32-37 Proceedings previously commenced deemed commenced under this act; exceptions, distribution of claims

7. a. Every proceeding heretofore commenced under the laws in effect before the enactment of this act shall be deemed to have been commenced under this act henceforth for all purposes and shall be governed by the provisions of this act, including, but not limited to, section 41 of this act, except that, in the discretion of the commissioner, the proceeding may be continued, in whole or in part, as it would have been continued had this act not been enacted.

b. Notwithstanding the provisions of subsection a. of this section and section 41 of this act to the contrary, one-half of the direct, non-contingent obligations incurred on or after August 9, 1991, which prior to May 4, 1992, the insurer in rehabilitation under the supervision of the commissioner as rehabilitator had stipulated were due, and which stipulation has been ordered by the court supervising pending delinquency proceedings, shall have a priority of distribution pursuant to section 41 of this act which is after Class 3 claims under paragraph (3) of subsection a. of section 41 of this act and before Class 4 claims under paragraph (4) of subsection a. of section 41 of this act.

§ 17B:32-38 Prohibitions relative to insurer subject to delinquency proceeding

8. No insurer that is subject to any delinquency proceedings, whether administrative or judicial, shall:

a. Be released from that proceeding, unless that proceeding is converted into a judicial rehabilitation or liquidation proceeding;

b. Be permitted to solicit or accept new business or request or accept the restoration of any suspended or revoked license or certificate of authority;

c. Be returned to the control of its shareholders or private management; or

d. Have any of its assets returned to the control of its shareholders or private management until all payments of or on account of the insurer's contractual obligations by all guaranty associations, along with all expenses thereof and interest on all such payments and expenses, shall have been repaid to the guaranty associations or a plan of repayment by the insurer shall have been approved by the guaranty associations.

§ 17B:32-39 Filing of petition; court orders

9. a. The commissioner may file in the Superior Court of this State a petition alleging that, with respect to a domestic insurer:

(1) There exist any grounds that would justify a court order for a formal delinquency proceeding against an insurer under this act;

(2) The interests of policyholders, creditors or the public will be endangered by delay; and

(3) The contents of an order deemed necessary by the commissioner.

b. Upon a filing under subsection a. of this section, the court may issue forthwith, ex parte and without a hearing, the requested order which shall direct the commissioner to take possession and control of all or a part of the property, books, accounts, documents, and other records of an insurer, and of the premises occupied by it for transaction of its business; and until further order of the court enjoin the insurer and its officers, managers, agents, and employees from disposition of its property and from the transaction of its business except with the written consent of the commissioner.

c. The court shall specify in the order what its duration shall be, which shall be the time the court deems necessary for the commissioner to ascertain the condition of the insurer. On motion of either party or on its own motion, the court may from time to time hold hearings it deems necessary after giving notice it deems appropriate, and may extend, shorten, or modify the terms of the seizure order. The court shall vacate the seizure order if the commissioner fails to commence a formal proceeding under this act after having had a reasonable opportunity to do so. An order of the court pursuant to a formal proceeding under this act shall ipso facto vacate the seizure order.

d. Entry of a seizure order under this section shall not constitute an anticipatory breach of any contract of the insurer.

e. An insurer subject to an ex parte order under this section may petition the court at any time after the issuance of the order for a hearing and review of the order. The court shall hold a hearing and review not more than 15 days after the request. A hearing under this subsection may be held privately in chambers and it shall be held privately in chambers if requested by the insurer proceeded against.

f. If, at any time after the issuance of such an order, it appears to the court that any person whose interest is or will be substantially affected by the order did not appear at the hearing and has not been served, the court may order that notice be given. An order that notice be given shall not stay the effect of any order previously issued by the court.

§ 17B:32-40 Confidentiality of documents, files, records, papers

10. In all proceedings and judicial reviews thereof under section 9 of this act, all records of the insurer, other documents, and all department files and court records and papers, so far as they pertain to or are a part of the record of the proceedings, shall be and remain confidential except as is necessary to obtain compliance therewith, unless and until the Superior Court, after hearing arguments from the parties in chambers, shall order otherwise; or unless the insurer requests that the matter be made public. Until such court order, all papers filed with the clerk of the Superior Court shall be held by him in a confidential file.

§ 17B:32-41 Petition for authority to rehabilitate insurer

11. The commissioner may petition the Superior Court for an order authorizing him to rehabilitate a domestic insurer or an alien insurer domiciled in this State on any one or more of the following grounds:

a. The insurer is in such condition that the further transaction of business would be hazardous financially to its policyholders, creditors or the public.

b. There is reasonable cause to believe that there has been embezzlement from the insurer, wrongful sequestration or diversion of the insurer's assets, forgery or fraud affecting the insurer, or other illegal conduct in, by, or with respect to, the insurer that if established would endanger assets in an amount threatening the solvency of the insurer.

c. The insurer has failed to remove any person who in fact has executive authority in the insurer, whether an officer, manager, general agent, employee or other person, if the person has been found after notice and hearing by the commissioner to be dishonest or untrustworthy in a way affecting the insurer's business.

d. Control of the insurer, whether by stock ownership or otherwise, and whether direct or indirect, is in a person or persons found after notice and hearing to be untrustworthy.

e. Any person who in fact has executive authority in the insurer, whether an officer, manager, general agent, director or trustee, employee or other person, has refused to be examined under oath by the commissioner concerning its affairs, whether in this State or elsewhere; and after reasonable notice of that fact, the insurer has failed promptly and effectively to terminate the employment and status of the person and all his influence on management.

f. After demand by the commissioner under chapter 21 of Title 17B of the New Jersey Statutes or any other law governing the examination of insurers, or under this act, the insurer has failed to promptly make available for examination any of its own property, books, accounts, documents or other records, or those of any subsidiary or related company within the control of the insurer, or those of any person having executive authority in the insurer so far as they pertain to the insurer.

g. Without first obtaining the written consent of the commissioner, the insurer has transferred, or attempted to transfer, in a manner contrary to section 2 of P.L.1970, c.22 (C.17:27A-2) or N.J.S.17B:18-64, substantially its entire property or business, or has entered into any transaction the effect of which is to merge, consolidate or reinsure substantially its entire property or business in or with the property or business of any other person.

h. The insurer or its property has been or is the subject of an application for the appointment of a receiver, trustee, custodian, conservator or sequestrator or similar fiduciary of the insurer or its property otherwise than as authorized under the insurance laws of this State, and such appointment has been made or is imminent, and such appointment might oust the courts of this State of jurisdiction or might prejudice orderly delinquency proceedings under this act.

i. Within the previous five years the insurer has willfully violated its charter or articles of incorporation, its bylaws, any insurance law of this State, or any valid order of the commissioner.

j. The insurer has failed to pay, within 60 days after the due date, any obligation to any state or any subdivision thereof or any judgment entered in any state, if the court in which such judgment was entered had jurisdiction over such subject matter, except that such nonpayment shall not be a ground until 60 days after any good faith effort by the insurer to contest the obligation has been terminated, whether it is before the commissioner or in the courts, or the insurer has systematically attempted to compromise or renegotiate previously agreed settlements with its creditors on the ground that it is financially unable to pay its obligations in full.

k. The insurer has failed to file its annual report or other financial report required by law within the time allowed by law and, after written demand by the commissioner, has failed to give an adequate explanation immediately.

l. The board of directors or the holders of a majority of the shares entitled to vote, or a majority of those individuals entitled to the control of a mutual insurer as defined in N.J.S.17B:18-3, request or consent to rehabilitation under this act. For purposes of this subsection, "control" means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of the insurer, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing, 10% or more of the voting securities of an insurer.

§ 17B:32-42 Appointment of rehabilitator

12. a. An order to rehabilitate the business of a domestic insurer, or an alien insurer domiciled in this State, shall appoint the commissioner and his successors in office the rehabilitator, and shall direct the rehabilitator forthwith to take possession of the assets of the insurer, and to administer them under the general supervision of the court. The filing or recording of the order with the clerk of the Superior Court or recorder of deeds of the county in which the principal business of the company is conducted, or the county in which its principal office or place of business is located, shall impart the same notice as a deed, bill of sale or other evidence of title duly filed or recorded with that recorder of deeds would have imparted. The order to rehabilitate the insurer shall by operation of law vest title to all assets of the insurer in the rehabilitator.

b. Any order issued under this section shall require accountings to the court by the rehabilitator. Accountings shall be at such intervals as the court specifies in its order, but no less frequently than semi-annually. Each accounting shall include a report concerning the rehabilitator's opinion as to the likelihood that a plan under subsection e. of section 13 of this act will be prepared by the rehabilitator and the timetable for doing so.

c. Entry of an order of rehabilitation shall not constitute an anticipatory breach of any contracts of the insurer nor shall it be grounds for retroactive revocation or retroactive cancellation of any contracts of the insurer, unless such revocation or cancellation is done by the rehabilitator pursuant to section 13 of this act.

§ 17B:32-43 Powers of rehabilitator

13. a. The commissioner as rehabilitator may appoint one or more special deputies, who shall have all the powers and responsibilities of the rehabilitator granted under this section, and the commissioner may employ such counsel, clerks and assistants as deemed necessary. The commissioner may fix the compensation of employees and agents of the insurer and, with the approval of the court, the special deputy, counsel, clerks and assistants, other than employees of the insurer, and all expenses of taking possession of the insurer and of conducting the proceedings shall be paid out of the funds or assets of the insurer. The persons appointed under this section shall serve at the pleasure of the commissioner. The commissioner, as rehabilitator, may, with the approval of the court, appoint an advisory committee of policyholders, claimants or other creditors, including guaranty associations, should he deem such a committee to be necessary. The committee shall serve at the pleasure of the commissioner and shall serve without compensation. No other committee of any nature shall be appointed by the commissioner or the court in rehabilitation proceedings conducted under this act.

b. In the event that the property of the insurer does not contain sufficient cash or liquid assets to defray the costs incurred, the commissioner may advance the costs so incurred out of any appropriation for the maintenance of the department. Any amounts so advanced for expenses of administration shall be repaid to the commissioner for the use of the department out of the first available money of the insurer.

c. The rehabilitator may take such action as he deems necessary or appropriate to reform and revitalize the insurer, including, but not limited to, any of the actions which could be taken by a liquidator under paragraphs (6) through (24) of subsection a. of section 20 of this act. He shall have all the powers of the directors, officers and managers, whose authority shall be suspended, except as they are redelegated by the rehabilitator. He shall have full power to direct and manage, to hire and discharge employees subject to any contract rights they may have, and to deal with the property and business of the insurer.

d. If it appears to the rehabilitator that there has been criminal or tortious conduct, or breach of any contractual or fiduciary obligation detrimental to the insurer by any officer, manager, agent, broker, employee or other person, he may pursue all appropriate legal remedies on behalf of the insurer.

e. If the rehabilitator determines that reorganization, consolidation, conversion, reinsurance, merger or other transformation of the insurer is appropriate, he shall prepare a plan to effect such changes. Upon application of the rehabilitator for approval of the plan, and after such notice and hearings as the court may prescribe, the court may either approve or disapprove the plan proposed, or may modify it and approve it as modified. Any plan approved under this section shall be, in the judgment of the court, fair and equitable to all parties concerned. If the plan is approved, the rehabilitator shall carry out the plan. In the case of a life insurer, the plan proposed may include the imposition of liens upon the policies of the company, if all rights of shareholders are first relinquished. A plan for a life insurer may also propose imposition of a moratorium upon loan and cash surrender rights under policies, for such period and to such an extent as may be necessary.

f. The rehabilitator shall have the power under sections 25 and 26 of this act to avoid fraudulent transfers.

§ 17B:32-44 Staying of pending actions

14. a. Any court in this State before which any action or proceeding in which the insurer is a party, or is obligated to defend a party, is pending when a rehabilitation order against the insurer is entered shall stay the action or proceeding for 90 days and such additional time as is necessary for the rehabilitator to obtain proper representation and prepare for further proceedings. The rehabilitator shall take such action respecting the pending litigation as he deems necessary in the interests of justice and for the protection of creditors, policyholders and the public. The rehabilitator shall immediately consider all litigation pending outside this State and shall petition the courts having jurisdiction over that litigation for stays whenever necessary to protect the estate of the insurer.

b. No statute of limitations or defense of laches shall run with respect to any action by or against an insurer between the filing of a petition for appointment of a rehabilitator for that insurer and the order granting or denying that petition. Any action against the insurer that might have been commenced when the petition was filed may be commenced for at least 60 days after the order of rehabilitation is entered. The rehabilitator may, upon an order for rehabilitation, within one year or such other longer time as applicable law may permit, institute an action or proceeding on behalf of the insurer upon any cause of action against which the period of limitation fixed by applicable law has not expired at the time of the filing of the petition upon which such order is entered.

c. Any guaranty association or foreign guaranty association covering life or health insurance or annuities shall have standing to appear in any court proceeding concerning the rehabilitation of an insurer if that association is or may become liable to act as a result of the rehabilitation.

§ 17B:32-45 Petition for order of liquidation

15. a. Whenever the commissioner believes further attempts to rehabilitate an insurer would substantially increase the risk of loss to creditors, policyholders or the public, or would be futile, the commissioner may petition the Superior Court for an order of liquidation. A petition under this subsection shall have the same effect as a petition under section 16 of this act. The Superior Court shall permit the directors of the insurer to take such actions as are reasonably necessary to defend against the petition and may order payment from the estate of the insurer of such costs and other expenses of defense as justice may require.

b. The protection of the interests of insureds, claimants and the public requires the timely performance of all insurance policy obligations. If the payment of policy obligations is suspended in substantial part for a period of 12 months at any time after the appointment of the rehabilitator and the rehabilitator has not filed an application for approval of a plan under subsection e. of section 13 of this act during the 12-month period, the rehabilitator shall petition the court for an order of liquidation on the grounds of insolvency; provided, however, that prior to the end of that 12-month period the commissioner may petition the court for an extension of the time period to file an application for approval of a plan.

c. The rehabilitator may at any time petition the Superior Court for an order terminating rehabilitation of an insurer. The court shall also permit the directors of the insurer to petition the court for an order terminating rehabilitation of the insurer and may order payment from the estate of the insurer of such costs and other expenses of that petition as justice may require. If the court finds that rehabilitation has been accomplished and that grounds for rehabilitation under section 11 of this act no longer exist, it shall order that the insurer be restored to possession of its property and the control of the business. The court may also make that finding and issue that order at any time upon its own motion.

§ 17B:32-46 Basis for order of liquidation

16. The commissioner may petition the Superior Court for an order directing him to liquidate a domestic insurer or an alien insurer domiciled in this State on the basis:

a. Of any ground for an order of rehabilitation as specified in section 11 of this act, whether or not there has been a prior order directing the rehabilitation of the insurer;

b. That the insurer is insolvent; or

c. That the insurer is in such condition that the further transaction of business would be hazardous, financially or otherwise, to its policyholders, its creditors or the public.

§ 17B:32-47 Appointment of liquidator

17. a. An order to liquidate the business of a domestic insurer shall appoint the commissioner and his successors in office liquidator and shall direct the liquidator forthwith to take possession of the assets of the insurer and to administer them under the general supervision of the court. The liquidator shall be vested by operation of law with the title to all of the property, contracts and rights of action, and all of the books and records of the insurer ordered liquidated, wherever located, as of the entry of the final order of liquidation. The filing or recording of the order with the clerk of the Superior Court and the recorder of deeds of the county in which its principal office or place of business is located, or, in the case of real estate, with the recorder of deeds of the county where the property is located, shall impart the same notice as a deed, bill of sale or other evidence of title duly filed or recorded with that recorder of deeds would have imparted.

b. Upon issuance of the order, the rights and liabilities of that insurer and of its creditors, policyholders, shareholders, members and all other persons interested in its estate shall become fixed as of the date of entry of the order of liquidation, except as provided in sections 18 and 36 of this act.

c. An order to liquidate the business of an alien insurer domiciled in this State shall be in the same terms and have the same legal effect as an order to liquidate a domestic insurer, except that the assets and the business in the United States shall be the only assets and business included therein.

d. At the time of petitioning for an order of liquidation, or at any time thereafter, the commissioner, after making appropriate findings of an insurer's insolvency, may petition the court for a judicial declaration of that insolvency. After providing such notice and hearing as it deems proper, the court may make the declaration.

e. Any order issued under this section shall require financial reports to the court by the liquidator. Financial reports shall include, at a minimum, the assets and liabilities of the insurer and all funds received or disbursed by the liquidator during the current period. Financial reports shall be filed within one year of the liquidation order and at least annually thereafter.

f. (1) Within 90 days of the effective date of this act, or within 90 days after the initiation of an appeal of an order of liquidation, which order has not been stayed, whichever is later, the commissioner shall present for the court's approval a plan for the continued performance of the defendant insurer's policy claims obligations during the pendency of an appeal. The plan shall provide for the continued performance and payment of policy claims obligations in the normal course of events, notwithstanding the grounds alleged in support of the order of liquidation including the ground of insolvency. If the defendant insurer's financial condition will not, in the judgment of the commissioner, support the full performance of all policy claims obligations during the appeal pendency period, the plan may prefer the claims of certain policyholders and claimants over creditors and interested parties as well as other policyholders and claimants, as the commissioner finds to be fair and equitable, considering the relative circumstances of such policyholders and claimants. The court shall examine the plan submitted by the commissioner and if it finds the plan to be in the best interests of the parties, the court shall approve the plan. No action shall lie against the commissioner or any of his deputies, agents, clerks, assistants or attorneys by any party based on preference in an appeal pendency plan approved by the court.

(2) The appeal pendency plan shall not supersede or affect the obligations of the guaranty association or of any applicable foreign guaranty association.

(3) Any such plans shall provide for equitable adjustments to be made by the liquidator to any distributions of assets to guaranty associations, in the event that the liquidator pays claims from assets of the estate, which would otherwise be the obligations of any particular guaranty association, but for the appeal of the order of liquidation, such that all guaranty associations equally benefit on a pro rata basis from the assets of the estate. Further, if an order of liquidation is set aside upon any appeal, the insurer shall not be released from delinquency proceedings unless and until all funds advanced by any guaranty association, including reasonable administrative expenses in connection therewith relating to obligations of the insurer, shall be repaid in full, together with interest at the judgment rate of interest or unless an arrangement for repayment thereof has been made with the consent of all applicable guaranty associations.

§ 17B:32-48 Policies to continue in force

18. a. Policies of life or health insurance or annuities shall continue in force for such period and under such terms as is provided for by the guaranty association or any applicable foreign guaranty association.

b. Policies of life or health insurance or annuities or any period or coverage of those policies not covered by the guaranty association or a foreign guaranty association shall continue in force only for the lesser of:

(1) A period of 30 days from the date of entry of the liquidation orders;

(2) The expiration of the policy coverage;

(3) The date when the insured has replaced the insurance coverage with equivalent insurance in another insurer or otherwise terminated the policy;

(4) The liquidator has effected a transfer of the policy obligation pursuant to paragraph (9) of subsection a. of section 20 of this act; or

(5) The date proposed by the liquidator and approved by the court to cancel coverage.

An order for liquidation under section 17 of this act shall terminate coverages at the time specified in this subsection b. for purposes of any other law.

§ 17B:32-49 Petition for dissolution

19. The commissioner may petition for an order dissolving the corporate existence of a domestic insurer, or the United States branch of an alien insurer domiciled in this State, at the time he applies for a liquidation order. The court shall order dissolution of the corporation upon petition by the commissioner upon or after the granting of a liquidation order. If the dissolution has not previously been ordered, it shall be effected by operation of law upon the discharge of the liquidator if the insurer is insolvent but may be ordered by the court upon the discharge of the liquidator if the insurer is under a liquidation order for some other reason.

§ 17B:32-50 Powers of liquidator

20. a. The liquidator shall have the power:

(1) To appoint a special deputy or deputies to act for him under this act, and to determine his reasonable compensation. The special deputy shall have all powers of the liquidator granted by this section. The special deputy shall serve at the pleasure of the liquidator.

(2) To employ employees and agents, legal counsel, actuaries, accountants, appraisers, consultants and such other personnel as he may deem necessary to assist in the liquidation.

(3) To appoint, with the approval of the court, an advisory committee of policyholders, claimants or other creditors, including guaranty associations, should he deem such a committee to be necessary. Such committee shall serve at the pleasure of the commissioner and shall serve without compensation. No other committee of any nature shall be appointed by the commissioner or the court in liquidation proceedings conducted under this act.

(4) To fix the reasonable compensation of employees and agents of the insurer, and, with the approval of the court, legal counsel, actuaries, accountants, appraisers and consultants, other than employees and agents of the insurer.

(5) To pay reasonable compensation to persons appointed and to defray from the funds or assets of the insurer all expenses of taking possession of, conserving, conducting, liquidating, disposing of, or otherwise dealing with the business and property of the insurer. If the property of the insurer does not contain sufficient cash or liquid assets to defray the costs incurred, the commissioner may advance the costs so incurred out of any appropriation for the maintenance of the department. Any amounts so advanced for expenses of administration shall be repaid to the commissioner for the use of the department out of the first available moneys of the insurer.

(6) To hold hearings, to subpoena witnesses to compel their attendance, to administer oaths, to examine any person under oath, and to compel any person to subscribe to his testimony after it has been correctly reduced to writing; and in connection therewith to require the production of any books, papers, records or other documents which he deems relevant to the inquiry.

(7) To audit the books and records of all agents of the insurer insofar as those records relate to the business activities of the insurer.

(8) To collect all debts and moneys due and claims belonging to the insurer, wherever located, and for this purpose:

(a) To institute timely action in other jurisdictions, in order to forestall garnishment and attachment proceedings against those debts;

(b) To take other actions necessary or expedient to collect, conserve or protect its assets or property, including the power to sell, compound, compromise or assign debts for purposes of collection upon such terms and conditions as he deems best; and

(c) To pursue any creditor's remedies available to enforce his claims.

(9) To conduct public and private sales of the property of the insurer.

(10) To use assets of the estate of an insurer under a liquidation order to transfer policy obligations to a solvent assuming insurer, if the transfer can be arranged without prejudice to applicable priorities under section 41 of this act.

(11) To acquire, hypothecate, encumber, lease, improve, sell, transfer, abandon or otherwise dispose of or deal with, any property of the insurer at its market value or upon such terms and conditions as are fair and reasonable. He shall also have power to execute, acknowledge and deliver any and all deeds, assignments, releases and other instruments necessary or proper to effectuate any sale of property or other transaction in connection with the liquidation.

(12) To borrow money on the security of the insurer's assets, or without security, and to execute and deliver all documents necessary to that transaction for the purpose of facilitating the liquidation. Any funds so borrowed may be repaid as an administrative expense and have priority over any other claims in Class 1 under the priority of distribution of claims pursuant to section 41 of this act.

(13) To enter into any contracts necessary to carry out the order to liquidate, and to affirm or disavow any contracts to which the insurer is a party.

(14) To continue to prosecute and to institute in the name of the insurer or in his own name any and all suits and other legal proceedings, in this State or elsewhere, and to abandon the prosecution of claims he deems unprofitable to pursue further. If the insurer is dissolved under section 19 of this act, he shall have the power to apply to any court in this State or elsewhere for leave to substitute himself for the insurer as plaintiff.

(15) To prosecute any action which may exist on behalf of the creditors, members, policyholders or shareholders of the insurer against any director or officer of the insurer, or any other person.

(16) To remove any or all records and property of the insurer to the offices of the commissioner or to such other place as may be convenient for the purposes of efficient and orderly execution of the liquidation. Guaranty associations and foreign guaranty associations shall have reasonable access to the records of the insurer as is necessary for them to carry out their legal obligations.

(17) To deposit in one or more banks in this State any sums required for meeting current administration expenses and dividend distributions.

(18) To invest all sums not currently needed, unless the court orders otherwise.

(19) To file any necessary documents for record in the office of any recorder of deeds or record office in this State or elsewhere where property of the insurer is located.

(20) To assert all defenses available to the insurer as against third persons, including statutes of limitation, statutes of frauds, and the defense of usury. A waiver of any defense by the insurer after a petition in liquidation has been filed shall not bind the liquidator. Whenever the guaranty association or a foreign guaranty association has an obligation to defend any suit, the liquidator shall give precedence to that obligation and may defend only in the absence of a defense by those guaranty associations.

(21) To exercise and enforce all the rights, remedies and powers of any creditor, shareholder, policyholder or member; including any power to avoid any transfer or lien that may be given by law and that is not included with sections 25 through 27 of this act.

(22) To intervene in any proceeding, wherever instituted, that might lead to the appointment of a receiver or trustee, and to act as the receiver or trustee whenever the appointment is offered.

(23) To enter into agreements with any receiver or commissioner or insurance regulator of any other state relating to the rehabilitation, liquidation, conservation or dissolution of an insurer doing business in both states.

(24) To exercise all powers now held or hereafter conferred upon receivers by the laws of this State not inconsistent with the provisions of this act.

b. The enumeration in this section of the powers and authority of the liquidator shall not be construed as a limitation upon him, nor shall it exclude in any manner his right to do such other acts not herein specifically enumerated, or otherwise provided for, as may be necessary or appropriate for the accomplishment of or in aid of the purpose of liquidation.

c. Notwithstanding the powers of the liquidator as stated in subsections a. and b. of this section, the liquidator shall have no obligation to defend claims or to continue to defend claims subsequent to the entry of a liquidation order.

§ 17B:32-51 Notice of liquidation order

21. a. Unless the court otherwise directs, the liquidator shall give or cause to be given notice of the liquidation order as soon as possible:

(1) By first class mail and either by telegram or telephone to the commissioner or insurance regulator of each jurisdiction in which the insurer is doing business;

(2) By first class mail to the guaranty association and any foreign guaranty association which is or may become obligated as a result of the liquidation;

(3) By first class mail to all insurance agents of the insurer;

(4) By first class mail to all persons known or reasonably expected to have claims against the insurer, including all policyholders, at their last known address as indicated by the records of the insurer; and

(5) By publication in a newspaper of general circulation in the county in which the insurer has its principal place of business and in such other locations as the liquidator deems appropriate.

b. Except as otherwise established by the liquidator with approval of the court, notice to potential claimants under subsection a. of this section shall require claimants to file with the liquidator their claims, together with proper proofs thereof under section 35 of this act, on or before a date the liquidator shall specify in the notice. The liquidator need not require persons claiming cash surrender values or other investment values in life insurance and annuities to file a claim. All claimants shall have a duty to keep the liquidator informed of any changes of address.

c. (1) Notice under subsection a. of this section to agents of the insurer and to potential claimants who are policyholders shall include, where applicable, notice that coverage by state guaranty associations may be available for all or part of policy benefits in accordance with applicable state guaranty association laws.

(2) The liquidator shall promptly provide to the guaranty associations such information concerning the identities and addresses of policyholders and their policy coverages as may be within the liquidator's possession or control, and otherwise cooperate with guaranty associations to assist them in providing to those policyholders timely notice of the guaranty associations' coverage of policy benefits, including, as applicable, coverage of claims and continuation or termination of coverages.

d. If notice is given in accordance with this section, the distribution of assets of the insurer under this act shall be conclusive with respect to all claimants, whether or not they received notice.

§ 17B:32-52 Provision of information to liquidator by agents, licensing affected

22. a. Every person who receives notice, in the form prescribed in section 21 of this act, that an insurer which he represents as an agent is the subject of a liquidation order, shall within 30 days of such notice provide to the liquidator, in addition to the information he may be required to provide pursuant to section 6 of this act, the information in the agent's records related to any policy issued by the insurer through the agent, and, if the agent is a general agent, the information in the general agent's records related to any policy issued by the insurer through an agent under contract to him, including the name and address of such subagent. A policy shall be deemed issued through an agent if the agent has a property interest in the expiration of the policy, or if the agent has had in his possession a copy of the declarations of the policy at any time during the life of the policy, except where the ownership of the expiration of the policy has been transferred to another.

b. The commissioner may refuse to renew a license, or may suspend or revoke a license, if he finds after notice and an opportunity for a hearing that an agent has failed to provide information to the liquidator as required in subsection a. of this section. In addition or an alternative to any other penalty, the commissioner may, after a hearing, impose an administrative penalty of not more than $10,000 for each violation of this section.

§ 17B:32-53 Actions against or by insurer, liquidator

23. a. Upon issuance of an order appointing a liquidator of a domestic insurer or of an alien insurer domiciled in this State, no action at law or equity or in arbitration shall be brought against the insurer or liquidator, whether in this State or elsewhere, nor shall any such existing actions be maintained or further presented after issuance of that order. The courts of this State shall give full faith and credit to injunctions against the liquidator or the insurer or the continuation of existing actions against the liquidator or the insurer, when those injunctions are included in an order to liquidate an insurer issued pursuant to corresponding provisions in other states. Whenever, in the liquidator's judgment, protection of the estate of the insurer necessitates intervention in an action against the insurer that is pending outside this State, he may intervene in the action. The liquidator may defend any action in which he intervenes under this section at the expense of the estate of the insurer.

b. The liquidator may, upon or after an order for liquidation, institute an action or proceeding on behalf of the estate of the insurer upon any cause of action against which the period of limitation fixed by applicable law has not expired at the time of the filing of the petition upon which that order is entered. If, by any agreement, a period of limitation is fixed for instituting an action or proceeding upon any claim, or for filing any claim, proof of claim, proof of loss, demand, notice or the like, or if in any proceeding, judicial or otherwise, a period of limitation is fixed, either in the proceeding or by applicable law, for taking any action, filing any claim or pleading, or doing any act, and if in any such case the period had not expired at the date of the filing of the petition, the liquidator may, for the benefit of the estate, take any such action or do any such act, required of or permitted to the insurer, within a period of 180 days subsequent to the entry of an order for liquidation, or within any further period as is shown to the satisfaction of the court not to be unfairly prejudicial to the other party.

c. No statute of limitation or defense of laches shall run with respect to any action against an insurer between the filing of a petition for liquidation against an insurer and the denial of the petition.

d. Any guaranty association or foreign guaranty association shall have standing to appear in any court proceeding concerning the liquidation of an insurer if such association is or may become liable to act as a result of the liquidation.

§ 17B:32-54 Preparation of list of insurer's assets

24. a. As soon as practicable after the liquidation order but not later than 120 days thereafter, the liquidator shall prepare in duplicate a list of the insurer's assets. The list shall be amended or supplemented from time to time as the liquidator may determine. One copy shall be filed in the office of the clerk of the Superior Court and one copy shall be retained for the liquidator's files. All amendments and supplements shall be similarly filed.

b. The liquidator shall reduce the assets to a degree of liquidity that is consistent with the effective execution of the liquidation.

c. A submission to the court for disbursement of assets in accordance with section 33 of this act fulfills the requirements of subsection a. of this section.

§ 17B:32-55 Transfers, obligations deemed fraudulent.

25. a. Every transfer made or suffered and every obligation incurred by an insurer within one year prior to the filing of a successful petition for rehabilitation or liquidation under this act shall be fraudulent as to then existing and future creditors if made or incurred without fair consideration, or with actual intent to hinder, delay or defraud either existing or future creditors. A transfer made or an obligation incurred by an insurer ordered to be rehabilitated or liquidated under this act, which is fraudulent under this section, may be avoided by the receiver, except as to a person who in good faith is a purchaser, lienholder or obligee for a present fair equivalent value, and except that any purchaser, lienholder or obligee, who in good faith has given a consideration which is less than fair for that transfer, lien or obligation, may retain the property, lien or obligation as security for repayment. The court may, on due notice, order any such transfer or obligation to be preserved for the benefit of the estate, and in that event, the receiver shall succeed to and may enforce the rights of the purchaser, lienholder or obligee.

b. (1) A transfer of property other than real property shall be deemed to be made or suffered when it becomes so far perfected that no subsequent lien obtainable by legal or equitable proceedings on a simple contract could become superior to the rights of the transferee under subsection c. of section 27 of this act.

(2) A transfer of real property shall be deemed to be made or suffered when it becomes so far perfected that no subsequent bona fide purchaser from the insurer could obtain rights superior to the rights of the transferee.

(3) A transfer which creates an equitable lien shall not be deemed to be perfected if there are available means by which a legal lien could be created.

(4) Any transfer not perfected prior to the filing of a petition for liquidation shall be deemed to be made immediately before the filing of the successful petition.

(5) The provisions of this subsection apply whether or not there are or were creditors who might have obtained any liens or persons who might have become bona fide purchasers.

c. Any transaction of the insurer with a reinsurer shall be deemed fraudulent and may be avoided by the receiver under subsection a. of this section if:

(1) The transaction consists of the termination, adjustment or settlement of a reinsurance contract in which the reinsurer is released from any part of its duty to pay the originally specified share of losses that had occurred prior to the time of the transactions, unless the reinsurer gives a present fair equivalent value for the release; and

(2) Any part of the transaction took place within one year prior to the date of filing of the petition through which the receivership was commenced.

d. Every director, officer, employee, stockholder, policyholder and any other person acting on behalf of the insurer who is concerned in any fraudulent transfer and every person receiving any property from the insurer or any benefit thereof which is a fraudulent transfer under subsection a. of this section shall be personally liable therefor and shall be bound to account to the liquidator.

e. (1) A receiver for an insurer-member subject to a delinquency shall not void a transfer made to a federal home loan bank provided that the transfer:

(a) is made in the ordinary course of business and in compliance with the advance agreement with that federal home loan bank; and

(b) is valid pursuant to State law and the "Federal Home Loan Bank Act" (12 U.S.C. s.1421 et seq.).

(2) A receiver shall not void a redemption or repurchase of any stock or equity securities made by the federal home loan bank if the redemption or repurchase: (a) is made within 12 months of the commencement of the delinquency proceeding; or (b) has received prior approval of the receiver.

(3) A receiver may void any transfer if the transfer is made with actual intent to hinder, delay, or defraud the insurer-member, a receiver appointed for the insurer-member, or existing or future creditors.

f. Following the appointment of a receiver for an insurer-member and upon request of the receiver, the federal home loan bank shall, within 10 days of that request, provide a process and establish a timeline for:

(1) the release of collateral that exceeds the lending value required to support secured obligations remaining after a repayment of advances, as determined in accordance with the federal home loan bank security agreement;

(2) the release of any collateral remaining in the federal home loan bank's possession following repayment of all outstanding secured obligations in full;

(3) the payment of fees and the operation of deposits and other accounts with the federal home loan bank; and

(4) the possible redemption or repurchase of federal home loan bank stock or excess stock of any class that an insurer-member is required to own.

g. Upon the request of the receiver for an insurer-member, the federal home loan bank shall provide any available options for the insurer-member to renew or restructure an advance to defer associated prepayment fees, to the extent that market conditions, the terms of the advance outstanding to the insurer-member, the applicable policies of the federal home loan bank, and compliance with the "Federal Home Loan Bank Act" (12 U.S.C. s.1421 et seq.) and corresponding regulations permit.

h. Nothing in this section shall affect the receiver's rights pursuant to 12 C.F.R. s.1266.4 regarding advances to an insurer-member in delinquency proceedings.

§ 17B:32-56 Transfer of real property deemed valid

26. a. After a petition for rehabilitation or liquidation has been filed, but before an order of rehabilitation or liquidation is granted, a transfer of any of the real property of the insurer made to a person acting in good faith shall be valid against the receiver if made for a present fair equivalent value; or, if not made for a present fair equivalent value, then to the extent of the present consideration actually paid therefor, for which amount the transferee shall have a lien on the property so transferred. The commencement of a proceeding in rehabilitation or liquidation shall be constructive notice upon the recording of a copy of the petition for or order of rehabilitation or liquidation with the recorder of deeds in the county where any real property in question is located. The exercise by a court of the United States or any state or jurisdiction to authorize or effect a judicial sale of real property of the insurer within any county in any state shall not be impaired by the pendency of such a proceeding unless the copy is recorded in the county prior to the consummation of the judicial sale.

b. After a petition for rehabilitation or liquidation has been filed and before either the receiver takes possession of the property of the insurer or an order of rehabilitation or liquidation is granted:

(1) A transfer of any of the property of the insurer, other than real property, made to a person acting in good faith shall be valid against the receiver if made for a present fair equivalent value; or, if not made for a present fair equivalent value, then to the extent of the present consideration actually paid therefor, for which amount the transferee shall have a lien on the property so transferred.

(2) A person indebted to the insurer or holding property of the insurer may, if acting in good faith, pay the indebtedness or deliver the property, or any part thereof, to the insurer or upon his order, with the same effect as if the petition were not pending.

(3) A person having actual knowledge of the pending rehabilitation or liquidation shall be deemed not to act in good faith pursuant to the provisions of this section.

(4) A person asserting the validity of a transfer under this section shall have the burden of proof. Except as elsewhere provided in this section, no transfer by or on behalf of the insurer after the date of the petition for liquidation by any person other than the liquidator shall be valid against the liquidator.

c. Every director, officer, employee, stockholder, policyholder and any other person acting on behalf of the insurer who is concerned in any fraudulent transfer, and every person receiving any property from the insurer or any benefit thereof which is a fraudulent transfer under subsection a. of this section shall be personally liable therefor and shall be bound to account to the liquidator.

d. Nothing in this act shall impair the negotiability of currency or negotiable instruments.

§ 17B:32-57 Preferences.

27. a. (1) A preference is a transfer of any of the property of an insurer to or for the benefit of a creditor, for or on account of an antecedent debt, made or suffered by the insurer within one year before the filing of a successful petition for liquidation under this act, the effect of which transfer may be to enable the creditor to obtain a greater percentage of this debt than another creditor of the same class would receive. If a liquidation order is entered while the insurer is already subject to a rehabilitation order, then such transfers shall be deemed preferences if made or suffered within one year before the filing of the successful petition for rehabilitation, or within two years before the filing of the successful petition for liquidation, whichever time is shorter.

(2) Any preference may be avoided by the liquidator if:

(a) the insurer was insolvent at the time of the transfer;

(b) The transfer was made within four months before the filing of the petition;

(c) The creditor receiving it or to be benefitted thereby or his agent acting with reference thereto had, at the time the transfer was made, reasonable cause to believe that the insurer was insolvent or was about to become insolvent; or

(d) The creditor receiving it was an officer, or any employee or attorney or other person who was in fact in a position of comparable influence on the insurer to an officer, whether or not he held such position, or any shareholder holding directly or indirectly more than five percent of any class of any equity security issued by the insurer, or any other person, firm, corporation, association, or aggregation of persons with whom the insurer did not deal at arm's length.

(3) If the preference is voidable, the liquidator may recover the property or, if it has been converted, its value, from any person who has received or converted the property; except, if a bona fide purchaser or lienholder has given less than fair equivalent value, he shall have a lien upon the property to the extent of the consideration actually given by him. If a preference by way of lien or security title is voidable, the court may on due notice order the lien or title to be preserved for the benefit of the estate, in which event the lien or title shall pass to the liquidator.

b. (1) A transfer of property, other than real property, shall be deemed to be made or suffered when it becomes so far perfected that no subsequent lien obtainable by legal or equitable proceedings on a simple contract could become superior to the rights of the transferee.

(2) A transfer of real property shall be deemed to be made or suffered when it becomes so far perfected that no subsequent bona fide purchaser from the insurer could obtain rights superior to the rights of the transferee.

(3) A transfer which creates an equitable lien shall not be deemed to be perfected if there are available means by which a legal lien could be created.

(4) A transfer not perfected prior to the filing of a petition for liquidation shall be deemed to be made immediately before the filing of the successful petition.

(5) The provisions of this subsection apply whether or not there are or were creditors who might have obtained liens or persons who might have become bona fide purchasers.

c. (1) A lien obtainable by legal or equitable proceedings upon a simple contract is one arising in the ordinary course of such proceedings upon the entry or docketing of a judgment or decree, or upon attachment, garnishment, execution or like process, whether before, upon or after judgment or decree and whether before or upon levy. It does not include liens which under applicable law are given a special priority over other liens which are prior in time.

(2) A lien obtainable by legal or equitable proceedings may become superior to the rights of a transferee, or a purchaser may obtain rights superior to the rights of a transferee within the meaning of subsection b. of this section, if such consequences would follow only from the lien or purchase itself, or from the lien or purchase followed by any step wholly within the control of the respective lienholder or purchaser, with or without the aid of ministerial action by public officials. Such a lien could not, however, become superior and such a purchase could not create superior rights for the purpose of subsection b. of this section through any acts subsequent to the obtaining of such a lien or subsequent to such a purchase which require the agreement or concurrence of any third party or which require any further judicial action or ruling.

d. A transfer of property for or on account of a new and contemporaneous consideration which is deemed under subsection b. of this section to be made or suffered after the transfer because of delay in perfecting it does not thereby become a transfer for or on account of an antecedent debt if any acts required by the applicable law to be performed in order to perfect the transfer as against liens or bona fide purchasers' rights are performed within 21 days or any period expressly allowed by the law, whichever is less. A transfer to secure a future loan, if such a loan is actually made, or a transfer which becomes security for a future loan, shall have the same effect as a transfer for or on account of a new and contemporaneous consideration.

e. If any lien deemed voidable under paragraph (2) of subsection a. of this section has been dissolved by the furnishing of a bond or other obligation, the surety on which has been indemnified directly or indirectly by the transfer of, or the creation of a lien upon, any property of an insurer before the filing of a petition under this act which results in a liquidation order, the indemnifying transfer or lien shall also be deemed voidable.

f. The property affected by any lien deemed voidable under subsections a. and e. of this section shall be discharged from that lien, and that property and any of the indemnifying property transferred to or for the benefit of a surety shall pass to the liquidator, except that the court may on due notice order any such lien to be preserved for the benefit of the estate and the court may direct that such conveyance be executed as may be proper or adequate to evidence the title of the liquidator.

g. The Superior Court shall have summary jurisdiction of any proceeding by the liquidator to hear and determine the rights of any parties under this section. Reasonable notice of any hearing in the proceeding shall be given to all parties in interest, including the obligee of a releasing bond or other like obligation. If an order is entered for the recovery of indemnifying property in kind or for the avoidance of an indemnifying lien, the court, upon application of any party in interest, shall in the same proceeding ascertain the value of the property or lien, and if the value is less than the amount for which the property is indemnified or less than the amount of the lien, the transferee or lienholder may elect to retain the property or lien upon payment of its value, as ascertained by the court, to the liquidator, within a reasonable time as the court shall fix.

h. The liability of the surety under a releasing bond or other like obligation shall be discharged to the extent of the value of the indemnifying property recovered or the indemnifying lien nullified and avoided by the liquidator, or where the property is retained under subsection g. of this section, to the extent of the amount paid to the liquidator.

i. If a creditor has been preferred, and afterward in good faith gives the insurer further credit without security of any kind, for property which becomes a part of the insurer's estate, the amount of the new credit remaining unpaid at the time of the petition may be set off against the preference which would otherwise be recoverable from him.

j. If an insurer shall, directly or indirectly, within four months before the filing of a successful petition for liquidation under this act, or at any time in contemplation of a proceeding to liquidate it, pay money or transfer property to an attorney-at-law for services rendered or to be rendered, the transactions may be examined by the court on its own motion or shall be examined by the court on petition of the liquidator and shall be held valid only to the extent of a reasonable amount to be determined by the court, and the excess may be recovered by the liquidator for the benefits of the estate. If, however, the attorney is in a position of influence on the insurer or an affiliate thereof, payment of any money or the transfer of any property to the attorney-at-law for services rendered or to be rendered shall be governed by the provision of subparagraph (d) of paragraph (2) of subsection a. of this section.

k. (1) Every officer, manager, employee, shareholder, member, subscriber, attorney or any other person acting on behalf of the insurer who knowingly participates in giving any preference when he has reasonable cause to believe the insurer is or is about to become insolvent at the time of the preference shall be personally liable to the liquidator for the amount of the preference. It is permissible to infer that there is a reasonable cause to so believe if the transfer was made within four months before the date of filing of this successful petition for liquidation.

(2) Every person receiving any property from the insurer or the benefit thereof as a preference voidable under subsection a. of this section shall be personally liable therefor and shall be bound to account to the liquidator.

(3) Nothing in this subsection shall prejudice any other claim by the liquidator against any person.

l. (1) A receiver for an insurer-member subject to a delinquency shall not void a transfer made to a federal home loan bank provided that the transfer:

(a) is made in the ordinary course of business and in compliance with the advance agreement with that federal home loan bank; and

(b) is valid pursuant to State law and the "Federal Home Loan Bank Act" (12 U.S.C. s.1421 et seq.).

(2) A receiver shall not void a redemption or repurchase of any stock or equity securities made by the federal home loan bank if the redemption or repurchase: (a) is made within 12 months of the commencement of the delinquency proceeding; or (b) has received prior approval of the receiver.

(3) A receiver may void any transfer if the transfer is made with actual intent to hinder, delay, or defraud the insurer-member, a receiver appointed for the insurer-member, or existing or future creditors.

§ 17B:32-58 Claims of creditor

28. a. No claims of a creditor who has received or acquired a preference, lien, conveyance, transfer, assignment or encumbrance voidable under this act, shall be allowed unless he surrenders the preference, lien, conveyance, transfer, assignment or encumbrance. If the avoidance is effected by a proceeding in which a final judgment has been entered, the claim shall not be allowed unless the money is paid or the property is delivered to the liquidator within 30 days from the date of the entering of the final judgment, except that the court having jurisdiction over the liquidation may allow further time if there is an appeal or other continuation of the proceeding.

b. A claim allowable under subsection a. of this section by reason of the avoidance, whether voluntary or involuntary, of a preference, lien, conveyance, transfer, assignment or encumbrance, may be filed as an excused last filing under section 34 of this act if filed within 30 days from the date of the avoidance, or within the further time allowed by the court under subsection a. of this section.

§ 17B:32-59 Mutual debts, credits

29. a. Mutual debts or mutual credits, whether arising out of one or more contracts between the insurer and another person in connection with any action or proceeding under this act, shall be set off and the balance only shall be allowed or paid, except as provided in subsections b., c. and d. of this section and section 32 of this act.

b. No setoff shall be allowed in favor of any person if:

(1) The obligation of the insurer to the person would not at the date of the filing of a petition for liquidation entitle the person to share as a claimant in the assets of the insurer; or

(2) The obligation of the insurer to the person was purchased by or transferred to the person with a view to its being used as a setoff; or

(3) The obligation of the insurer is owed to an affiliate of such person, or any other entity or association other than the person; or

(4) The obligation of the person is owed to an affiliate of the insurer, or any other entity or association other than the insurer; or

(5) The obligation of the person is to pay an assessment levied against the members or subscribers of the insurer, or is to pay a balance upon a subscription to the capital stock of the insurer, or is in any other way in the nature of a capital contribution; or

(6) The obligations between the person and the insurer arise from business which is both ceded to and assumed from the insurer except that the rehabilitator may, with regard to such business, allow certain setoffs in rehabilitation if he finds the allowance of said setoffs appropriate.

c. The liquidator shall provide persons that assumed business from the insurer with accounting statements identifying debts which are currently due and payable. Such persons may set off against such debts only mutual credits which are currently due and payable by the insurer to such persons for the period covered by the accounting statement.

d. A person that ceded business to the insurer may set off debts due the insurer against only those mutual credits which the person has paid or which have been allowed in the insurer's delinquency proceedings.

e. Notwithstanding the foregoing, a setoff of sums due on obligations in the nature of those set forth in paragraph (6) of subsection b. of this section shall be allowed for those sums accruing from business written if: the contracts were entered into, renewed or extended with the express written approval of the commissioner or other insurance regulator of the state of domicile of the insolvent insurer, when in the judgment of that commissioner or regulator it was necessary to provide reinsurance in order to prevent or mitigate a threatened impairment or insolvency of a domiciliary insurer in connection with the exercise of the commissioner's or regulator's regulatory responsibilities.

f. The provisions of this section shall become effective on the 180th day following the effective date of this act and shall apply to all contracts entered into, renewed, extended or amended on or after that 180th day, and to debts or credits arising from any business written or transactions occurring after that 180th day pursuant to any contract, including any contract in existence prior to that 180th day, and shall supersede any agreements or contractual provisions which might be construed to enlarge the setoff rights of any person under any contract with the insurer. For purposes of this section, any change in the terms of, or consideration for, any such contract shall be deemed an amendment.

§ 17B:32-60 Report by liquidator

30. a. As soon as practicable, but not more than two years from the date of an order of liquidation under section 17 of this act of an insurer issuing assessable policies, the liquidator shall make a report to the court setting forth:

(1) The reasonable value of the assets of the insurer;

(2) The insurer's probable total liabilities;

(3) The probable aggregate amount of the assessment necessary to pay all claims of creditors and expenses in full, including expenses of administration and costs of collecting the assessment; and

(4) A recommendation as to whether or not an assessment should be made and in what amount.

b. (1) Upon the basis of the report provided in subsection a. of this section, the Superior Court may levy one or more assessments against all members of the insurer who are subject to assessment.

(2) Subject to any applicable legal limits on assessability, the aggregate assessment shall be for the amount that the sum of the probable liabilities, the expenses of administration, and the estimated cost of collection of the assessment, exceeds the value of existing assets, with due regard being given to assessments that cannot be collected economically.

c. After levy of assessment under subsection b. of this section, the liquidator shall issue an order directing each member who has not paid the assessment pursuant to the order, to show cause why the liquidator should not pursue a judgment therefor.

d. The liquidator shall give notice of the order to show cause by publication and by first class mail to each member liable thereunder mailed to his last known address as it appears on the insurer's records, at least 20 days before the return day of the order to show cause.

e. (1) If a member does not appear and serve duly verified objections upon the liquidator on or before the return day of the order to show cause under subsection c. of this section, the court shall make an order adjudging the member liable for the amount of the assessment against him pursuant to subsection c. of this section, together with costs, and the liquidator shall have a judgment against the member therefor.

(2) If on or before such return day, the member appears and serves duly verified objections upon the liquidator, the commissioner may hear and determine the matter or may appoint a referee to hear it and make such order as the facts warrant. In the event that the commissioner determines that such objections do not warrant relief from assessment, the member may request the court to review the matter and vacate the order to show cause.

f. The liquidator may enforce any order or collect any judgment under subsection e. of this section by any lawful means.

§ 17B:32-61 Amount recoverable not affected by delinquency proceedings

31. The amount recoverable by the liquidator from reinsurers shall not be reduced as a result of the delinquency proceedings, regardless of any provision in the reinsurance contract or other agreement. Payment made directly to an insured or other creditor shall not diminish the reinsurer's obligation to the insurer's estate except when the reinsurance contract provided for direct coverage of a named insured and the payment was made in discharge of that obligation.

§ 17B:32-62 Payment of unpaid premium, violations; penalties; appeals

32. a. (1) An agent, broker, premium finance company, or any other person, other than the insured, responsible for the payment of a premium shall be obligated to pay any unpaid premium for the full policy term due the insurer at the time of the declaration of insolvency, whether earned or unearned, as shown on the records of the insurer. The liquidator shall also have the right to recover from such person any part of an unearned premium that represents commission of such person. Credits or setoffs or both shall not be allowed to an agent, broker or premium finance company for any amounts advanced to the insurer by the agent, broker or premium finance company on behalf of, but in the absence of a payment by, the insured.

(2) An insured shall be obligated to pay any unpaid earned premium due the insurer, as shown on the records of the insurer, at the time of the declaration of insolvency.

b. Upon satisfactory evidence of a violation of this section, the commissioner may pursue either one or both of the following courses of action:

(1) Suspend or revoke or refuse to renew the licenses of such offending party or parties.

(2) After a hearing, impose an administrative penalty of not more than $10,000 for each violation of this section.

c. Before the commissioner takes any action as set forth in subsection b. of this section, he shall give written notice to the person, company, association or exchange accused of violating the law, stating specifically the nature of the alleged violation; and fixing a time and place, at least 10 days thereafter, when a hearing on the matter shall be held. After that hearing, or upon failure of the accused to appear at the hearing, the commissioner, if he shall find a violation, shall impose those penalties under subsection b. of this section as he deems advisable.

d. When the commissioner takes action in any or all of the ways set out in subsection b. of this section, the party aggrieved may appeal from that action to the Superior Court.

§ 17B:32-63 Proposal to disburse assets

33. a. Within 120 days of a final determination of insolvency of an insurer by a court of competent jurisdiction of this State, the liquidator shall make application to the court for approval of a proposal to disburse assets out of marshalled assets, from time to time as those assets become available, to a guaranty association or foreign guaranty association having obligations because of that insolvency. If the liquidator determines that there are insufficient assets to disburse, the application required by this section shall be considered satisfied by a filing by the liquidator stating the reasons for this determination.

b. The proposal shall at least include provisions for:

(1) Reserving amounts for the payment of expenses of administration and the payment of claims of secured creditors, to the extent of the value of the security held, and claims falling within Classes 1 and 2 of the priorities of distribution established pursuant to paragraphs (1) and (2) of subsection a. of section 41 of this act;

(2) Disbursement of the assets marshalled to date and subsequent disbursement of assets as they become available;

(3) Equitable allocation of disbursements to each guaranty association and foreign guaranty association entitled thereto;

(4) The securing by the liquidator from each guaranty association and foreign guaranty association entitled to disbursements pursuant to this section of an agreement to return to the liquidator such assets, together with income earned on assets previously disbursed, as may be required to pay claims of secured creditors and claims falling within the priorities of distribution established in section 41 of this act in accordance with those priorities. No bond shall be required of any guaranty association or foreign guaranty association; and

(5) A full report to be made by each guaranty association and foreign guaranty association to the liquidator accounting for all assets so disbursed to the association, all disbursements made therefrom, any interest earned by the association on those assets and any other matter as the court may direct.

c. The liquidator's proposal shall provide for disbursements to each guaranty association and foreign guaranty association in amounts estimated at least equal to the claim payments made or to be made thereby for which such association could assert a claim against the liquidator, and shall further provide that if the assets available for disbursement from time to time do not equal or exceed the amount of those claims payments made or to be made by the association, then disbursements shall be in the amount of available assets.

d. Notice of application pursuant to this section shall be given to the guaranty association and foreign guaranty associations and the commissioners or other insurance regulators of each of the states. Any such notice shall be deemed to have been given when deposited in the United States certified mails, first class postage prepaid, at least 30 days prior to submission of the application to the court. Action on the application may be taken by the court provided the above required notice has been given and provided further that the liquidator's proposal complies with paragraphs (1) and (2) of subsection b. of this section.

§ 17B:32-64 Filing of proof of claims

34. a. Proof of all claims shall be filed with the liquidator in the form required by section 35 of this act on or before the last day for filing specified in the notice required under section 21 of this act, except that proof of claims for cash surrender values or other investment values in life insurance and annuities need not be filed unless the liquidator expressly so requires.

b. The liquidator may permit a claimant making a late filing to share in distributions, whether past or future, as if he were not late, to the extent that any such payment will not prejudice the orderly administration of the liquidation, under the following circumstances:

(1) The existence of the claim was not known to the claimant and he filed his claim as promptly thereafter as reasonably possible after learning of it;

(2) A transfer to a creditor was avoided under sections 25 through 27 of this act, or was voluntarily surrendered under section 28 of this act, and that the filing satisfies the conditions of section 28 of this act;

(3) The valuation under section 40 of this act, of any security held by a secured creditor shows a deficiency, which is filed within 30 days after the valuation; and

c. The liquidator shall permit late filing claims to share in distributions, whether past or future, as if they were not late, if they are claims of a guaranty association or foreign guaranty association for reimbursement of covered claims paid or expenses incurred, or both, subsequent to the last day for filing if those payments were made and expenses incurred as provided by law.

d. The liquidator may consider any claim filed late which is not covered by subsection b. of this section, and permit it to receive distributions which are subsequently declared on any claims of the same or lower priority if the payment does not prejudice the orderly administration of the liquidation. The late-filing claimant shall receive, at each distribution, the same percentage of the amount allowed on his claim as is then being paid to claimants of any lower priority. This shall continue until his claim has been paid in full.

§ 17B:32-65 Statement to proof of claim

35. a. Proof of claim shall consist of a statement signed by the claimant that includes all of the following that are applicable:

(1) The particulars of the claim including the consideration given for it;

(2) The identity and amount of the security on the claim;

(3) The payments made on the debt, if any;

(4) That the sum claimed is justly owing and that there is no setoff, counterclaim or defense to the claim;

(5) Any right of priority of payment or other specific right asserted by the claimants;

(6) A copy of the written instrument which is the foundation of the claim; and

(7) The name and address of the claimant and the attorney who represents him, if any.

b. No claim need be considered or allowed if it does not contain all the information in subsection a. of this section which may be applicable. The liquidator may require that a prescribed form be used, and may require that other information and documents be included.

c. At any time the liquidator may request the claimant to present information or evidence supplementary to that required under subsection a. of this section and may take testimony under oath, require production of affidavits or depositions, or otherwise obtain additional information or evidence.

d. No judgment or order against an insured or the insurer entered after the date of filing of a successful petition for liquidation, and no judgment or order against an insured or the insurer entered at any time by default or by collusion need be considered as evidence of liability or of quantum of damages. No judgment or order against an insured or the insurer entered within four months before the filing of the petition need be considered as evidence of liability or of the quantum of damages.

e. All claims of a guaranty association or foreign guaranty association shall be in such form and contain such substantiation as may be agreed to by the association and the liquidator.

§ 17B:32-66 Contingent, absolute, limited claims

36. a. A claim may be allowed even if contingent, if it is filed in accordance with section 34 of this act. It may be allowed and may participate in all distributions declared after it is filed to the extent that it does not prejudice the orderly administration of the liquidation.

b. Claims that are due except for the passage of time shall be treated as absolute claims are treated, except that such claims may be discounted at a rate of interest determined by the commissioner.

c. Claims made under employment contracts by directors, principal officers, or persons in fact performing similar functions or having similar powers are limited to payment for services rendered prior to the issuance of any order of rehabilitation or liquidation under section 12 or 17 of this act.

§ 17B:32-67 Third party, insured claims

37. a. Whenever any third party asserts a cause of action against an insured of an insurer in liquidation, the third party may file a claim with the liquidator.

b. Whether or not the third party files a claim, the insured may file a claim on its own behalf in the liquidation. If the insured fails to file a claim by the date for filing claims specified in the order of liquidation or within 60 days after mailing of the notice required by section 21 of this act, whichever is later, he is an unexcused late filer.

c. The liquidator shall make his recommendations to the court under section 42 of this act, for the allowance of an insured's claim under subsection b. of this section after consideration of the probable outcome of any pending action against the insured on which the claim is based, the probable damages recoverable in the action and the probable costs and expenses of defense. After allowance by the court, the liquidator shall withhold any dividends payable on the claim, pending the outcome of litigation and negotiation with the insured. Whenever it seems appropriate, he shall reconsider the claim on the basis of additional information and amend his recommendations to the court. The insured shall be afforded the same notice and opportunity to be heard on all changes in the recommendation as in its initial determination. The court may amend its allowance as it deems appropriate. As claims against the insured are settled or barred, the insured shall be paid from the amount withheld the same percentage dividend as was paid on other claims of like property, based on the lesser of: (1) the amount actually recovered from the insured by action or paid by agreement plus the reasonable costs and expense of defense, or (2) the amount allowed on the claims by the court.

After all claims are settled or barred, any sum remaining from the amount withheld shall revert to the undistributed assets of the insurer. Delay in final payment under this subsection shall not be a reason for unreasonable delay of final distribution and discharge of the liquidator.

d. If several claims founded upon one policy are filed, whether by third parties or as claims by the insured under this section, and the aggregate allowed amount of the claims to which the same limit of liability in the policy is applicable exceeds that limit, each claim as allowed shall be reduced in the same proportion so that the total equals the policy limit. Claims by the insured shall be evaluated as in subsection c. of this section. If any insured's claim is subsequently reduced under subsection c., the amount thus freed shall be apportioned ratably among the claims which have been reduced under this subsection.

e. No claim may be presented under this section if it is or may be covered by any guaranty association or foreign guaranty association.

§ 17B:32-68 Denial of claims

38. a. When a claim is denied in whole or in part by the liquidator, written notice of the determination shall be given to the claimant or his attorney by first class mail at the address shown in the proof of claim. Within 60 days from the mailing of the notice, the claimant may file his objections with the liquidator. If no such filing is made, the claimant may not further object to the determination.

b. Whenever objections are filed with the liquidator and the liquidator does not alter his denial of the claim as a result of the objections, the liquidator shall ask the court for a hearing as soon as practicable and give notice of the hearing by first class mail to the claimant or his attorney and to any other persons directly affected, not less than 10 nor more than 30 days before the date of the hearing. The matter may be heard by the court or by a court-appointed referee who shall submit findings of fact along with his recommendation.

§ 17B:32-69 Proving, filing of claim of subrogee

39. Whenever a creditor, whose claim against an insurer is secured, in whole or in part, by the undertaking of another person, fails to prove and file that claim, the other person may do so in the creditor's name, and shall be subrogated to the rights of the creditor, whether the claim has been filed by the creditor or by the other person in the creditor's name, to the extent that he discharges the undertaking. In the absence of an agreement with the creditor to the contrary, the other person shall not be entitled to any distribution, however, until the amount paid to the creditor on the undertaking plus the distributions paid on the claim from the insurer's estate to the creditor equals the amount of the entire claim of the creditor. Any excess received by the creditor shall be held by him in trust for that other person. The term "other person," as used in this section, shall not apply to a guaranty association or foreign guaranty association.

§ 17B:32-70 Determination of value of security

40. a. The value of any security held by a secured creditor shall be determined in one of the following ways, as the court may direct:

(1) By converting the same into money according to the terms of the agreement pursuant to which the security was delivered to the creditor; or

(2) By agreement, arbitration, compromise or litigation between the creditor and the liquidator.

b. The determination shall be under the supervision and control of the court with due regard for the recommendation of the liquidator. The amount so determined shall be credited upon the secured claim, and any deficiency shall be treated as an unsecured claim. If the claimant shall surrender his security to the liquidator, the entire claim shall be allowed as if unsecured.

§ 17B:32-71 Priority of distribution of claims

41. a. The priority of distribution of claims from the insurer's estate shall be in accordance with the order in which each class of claims is set forth in this section. Every claim in each class shall be paid in full or adequate funds or other assets retained for such payment before the members of the next class receive any payment. No subclasses shall be established within any class. The order of distribution of claims shall be:

(1) Class 1. The costs and expenses of administration during rehabilitation and liquidation, including but not limited to the following:

(a) The actual and necessary costs of preserving or recovering the assets of the insurer;

(b) Compensation for all authorized services rendered in the rehabilitation and liquidation;

(c) Any necessary filing fees;

(d) The fees and mileage payable to witnesses;

(e) Authorized reasonable attorney's fees and other professional services rendered in the rehabilitation and liquidation;

(f) The reasonable expenses of a guaranty association or foreign guaranty association for unallocated loss adjustment expenses. For purposes of this subparagraph, "unallocated loss adjustment expenses" means expenses associated with claims settlement due to the insolvency of a member insurer that cannot be assigned to an individual claim.

(2) Class 2. Reasonable compensation to employees for services performed to the extent that they do not exceed two months of monetary compensation and represent payment for services performed within one year before the filing of the petition for liquidation or, if rehabilitation preceded liquidation, within one year before the filing of the petition for rehabilitation. Principal officers and directors shall not be entitled to the benefit of this priority except as otherwise approved by the liquidator and the court. Such priority shall be in lieu of any other similar priority which may be authorized by law as to wages or compensation of employees.

(3) Class 3. All claims under policies, including claims of the federal or any state or local government for losses incurred and including third party claims and all claims of a guaranty association or foreign guaranty association, but excluding amounts recoverable under Class 1 claims pursuant to paragraph (1) of this subsection. All claims under life insurance and annuity policies, whether for death proceeds, annuity proceeds, or investment values, shall be treated as loss claims. For the purpose of this section, life insurance and annuity policies shall include, but not be limited to, any and all individual and group annuity and investment contracts issued by an insurer under or in connection with an employee benefit plan or program to which section 401, 403(b), 408 or 457 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.401, 403(b), 408 or 457) relates, to whomever or whatever persons or entities such contracts are issued, together with all individual annuities issued pursuant to any such contracts. That portion of any loss, indemnification for which is provided by other benefits or advantages recovered by the claimant, shall not be included in this class, other than benefits or advantages recovered or recoverable in discharge of familial obligation of support or by way of succession at death or as proceeds of life insurance, or as gratuities. No payment by an employer to his employee shall be treated as a gratuity. Claims of enrollees, members or subscribers, and their beneficiaries, of a fraternal benefit society, mutual benefit association, hospital service corporation, medical service corporation, health service corporation, dental service corporation, dental plan organization or health maintenance organization, as the case may be, shall have the same priority established by this section for policyholders and beneficiaries of insurers. Any provider of health care services to an enrollee, member or subscriber shall have a priority of distribution of general assets immediately following that of enrollees, members or subscribers and their beneficiaries, and immediately preceding Class 4 claims under paragraph (4) of this subsection.

(4) Class 4. Claims under nonassessable policies for unearned premium or other premium refunds and claims of general creditors including claims of ceding and assuming companies in their capacity as such.

(5) Class 5. Claims of the federal or any state or local government except those under Class 3 claims pursuant to paragraph (3) of subsection a. of this section. Claims, including those of any governmental body for a penalty or forfeiture, shall be allowed in this class only to the extent of the pecuniary loss sustained from the act, transaction or proceeding out of which the penalty or forfeiture arose, with reasonable and actual costs occasioned thereby. The remainder of such claims shall be postponed to the Class 8 claims under paragraph (8) of this subsection.

(6) Class 6. Claims filed late or any other claims other than Class 7 and Class 8 claims under paragraphs (7) and (8) of this subsection.

(7) Class 7. Surplus or contribution notes, or similar obligations, and premium refunds on assessable policies. Payments to members of domestic mutual insurance companies shall be limited in accordance with law.

(8) Class 8. The claims of shareholders or other owners in their capacity as shareholders.

b. Every claim under a separate account agreement providing, in effect, that the assets in the separate account shall not be chargeable with liabilities arising out of any other business of the insurer shall be satisfied out of the assets in the separate account equal to the reserves maintained in that account for that agreement. To the extent, if any, that a claim under a separate account agreement is not fully discharged by such assets, such claim shall be treated as a Class 3 claim pursuant to paragraph (3) of subsection a. of this section against the estate of the insurer.

§ 17B:32-72 Review of claims

42. a. The liquidator shall review all claims duly filed in the liquidation and shall make such further investigation as he shall deem necessary. He may compound, compromise or in any other manner negotiate the amount for which claims will be recommended to the court except where the liquidator is required by law to accept claims as settled by any person or organization, including any guaranty association or foreign guaranty association. Unresolved disputes shall be determined under section 38 of this act. As soon as practicable, he shall present to the court a report of the claims against the insurer with his recommendations. The report shall include the name and address of each claimant and the amount of the claim finally recommended, if any. If the insurer has issued annuities or life insurance policies, the liquidator shall report the persons to whom, according to the records of the insurer, amounts are owed as cash surrender values or other investment value and the amounts owed.

b. The court may approve, disapprove or modify the report on claims by the liquidator. Reports that are not modified by the court within a period of 60 days following submission by the liquidator shall be treated by the liquidator as allowed claims, subject thereafter to later modification or to rulings made by the court pursuant to section 38 of this act. No claim under a policy of insurance shall be allowed for an amount in excess of the applicable policy limits.

§ 17B:32-73 Payment of distributions

43. Under the direction of the court, the liquidator shall pay distributions in a manner that will assure the proper recognition of priorities and a reasonable balance between the expeditious completion of the liquidation and the protection of unliquidated and undetermined claims, including third party claims. Distribution of assets in kind may be made at valuations set by agreement between the liquidator and the creditor and approved by the court.

§ 17B:32-74 Distribution of unclaimed funds

44. Distribution of all unclaimed funds subject to distribution remaining in the liquidator's hands when he is ready to apply to the court for discharge, including the amount distributable to any creditor, shareholder, member or other person who is unknown or cannot be found, shall be made in accordance with the "Uniform Unclaimed Property Act (1981)," R.S. 46:30B-1 et seq.

§ 17B:32-75 Application for discharge

45. a. When all assets justifying the expense of collection and distribution have been collected and distributed under this act, the liquidator shall apply to the court for discharge. The court may grant the discharge and make any other orders, including an order to transfer any remaining funds that are uneconomic to distribute, as may be deemed appropriate.

b. Any other person may apply to the court at any time for an order under subsection a. of this section. If the application is denied, the applicant shall pay the costs and expenses of the liquidator in resisting the application, including reasonable attorney's fees.

§ 17B:32-76 Petition for reopening of proceedings

46. After the liquidation proceeding has been terminated and the liquidator discharged, the commissioner or other interested party may at any time petition the Superior Court to reopen the proceedings for good cause, including the discovery of additional assets. If the court is satisfied that there is justification for reopening, it shall so order.

§ 17B:32-77 Retaining, destruction of records

47. Whenever it shall appear to the commissioner that the records of any insurer in the process of liquidation or completely liquidated are no longer useful, he may recommend to the court and the court shall direct what records should be retained for future reference and what should be destroyed.

§ 17B:32-78 Audits of receiverships

48. The Superior Court may, as it deems appropriate, cause audits to be made of the books of the commissioner relating to any receivership established under this act, and a report of each audit shall be filed with the commissioner and with the court. The books, records and other documents of the receivership shall be made available to the auditor at any time without notice. The expense of each audit shall be considered a cost of administration of the receivership.

§ 17B:32-79 Grounds for appointment of conservator

49. a. If a domiciliary liquidator has not been appointed, the commissioner may apply to the Superior Court by verified petition for an order directing him to act as conservator to conserve the property of an alien insurer not domiciled in this state or a foreign insurer on any one or more of the following grounds:

(1) Any of the grounds in section 11 of this act;

(2) That any of its property has been sequestered by official action in its domiciliary state, or in any other state;

(3) That enough of its property has been sequestered in a foreign country to give reasonable cause to fear that the insurer is or may become insolvent;

(4) (a) That its certificate of authority to do business in this State has been revoked or that none was ever issued; and

(b) That there are residents of this State with outstanding claims or outstanding policies.

b. When an order is sought under subsection a. of this section, the court shall give the insurer notice and time to respond thereto as is reasonable under the circumstances.

c. The court may issue the order in whatever terms it shall deem appropriate. The filing or recording of the order with the clerk of the Superior Court or the recorder of deeds of the county in which the principal business of the insurer is located, shall impart the same notice as a deed, bill of sale or other evidence of title duly filed or recorded with that recorder of deeds would have imparted.

d. The conservator may at any time petition for and the court may grant an order under section 50 of this act to liquidate assets of a foreign or alien insurer under conservation, or, if appropriate, for an order under section 52 of this act, to be appointed ancillary receiver.

e. The conservator may at any time petition the court for an order terminating conservation of an insurer. If the court finds that the conservation is no longer necessary, it shall order that the insurer be restored to possession of its property and the control of its business. The court may also make such finding and issue such order at any time upon motion of any interested party, but if such motion is denied all costs shall be assessed against that party.

§ 17B:32-80 Grounds for liquidation of assets of insurer

50. a. If no domiciliary receiver has been appointed, the commissioner may apply to the Superior Court by verified petition for an order directing him to liquidate the assets found in this State of a foreign insurer or an alien insurer not domiciled in this State, on any of the following grounds:

(1) Any of the grounds in section 11 or 16 of this act; or

(2) Any of the grounds specified in paragraphs (2) through (4) of subsection a. of section 49 of this act.

b. When an order is sought under subsection a. of this section, the court shall give the insurer notice and time to respond thereto as is reasonable under the circumstances.

c. If it shall appear to the court that the best interests of creditors, policyholders and the public require, the court may issue an order to liquidate in whatever terms it shall deem appropriate. The filing or recording of the order with the clerk of the Superior Court or the recorder of deeds of the county in which the principal business of the insurer is located or the county in which its principal office or place of business is located, shall impart the same notice as a deed, bill of sale or other evidence of title duly filed or recorded with that recorder of deeds would have imparted.

d. If a domiciliary liquidator is appointed in a reciprocal state while a liquidation is proceeding under this section, the liquidator under this section shall thereafter act as ancillary receiver under section 52 of this act. If a domiciliary liquidator is appointed in a nonreciprocal state while a liquidation is proceeding under this section, the liquidator under this section may petition the court for permission to act as ancillary receiver under section 52 of this act.

e. On the same grounds as are specified in subsection a. of this section, the commissioner may petition any appropriate federal district court to be appointed receiver to liquidate that portion of the insurer's assets and business over which the court will exercise jurisdiction, or any lesser part thereof that the commissioner deems desirable for the protection of the policyholders and creditors in this State.

f. The court may order the commissioner, when he has liquidated the assets of a foreign or alien insurer under this section, to pay claims of residents of this State against the insurer under such rules as to the liquidation of insurers under this act as are otherwise compatible with the provisions of this section.

§ 17B:32-81 Vesting of title with domiciliary liquidator

51. a. The domiciliary liquidator of an insurer domiciled in a reciprocal state shall, except as to special deposits and security on secured claims under subsection c. of section 52 of this act, be vested by operation of law with the title to all of the assets, property, contracts and rights of action, agents' balances, and all of the books, accounts and other records of the insurer located in this State. The date of vesting shall be the date of the filing of the petition, if that date is specified by the domiciliary law for the vesting of property in the domiciliary state. Otherwise, the date of vesting shall be the date of entry of the order directing possession to be taken. The domiciliary liquidator shall have the immediate right to recover balances due from agents and to obtain possession of the books, accounts and other records of the insurer located in this State. He also shall have the right to recover all other assets of the insurer located in this State, subject to the provisions of section 52 of this act.

b. If a domiciliary liquidator is appointed for an insurer not domiciled in a reciprocal state, the commissioner of this State shall be vested by operation of law with the title to all of the property, contracts and right of action, and all of the books, accounts and other records of the insurer located in this State, at the same time that the domiciliary liquidator is vested with title in the domicile. The commissioner of this State may petition for a conservation or liquidation order under section 49 or 50 of this act, or for an ancillary receivership under section 52 of this act, or after approval by the Superior Court may transfer title to the domiciliary liquidator, as the interests of justice and the equitable distribution of the assets require.

c. Claimants residing in this State may file claims with the liquidator or ancillary receiver, if any, in this State or with the domiciliary liquidator, if the domiciliary law permits. The claims shall be filed on or before the last date fixed for the filing of claims in the domiciliary liquidation proceedings.

§ 17B:32-82 Petition for appointment as ancillary receiver

52. a. If a domiciliary liquidator has been appointed for an insurer not domiciled in this State, the commissioner may file a petition with the Superior Court requesting appointment as ancillary receiver in this State:

(1) If he finds that there are sufficient assets of the insurer located in this State to justify the appointment of an ancillary receiver;

(2) If the protection of creditors or policyholders in this State so requires.

b. The court may issue an order appointing an ancillary receiver in whatever terms it shall deem appropriate. The filing or recording of the order with the recorder of deeds in this State imparts the same notice as a deed, bill of sale or other evidence of title duly filed or recorded with that recorder of deeds.

c. When a domiciliary liquidator has been appointed in a reciprocal state, then the ancillary receiver appointed in this State may, whenever necessary, aid and assist the domiciliary liquidator in recovering assets of the insurer located in this State. The ancillary receiver shall, as soon as practicable, liquidate from their respective securities those special deposit claims and secured claims which are proved and allowed in the ancillary proceedings in this State, and shall pay the necessary expenses of the proceedings. He shall promptly transfer all remaining assets, books, accounts and records to the domiciliary liquidator. Subject to this section, the ancillary receiver and his deputies shall have the same powers and be subject to the same duties with respect to the administration of assets as a liquidator of an insurer domiciled in this State.

d. When a domiciliary liquidator has been appointed in this State, ancillary receivers appointed in reciprocal states shall have, as to assets and books, accounts and other records in their respective states, corresponding rights, duties and powers to those provided in subsection c. of this section for ancillary receivers appointed in this State.

§ 17B:32-83 Institution of proceedings

53. The commissioner in his sole discretion may institute proceedings under sections 9 and 10 of this act at the request of the commissioner or other appropriate insurance official of the domiciliary state of any foreign or alien insurer having property located in this State.

§ 17B:32-84 Claims filed in liquidation proceedings begun in State

54. a. In a liquidation proceeding begun in this State against an insurer domiciled in this State, claimants residing in foreign countries or in states not reciprocal states must file claims in this State, and claimants residing in reciprocal states may file claims either with the ancillary receivers, if any, in their respective states, or with the domiciliary liquidator. Claims shall be filed on or before the last date fixed for the filing of claims in the domiciliary liquidation proceeding.

b. Claims belonging to claimants residing in reciprocal states may be proved either in the liquidation proceeding in this State as provided in this act, or in ancillary proceedings, if any, in the reciprocal states. If notice of the claims and opportunity to appear and be heard is afforded the domiciliary liquidator of this State as provided in subsection b. of section 55 of this act with respect to ancillary proceedings, the final allowance of claims by the courts in ancillary proceedings in reciprocal states shall be conclusive as to amount and as to priority against special deposits or other security located in such ancillary states, but shall not be conclusive with respect to priorities against general assets under section 41 of this act.

§ 17B:32-85 Claims filed in liquidation proceedings in reciprocal state

55. a. In a liquidation proceeding in a reciprocal state against an insurer domiciled in that state, claimants against the insurer who reside within this State may file claims either with the ancillary receiver, if any, in this State, or with the domiciliary liquidator. Claims shall be filed on or before the last dates fixed for the filing of claims in the domiciliary liquidation proceeding.

b. Claims belonging to claimants residing in this State may be proved either in the domiciliary state under the law of that state, or in ancillary proceedings, if any, in this State. If a claimant elects to prove his claim in this State, he shall file his claim with the liquidator in the manner provided in sections 34 and 35 of this act. The ancillary receiver shall make his recommendation to the court as under section 42 of this act. He shall also arrange a date for hearing if necessary under section 38 of this act and shall give notice to the liquidator in the domiciliary state, either by certified mail or by personal service at least 40 days prior to the date set for hearing. If the domiciliary liquidator, within 30 days after the giving of such notice, gives notice in writing to the ancillary receiver and to the claimant, either by certified mail or by personal service, of his intention to contest the claim, he shall be entitled to appear or to be represented in any proceeding in this State involving the adjudication of the claim.

c. The final allowance of the claim by the courts of this State shall be accepted as conclusive as to amount and as to priority against special deposits or other security located in this State.

§ 17B:32-86 Actions, proceedings prohibited during pendency of liquidation proceeding

56. During the pendency in this or any other state of a liquidation proceeding, whether called by that name or not, no action or proceeding in the nature of an attachment, garnishment or levy of execution shall be commenced or maintained in this State against the delinquent insurer or its assets.

§ 17B:32-87 Order of distribution of claims

57. a. In a liquidation proceeding in this State involving one or more reciprocal states, the order of distribution of the domiciliary state shall control as to all claims of residents of this and reciprocal states. All claims of residents of reciprocal states shall be given equal priority of payment from general assets regardless of where such assets are located.

b. The owners of special deposit claims against an insurer for which a liquidator is appointed in this or any other state shall be given priority against the special deposits in accordance with the laws governing the creation and maintenance of the deposits. If there is a deficiency in any deposit, so that the claims secured by it are not fully discharged from it, the claimants may share in the general assets, but the sharing shall be deferred until general creditors, and also claimants against other special deposits who have received smaller percentages from their respective special deposits, have been paid percentages of their claims equal to the percentage paid from the special deposit.

c. The owner of a secured claim against an insurer for which a liquidator has been appointed in this or any other state may surrender his security and file his claim as a general creditor, or the claim may be discharged by resort to the security in accordance with section 40 of this act, in which case the deficiency, if any, shall be treated as a claim against the general assets of the insurer on the same basis as claims of unsecured creditors, except to the extent such deficiency is treated as a Class 3 claim pursuant to subsection b. of section 41 of this act.

§ 17B:32-88 Failure of ancillary receiver to transfer assets

58. If an ancillary receiver in another state or foreign country, whether called by that name or not, fails to transfer to the domiciliary liquidator in this State any assets within his control, other than special deposits, diminished only by the expenses of the ancillary receivership, if any, the claims filed in the ancillary receivership, other than special deposit claims or secured claims, shall be Class 7 claims pursuant to paragraph (7) of subsection a. of section 41 of this act.

§ 17B:32-89 Persons entitled to protection

59. a. For the purpose of this section, the following persons are entitled to protection under subsection b. of this section:

(1) All receivers responsible for the conduct of a delinquency proceeding under this act including present and former receivers; and

(2) Their employees, including all present and former special deputies and assistant special deputies appointed by the commissioner and all persons whom the commissioner, special deputies, or assistant special deputies have employed to assist in a delinquency proceeding under this act. Attorneys, accountants, auditors and other professional persons or firms who are retained by the receiver as independent contractors and their employees shall not be considered employees of the receiver for purposes of this section.

b. No person covered under subsection a. of this section shall be liable, either personally or in his official capacity, for any claim for damage to or loss of property or personal injury or other civil liability caused by or resulting from any alleged act, error or omission of that person arising out of or by reason of his duties as a receiver, or employment by a receiver, except that nothing in this subsection shall be deemed to grant immunity to any person causing such damage by his willful, wanton or grossly negligent act of commission or omission.

§ 17B:32-90 Commissioner's powers unaffected

60. This act shall not be interpreted to limit the powers granted to the commissioner by other provisions of law.

§ 17B:32-91 Rules, regulations

61. The commissioner may, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), promulgate necessary rules and regulations to implement the provisions of this act.

§ 17B:32-92 Rights relative to certain financial agreements; terms defined.

1. a. (1) Notwithstanding any other provision of the "Life and Health Insurers Rehabilitation and Liquidation Act," P.L.1992, c.65 (C.17B:32-31 et seq.) to the contrary, a person shall not be stayed or prohibited from exercising:

(a) A contractual right to cause the termination, liquidation, acceleration or close out of any obligation under or in connection with a netting agreement or qualified financial contract with an insurer because of: (i) the insolvency, financial condition or default of the insurer at any time, provided that the right is enforceable under applicable law other than the provisions of P.L.1992, c.65 (C.17B:32-31 et seq.); or (ii) the commencement of a formal delinquency proceeding under P.L.1992, c.65 (C.17B:32-31 et seq.);

(b) Any right under a security arrangement relating to one or more netting agreements or qualified financial contracts; or

(c) Subject to subsection b. of section 29 of P.L.1992, c.65 (C.17B:32-59), any right to setoff or net out any termination value, payment amount, or other transfer obligation arising under or in connection with one or more netting agreements or qualified financial contracts where the counterparty or its guarantor is organized under the laws of the United States, a state, or a foreign jurisdiction approved by the Securities Valuation Office of the National Association of Insurance Commissioners as eligible for netting.

(2) If a counterparty to a master netting agreement or a qualified financial contract with an insurer subject to a proceeding under P.L.1992, c.65 (C.17B:32-31 et seq.) terminates, liquidates, closes out or accelerates the agreement or contract, damages shall be measured as of the date or dates of termination, liquidation, close out or acceleration. The amount of a claim for damages shall be actual direct compensatory damages.

b. Upon termination of a netting agreement or qualified financial contract, the net or settlement amount, if any, owed by a non-defaulting party to an insurer against which a petition has been filed pursuant to P.L.1992, c.65 (C.17B:32-31 et seq.) shall be transferred to the receiver for the insurer or as directed by the receiver for the insurer, even if the insurer is the defaulting party, notwithstanding any walkaway clause in the netting agreement or qualified financial contract. Any limited two-way payment or first method provision in a netting agreement or qualified financial contract with an insurer that has defaulted shall be deemed to be a full two-way payment or second method provision as against the defaulting insurer. Any such net or settlement amount shall, except to the extent it is subject to one or more secondary liens or encumbrances or rights of netting or setoff, be an asset of the insurer.

c. In making any transfer of a netting agreement or qualified financial contract of an insurer subject to a proceeding under P.L.1992, c.65 (C.17B:32-31 et seq.), the receiver shall either:

(1) Transfer to one party, other than an insurer subject to a proceeding under P.L.1992, c.65 (C.17B:32-31 et seq.), all netting agreements and qualified financial contracts between a counterparty or any affiliate of such counterparty and the insurer that is the subject of the proceeding, including: (a) all rights and obligations of each party under each such netting agreement and qualified financial contract; and (b) all property, including any guarantees or credit support documents, securing any claims of each party under each such netting agreement and qualified financial contract; or

(2) Transfer none of the netting agreements, qualified financial contracts, rights, obligations, or property referred to in subparagraph (b) of paragraph (1) of this subsection with respect to such counterparty and any affiliate of such counterparty.

d. If a receiver for an insurer makes a transfer of one or more netting agreements or qualified financial contracts, then the receiver shall use his or her best efforts to notify any person who is party to the netting agreements or qualified financial contracts of the transfer by 12 o'clock noon, the receiver's local time, on the business day following the transfer. For purposes of this subsection, "business day" means a day other than a Saturday, a Sunday, or any day on which either the New York Stock Exchange or the Federal Reserve Bank of New York is closed.

e. Notwithstanding any other provision of P.L.1992, c.65 (C.17B:32-31 et seq.), a receiver may not avoid a transfer of money or other property arising under or in connection with a netting agreement or qualified financial contract or any security arrangement relating to a netting agreement or qualified financial contract that is made before the commencement of a formal delinquency proceeding under P.L.1992, c.65 (C.17B:32-31 et seq.), except that a transfer may be avoided under section 25 of P.L.1992, c.65 (C.17B:32-55) if the transfer was made with actual intent to hinder, delay, or defraud the insurer, a receiver appointed for the insurer, or existing or future creditors.

f. (1) In exercising any rights of disaffirmance or repudiation of a receiver with respect to any netting agreement or qualified financial contract to which an insurer is a party, the receiver for the insurer shall either: (a) disaffirm or repudiate all netting agreements and qualified financial contracts between a counterparty or any affiliate of that counterparty and the insurer that is the subject of the proceeding; or (b) disaffirm or repudiate none of the netting agreements and qualified financial contracts referred to in subparagraph (a) of this paragraph with respect to that person or any affiliate of that person.

(2) Notwithstanding any other provision of P.L.1992, c.65 (C.17B:32-31 et seq.), any claim of a counterparty against the estate arising from the receiver's disaffirmance or repudiation of a netting agreement or qualified financial contract that has not been previously affirmed in the liquidation proceeding or in the immediately preceding rehabilitation proceeding shall be determined and shall be allowed or disallowed: (a) as if the claim had arisen before the date of the filing of the petition for liquidation; or (b) if a rehabilitation proceeding is converted to a liquidation proceeding, as if the claim had arisen before the date of the filing of the petition for rehabilitation.

(3) The amount of the claim identified in paragraph (2) of this subsection shall be the actual direct compensatory damages determined as of the date of the disaffirmance or repudiation of the netting agreement or qualified financial contract.

g. All rights of a counterparty under this section shall apply to a netting agreement and a qualified financial contract entered into on behalf of, or allocated to:

(1) the general account of the insurer; or

(2) a separate account of the insurer if the assets of the separate account are available only to a counterparty to a netting agreement and a qualified financial contract entered into on behalf of, or allocated to, that separate account.

h. As used in this section:

(1) "Actual direct compensatory damages" includes normal and reasonable costs of cover or other reasonable measures of damages utilized in the derivatives market for the contract and agreement claims, but does not include punitive and exemplary damages, damages for lost profit or lost opportunity, or damages for pain and suffering.

(2) "Commodity contract" means any of the following:

(a) A contract for the purchase or sale of a commodity for future delivery on, or subject to the rules of, a board of trade designated as a contract market by the Commodity Futures Trading Commission under the "Commodity Exchange Act," 7 U.S.C. s.1 et seq., or board of trade outside the United States;

(b) An agreement that is subject to regulation under section 19 of the "Commodity Exchange Act," 7 U.S.C. s.23, and that is commonly known to the commodities trade as a margin account, margin contract, leverage account, or leverage contract;

(c) An agreement or transaction that is subject to regulation under subsection 4c(b) of the "Commodity Exchange Act," 7 U.S.C. s.6c(b), and that is commonly known to the commodities trade as a commodity option;

(d) Any combination of the agreements or transactions referred to in this paragraph; or

(e) Any option to enter into an agreement or transaction referred to in this paragraph.

(3) "Contractual right" includes any right set forth in a rule or bylaw of a derivatives clearing organization as defined in the "Commodity Exchange Act," 7 U.S.C. s.1a(9), a multilateral clearing organization as defined in the "Federal Deposit Insurance Corporation Improvement Act of 1991," 12 U.S.C. s.4421(1), a national securities exchange, a national securities association, a securities clearing agency, or a contract market designated under the "Commodity Exchange Act," 7 U.S.C. s.1 et seq., a swap execution facility registered under the "Commodity Exchange Act," 7 U.S.C. s.1 et seq., or a board of trade as defined in the "Commodity Exchange Act," 7 U.S.C. s.1a(2), or in a resolution of the governing board thereof, and any right, whether or not evidenced in writing, arising under statutory or common law, or under law merchant, or by reason of normal business practice.

(4) "Forward contract" means the same as the term is defined in the "Federal Deposit Insurance Act," 12 U.S.C. s.1821(e)(8)(D).

(5) "Netting agreement" means:

(a) A contract or agreement, including the terms and conditions incorporated by reference in such contract or agreement, including a master agreement, which master agreement, together with all schedules, confirmations, definitions and addenda thereto and transactions under any thereof, shall be treated as one netting agreement, that documents one or more transactions between the parties to the agreement for or involving one or more qualified financial contracts and that provides for the netting, setoff, liquidation, termination, acceleration or close out, under or in connection with one or more qualified financial contracts or present or future payment or delivery obligations or payment or delivery entitlements thereunder, including liquidation or close-out values relating to such obligations or entitlements, among the parties to the netting agreement;

(b) Any master agreement or bridge agreement for one or more master agreements described in subparagraph (a) of this paragraph; or

(c) Any security arrangement related to one or more contracts or agreements described in subparagraph (a) or (b) of this paragraph, provided that any contract or agreement described in subparagraph (a) or (b) of this paragraph relating to agreements or transactions that are not qualified financial contracts shall be deemed to be a netting agreement only with respect to those agreements or transactions that are qualified financial contracts.

(6) "Qualified financial contract" means a commodity contract, forward contract, repurchase agreement, securities contract, swap agreement, and any similar agreement that the commissioner determines by regulation to be a qualified financial contract for the purposes of this section.

(7) "Repurchase agreement" means the same as that term is defined in the "Federal Deposit Insurance Act," 12 U.S.C. s.1821(e)(8)(D). The term "repurchase agreement" shall include a reverse repurchase agreement.

(8) "Security arrangement" means any security agreement or arrangement or other credit enhancement or guarantee or reimbursement obligation, including a pledge, security, collateral or guarantee agreement or credit support document.

(9) "Securities contract" means the same as that term is defined in the "Federal Deposit Insurance Act," 12 U.S.C. s.1821(e)(8)(D).

(10) "Separate account" means the same as that term is defined in N.J.S.17B:28-1.

(11) "Swap agreement" means the same as that term is defined in the "Federal Deposit Insurance Act," 12 U.S.C. s.1821(e)(8)(D).

(12) "Walkaway clause" means a provision in a netting agreement or a qualified financial contract that, after calculation of a value of a party's position or an amount due to or from one of the parties in accordance with its terms upon termination, liquidation or acceleration of the netting agreement or qualified financial contract, either does not create a payment obligation of a party or extinguishes a payment obligation of a party in whole or in part solely because of the party's status as a non-defaulting party.

Chapter 32A

§ 17B:32A-1 Short title

1. Sections 2 through 19 of this act shall be known and may be cited as the "New Jersey Life and Health Insurance Guaranty Association Act."

§ 17B:32A-2 Purpose; protection from hardship.

2. a. The purpose of P.L.1991, c.208 (C.17B:32A-1 et seq.) is to protect, subject to certain limitations, those persons specified in subsection a. of section 3 of P.L.1991, c.208 (C.17B:32A-1 et seq.) from hardship because of the impairment or insolvency of any member insurer that issued the life, health, and annuity policies, plans or contracts specified in subsection b. of section 3 of P.L.1991, c.208 (C.17B:32A-1 et seq.).

b. To provide this protection, an association of member insurers is created to pay benefits and to continue coverages, as limited by P.L.1991, c.208 (C.17B:32A-1 et seq.), and members of the association are subject to assessment to provide funds to carry out the purposes of P.L.1991, c.208 (C.17B:32A-1 et seq.).

§ 17B:32A-3 Provision of coverage

3. a. P.L.1991, c.208 (C.17B:32A-1 et seq.) shall provide coverage, for the policies and contracts specified in subsection b. of this section, to:

(1) persons who, regardless of where they reside (except for nonresident certificate holders under group policies or contracts), are the beneficiaries, assignees or payees, including health care providers rendering services covered under health insurance policies or certificates, of the persons covered under paragraph (2) of this subsection; and

(2) persons who are owners of or certificate holders or enrollees under those policies or contracts (other than unallocated annuity contracts, and structured settlement annuities) and in each case who:

(a) are residents, or

(b) are not residents, but only if:

(i) the member insurers which issued the policies or contracts are domiciled in this State;

(ii) those member insurers, health service corporations, hospital service corporations, medical service corporations, or health maintenance organizations never held a license or certificate of authority in the states in which those persons reside;

(iii) those states have associations and coverage provisions with respect to residency similar to the association created by P.L.1991, c.208 (C.17B:32A-1 et seq.); and

(iv) those persons are not eligible for coverage by those associations.

(3) For unallocated annuity contracts specified in subsection b. of this section, paragraphs (1) and (2) of this subsection shall not apply, and P.L.1991, c.208 (C.17B:32A-1 et seq.) shall (except as provided in paragraphs (5) and (6) of this subsection) provide coverage to persons who are the owners of the unallocated annuity contracts:

(a) if the contracts are issued to or in connection with a specific benefit plan whose plan sponsor has its principal place of business in this State; and

(b) issued to or in connection with government lotteries if the owners are residents.

(4) For structured settlement annuities specified in subsection b. of this section, paragraphs (1) and (2) of this subsection shall not apply, and P.L.1991, c.208 (C.17B:32A-1 et seq.) shall (except as provided in paragraphs (5) and (6) of this subsection) provide coverage to a person who is a payee under a structured settlement annuity (or beneficiary of a payee if the payee is deceased) if the payee:

(a) is a resident, regardless of where the contract owner resides; or

(b) is not a resident, but only under both of the following conditions:

(i) the contract owner of the structured settlement annuity is a resident or is not a resident but the insurer that issued the settlement annuity is domiciled in New Jersey and the state in which the contract owner resides has an association similar to the association created by P.L.1991, c.208 (C.17B:32A-1 et seq.); and

(ii) the payee (or beneficiary) and the contract owner are not eligible for coverage by the association of the state in which the payee or contract owner resides.

(5) P.L.1991, c.208 (C.17B:32A-1 et seq.) shall not provide coverage to a person:

(a) who is a payee (or beneficiary) of a contract owner resident of this State, if the payee (or beneficiary) is afforded any coverage by the association of another state;

(b) covered under paragraph (3) of this subsection, if any coverage is provided by the association of another state to the person; or

(c) who acquires rights to receive payments through a structured settlement factoring transaction as defined in section 5891 of the federal Internal Revenue Code, 26 U.S.C. s.5891(c)(3)(A), regardless of whether the transaction occurred before or after that section became effective.

(6) P.L.1991, c.208 (C.17B:32A-1 et seq.) is intended to provide coverage to a person who is a resident of this State and, in special circumstances, to a nonresident. In order to avoid duplicate coverage, if a person who would otherwise receive coverage under P.L.1991, c.208 (C.17B:32A-1 et seq.) is provided coverage under the law of another state, the person shall not be provided coverage under P.L.1991, c.208 (C.17B:32A-1 et seq.). In determining the application of the provisions of this paragraph in situations where a person could be covered by the association of more than one state, whether as an owner, payee, enrollee, beneficiary or assignee, P.L.1991, c.208 (C.17B:32A-1 et seq.) shall be construed in conjunction with other state laws to result in coverage by only one association.

b. P.L.1991, c.208 (C.17B:32A-1 et seq.) shall provide coverage to the persons specified in subsection a. of this section for policies or contracts of:

(1) direct, non-group life insurance, health insurance (which for the purposes of P.L.1991, c.208 (C.17B:32A-1 et seq.) includes health service corporation contracts, hospital service corporation contracts, medical service corporation contracts, and health maintenance organization subscriber contracts and certificates), or annuities and supplemental policies or contracts, for certificates under direct group life insurance, health insurance, annuities and supplemental policies and contracts, for individual and group long-term care insurance policies and contracts, and for unallocated annuity contracts, issued by member insurers, except as limited by P.L.1991, c.208 (C.17B:32A-1 et seq.); and

(2) policies or contracts issued by medical service corporations declared to be insolvent or impaired by a court of competent jurisdiction on or after September 1, 1987, but prior to the effective date of P.L.1991, c.208 (C.17B:32A-1 et seq.), except as otherwise limited by P.L.1991, c.208 (C.17B:32A-1 et seq.).

c. Except as otherwise provided in subsection d. of this section, P.L.1991, c.208 (C.17B:32A-1 et seq.) shall not provide coverage for:

(1) any portion of a policy or contract not guaranteed by the member insurer, or under which the risk is borne by the policy or contract owner;

(2) any policy or contract of reinsurance, unless assumption certificates have been issued;

(3) any portion of a policy or contract to the extent that the rate of interest on which it is based:

(a) averaged over the four-year period prior to the date on which the association becomes obligated with respect to that policy or contract, exceeds the lesser of:

(i) the rate of interest determined by subtracting three percentage points from Moody's Corporate Bond Yield Average averaged for that same four-year period, or for such lesser period if the policy or contract was issued less than four years before the association became obligated, or

(ii) the rate of interest specified in the standard valuation law, or the rules of this State for determining the minimum standard for the valuation of policies or contracts issued during the year of insolvency; and

(b) on and after the date on which the association becomes obligated with respect to that policy or contract, exceeds the rate of interest determined by subtracting four percentage points from Moody's Corporate Bond Yield Average as most recently available; except that the limitation of this paragraph shall not preclude the association from providing more extensive coverage if it is proceeding under the authority of section 7 of P.L.1991, c.208 (C.17B:32A-7);

(4) any plan or program of an employer, association or similar entity to provide life, health, or annuity benefits to its employees or members to the extent that such plan or program is self-funded or uninsured, including, but not limited to, benefits payable by an employer, association or similar entity under:

(a) a Multiple Employer Welfare Arrangement as defined in the Employee Retirement Income Security Act of 1974 (29 U.S.C. s.1002);

(b) a minimum premium group insurance plan;

(c) a stop-loss group insurance plan; or

(d) an administrative services only contract;

(5) any portion of a policy or contract to the extent that it provides dividends or experience rating credits, or provides that any fees or allowances be paid to any person, including the owner of the policy or contract, in connection with the service to or administration of that policy or contract;

(6) any policy or contract issued in this State by a member insurer at a time when it was not licensed or did not have a certificate of authority to issue that policy or contract in this State;

(7) any unallocated annuity contract issued to an employee benefit plan covered by the Pension Benefit Guaranty Corporation and whose benefits will be paid under such system;

(8) any portion of any unallocated annuity contract which is not issued to or in connection with a specific plan providing benefits to employees or an association of natural persons;

(9) a portion of a policy or contract to the extent it provides for interest or other changes in value to be determined by the use of an index or other external reference stated in the policy or contract, but which has not been credited to the policy or contract, or as to which the policy or contract owner's rights are subject to forfeiture, as of the date the member insurer becomes an impaired or insolvent insurer under P.L.1991, c.208 (C.17B:32A-1 et seq.), whichever is earlier. If a policy or contract's interest or changes in value are credited less frequently than annually, then for purposes of determining the values that have been credited and are not subject to forfeiture under this paragraph, the interest or change in value determined by using the procedures defined in the policy or contract shall be credited as if the contractual date of crediting interest or changing values was the date of impairment or insolvency, whichever is earlier, and shall not be subject to forfeiture;

(10) a policy or contract providing any hospital, medical, prescription drug, or other health care benefits pursuant to Medicare Parts C or D or the Medicaid program, 42 U.S.C. ss.1396 et seq., including the Children's Health Insurance Program (CHIP) which provides health coverage to eligible children, either through Medicaid or separate CHIP programs, or any regulations issued pursuant thereto, or the "Family Health Care Coverage Act," P.L.2005, c.156 (C.30:4J-8 et seq.), or

(11) structured settlement annuity benefits to which a payee (or beneficiary) has transferred rights in a structured settlement factoring transaction as defined pursuant to section 5891 of the federal Internal Revenue Code, 26 U.S.C. s.5891(c)(3)(A), regardless of whether the transaction occurred before or after that section became effective.

d. The exclusion from coverage referenced in paragraph (3) of subsection c. of this section shall not apply to any portion of a policy or contract, including a rider, that provides a long-term care or any other health insurance benefits.

e. The benefits for which the association may become liable shall in no event exceed the lesser of:

(1) the contractual obligations for which the member insurer is liable or would have been liable if it were not an impaired or insolvent insurer; or

(2) with respect to one life, regardless of the number of policies or contracts:

(a) $500,000 in life insurance death benefits, but not more than $100,000 in net cash surrender and net cash withdrawal values for life insurance;

(b) $500,000 in present value annuity benefits, including net cash surrender and net cash withdrawal values, but not more than $250,000 in net cash surrender and net cash withdrawal values for annuity benefits; provided, however, that in no event shall the association be liable to expend more than $500,000 in the aggregate with respect to any one individual under this paragraph (2); or

(3) with respect to any one unallocated annuity contract, $2,000,000 in benefits; or

(4) with respect to any one group, blanket, or individual accident or health insurance or group, blanket or individual accident or health insurance policy, unlimited benefits;

(5) with respect to each individual participating in a governmental retirement benefit plan established under sections 401, 403(b), or 457 of the U.S. Internal Revenue Code, 26 U.S.C. ss.401, 403(b), and 457, covered by an unallocated annuity contract or the beneficiaries of each such individual if deceased, in the aggregate, $500,000 in present value annuity benefits, including net cash surrender and net cash withdrawal values; and

(6) with respect to each payee of a structured settlement annuity (or beneficiary or beneficiaries of the payee if deceased), $500,000 in present value annuity benefits, in the aggregate, including net cash surrender and net cash withdrawal values, if any.

(7) The limitations set forth in this subsection are limitations on the benefits for which the association is obligated before taking into account either its subrogation and assignment rights or the extent to which those benefits could be provided out of the assets of the impaired or insolvent insurer attributable to covered policies. The costs of the obligation of the association under P.L.1991, c.208 (C.17B:32A-1 et seq.) may be met by the use of assets attributable to covered policies or reimbursed to the association pursuant to its subrogation and assignment rights.

f. A provider of health care services, in order to receive payment directly from the association upon a claim of the provider against an insured or enrollee, shall agree to forgive the insured of 20% of the obligation which would otherwise be paid by the member insurer had it not been insolvent. The obligations of solvent member insurers to pay all or part of the covered claim are not diminished by the forgiveness provided in this subsection. The association is not bound by an assignment of benefits executed with respect to the coverage provided by the insolvent insurer. The association may aggregate all claims owed health care providers when negotiating direct payment of claims of all covered individuals.

§ 17B:32A-4 Definitions

4. As used in P.L.1991, c.208 (C.17B:32A-1 et seq.):

"Account" means either of the two accounts created under subsection b. of section 5 of P.L.1991, c.208 (C.17B:32A-5).

"Association" means the New Jersey Life and Health Insurance Guaranty Association created in subsection a. of section 5 of P.L.1991, c.208 (C.17B:32A-5).

"Benefit plan" means the benefit plan of a specific employee, union or association of natural persons.

"Called assessment" or "called" when used in the context of assessments means that a notice has been issued by the association to member insurers requiring that an authorized assessment be paid within the timeframe set forth within the notice. An authorized assessment becomes a called assessment when notice is mailed by the association to member insurers.

"Commissioner" means the Commissioner of Banking and Insurance.

"Contractual obligation" means any obligation under a policy or contract or certificate under a group policy or contract, or portion thereof, for which coverage is provided under section 3 of P.L.1991, c.208 (C.17B:32A-3), but does not include unearned premium under a health insurance policy or contract.

"Covered policy" or "covered contract" means any policy or contract within the scope of P.L.1991, c.208 (C.17B:32A-1 et seq.) as provided by section 3 of P.L.1991, c.208 (C.17B:32A-3).

"Department" means the Department of Banking and Insurance.

"Health benefit plan" means any hospital or medical expense policy or certificate, health service corporation contract, hospital service corporation contract, medical service corporation contract, health maintenance organization subscriber contract, or any other similar health contract. "Health benefit plan" does not include accident-only insurance; credit insurance; dental-only insurance; vision-only insurance; Medicare Supplement income; benefits for long-term care, home health care, community-based care, or any combination thereof; liability insurance, including general liability insurance, or coverage issued as a supplement to liability insurance; disability income insurance; coverage for on-site medical clinics; or specified disease, hospital, confinement indemnity, or limited benefit health insurance if the types of coverage do not provide coordination of benefits and are provided under separate policies or certificates.

"Impaired insurer" means a member insurer which, after the effective date of P.L.1991, c.208 (C.17B:32A-1 et seq.): (1) is determined by the commissioner to be potentially unable to fulfill its contractual obligations; or (2) is placed under an order of receivership, rehabilitation or conservation by a court of competent jurisdiction.

"Insolvent insurer" means a member insurer which, after the effective date of P.L.1991, c.208 (C.17B:32A-1 et seq.), is placed under an order of liquidation by a court of competent jurisdiction with a finding of insolvency.

"Member insurer" means any insurer, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization licensed in this State or which holds a certificate of authority to transact any kind of insurance, health service corporation business, hospital service corporation business, medical service corporation business, or health maintenance organization business in this State for which coverage is provided under section 3 of P.L.1991, c.208 (C.17B:32A-3), and includes any insurer, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization whose license or certificate of authority in this State may have been suspended, revoked, not renewed or voluntarily withdrawn, but does not include:

(1) A dental service corporation established pursuant to the provisions of P.L.1968, c.305 (C.17:48C-1 et seq.);

(2) A dental plan organization established pursuant to the provisions of P.L.1979, c.478 (C.17:48D-1 et seq.);

(3) (Deleted by amendment, P.L.2022, c.98);

(4) A fraternal benefit society established pursuant to the provisions of P.L.1959, c.167 (C.17:44A-1 et seq.);

(5) A mandatory state pooling plan;

(6) A mutual assessment company or any entity that operates on an assessment basis to the extent of the assessment liability of its members;

(7) An insurance exchange;

(8) A licensed organized delivery system licensed pursuant to P.L.1999, c.409 (C.17:48H-1 et seq.);

(9) A captive insurer, established pursuant to P.L.2011, c.25 (C.17:47B-1 et seq.); or

(10) An entity similar to any of the above.

"Moody's Corporate Bond Yield Average" means the Monthly Average Corporates as published by Moody's Investors Service, Inc., or any successor thereto.

"Owner" of a policy or contract and "policyholder," "policy owner," and "contract owner" means the person who is identified as the legal owner under the terms of the policy or contract or who is otherwise vested with legal title to the policy or contract through a valid assignment completed in accordance with the terms of the policy or contract and properly recorded as the owner of the books of the member insurer. The terms owner, contract owner, policyholder, and policy owner do not include persons with a mere beneficial interest in a policy or contract.

"Person" means an individual or natural person, corporation, partnership, association or voluntary organization.

"Plan sponsor" means:

(1) the employer in the case of a benefit plan established or maintained by a single employer;

(2) the employee organization in the case of a benefit plan established or maintained by an employee organization; or

(3) in a case of a benefit plan established or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, the association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the benefit plan.

"Premiums" means amounts or considerations received in any calendar year on covered policies or contracts less premiums, considerations and deposits returned thereon, and less dividends and experience credits thereon. "Premiums" shall not include any amounts or considerations received for any policies or contracts or for the portions of any policies or contracts for which coverage is not provided under subsection b. of section 3 of P.L.1991, c.208 (C.17B:32A-3) except that assessable premium shall not be reduced as the result of the application of: paragraph (3) of subsection c. of section 3 relating to interest limitations; or paragraph (2) of subsection d. of section 3 relating to limitations with respect to any one insured or enrolled individual. "Premiums" shall not include any premiums in excess of $2,000,000 per contract on any unallocated annuity contract.

"Resident" means a person who resides in this State at the time a member insurer is an impaired insurer or insolvent insurer and to whom a contractual obligation is owed. For the purposes of P.L.1991, c.208 (C.17B:32A-1 et seq.), a person may be a resident of only one state, which in the case of a person other than a natural person shall be its principal place of business. A citizen of the United States that is a resident of a foreign country or of a United States possession, territory, or protectorate that does not have an association similar to the association created by P.L.1991, c.208 (C.17B:32A-1 et seq.) shall be deemed a resident of the state of domicile of the member insurer that issued the policies or contracts.

"State" means a state, the District of Columbia, Puerto Rico, and a United States possession, territory, or protectorate.

"Structured settlement annuity" means an annuity purchased in order to fund periodic payments for a plaintiff or other claimant in payment for or with respect to personal injury suffered by the plaintiff or other claimant.

"Supplemental contract" means an agreement entered into for the distribution of policy or contract proceeds.

"Unallocated annuity contract" means: (1) an annuity contract or group annuity certificate which is not issued to and owned by an individual, except to the extent of any annuity benefits guaranteed to an individual by an insurer under that contract or certificate; or (2) any unallocated life insurance or health insurance funding agreement, where insurance certificates or contracts are not issued to and owned by individuals, except to the extent of any life insurance or health insurance benefits guaranteed to an individual by an insurer under such funding agreement.

§ 17B:32A-5 New Jersey Life and Health Insurance Guaranty Association created

5. a. There is created a nonprofit legal entity to be known as the New Jersey Life and Health Insurance Guaranty Association. All member insurers shall be and remain members of the association as a condition of their authority or license to transact insurance, health service corporation business, hospital service corporation business, medical service corporation business, or health maintenance organization business in this State. Any member insurer shall remain a member insurer for four years after it ceases to hold a certificate of authority or license. The association shall perform its functions under the plan of operation established and approved pursuant to section 9 of P.L.1991, c.208 (C.17B:32A-9) and shall exercise its powers through the board of directors established under section 6 of P.L.1991, c.208 (C.17B:32A-6). The association shall be under the immediate supervision of the commissioner and shall be subject to the applicable provisions of the insurance laws of this State. Meetings or records of the association may be opened to the public upon majority vote of the board of directors of the association.

b. For purposes of administration and assessment the association shall maintain two accounts:

(1) The life insurance and annuity account which shall include the following subaccounts:

(a) life insurance subaccount;

(b) annuity subaccount; and

(c) unallocated annuity subaccount.

(2) The health account.

§ 17B:32A-6 Board of Directors of association

6. a. There shall be a board of directors of the association which shall consist of not less than seven nor more than eleven member insurers serving terms as established in the plan of operation. The members of the board shall be selected by member insurers subject to the approval of the commissioner. Vacancies on the board shall be filled for the remaining period of the term by a majority vote of the remaining board members, subject to the approval of the commissioner. To select the initial board of directors, and initially organize the association, the commissioner shall give notice to all member insurers of the time and place of the organizational meeting. In determining voting rights at the organizational meeting each member insurer shall be entitled to one vote in person or by proxy. If the board of directors is not selected within 60 days after notice of the organizational meeting, the commissioner may appoint the initial members.

b. In approving selections or appointing members to the board, the commissioner shall consider, among other things, whether all member insurers are fairly represented.

c. Members of the board may be reimbursed from the assets of the association for reasonable expenses incurred by them as members of the board of directors, but members of the board shall not otherwise be compensated by the association for their services.

§ 17B:32A-7 Powers of the association

7. a. If a member insurer is an impaired insurer, the association may, in its discretion, and subject to any conditions imposed by the association that do not unreasonably impair the contractual obligations of the impaired insurer, that are approved by the commissioner:

(1) guaranty, assume, reissue, or reinsure, or cause to be guaranteed, assumed, reissued, or reinsured, any or all of the policies or contracts of the impaired insurer;

(2) provide such monies, pledges, notes, guarantees, or other means as are proper to effectuate the provisions of paragraph (1) of this subsection and assure payment of the contractual obligations of the impaired insurer pending action under paragraph (1); or

(3) loan money to the impaired insurer.

b. (Deleted by amendment, P.L.2022, c.98);

c. If a member insurer is an insolvent insurer, the association shall, in its discretion, either:

(1) (a) guaranty, assume, reissue, or reinsure, or cause to be guaranteed, assumed, reissued, or reinsured, the policies or contracts of the insolvent insurer; or

(b) assure payment of the contractual obligations of the insolvent insurer; and

(c) provide those monies, pledges, guarantees, or other means as are reasonably necessary to discharge those obligations; or

(2) with respect only to policies or contracts, provide benefits and coverages in accordance with subsection d. of this section.

d. When proceeding under paragraph (2) of subsection c. of this section, the association shall, with respect only to policies or contracts:

(1) assure payment of benefits that would have been payable under the policies or contracts of the impaired or insolvent insurer, for claims incurred:

(a) with respect to group policies or contracts, not later than the earlier of the next renewal date under those policies or contracts or 45 days, but in no event less than 30 days, after the date on which the association becomes obligated with respect to those policies or contracts;

(b) with respect to individual policies or contracts, not later than the earlier of the next renewal date, if any, under those policies or contracts or one year, but in no event less than 30 days, from the date on which the association becomes obligated with respect to those policies or contracts;

(2) make a diligent effort to provide all known insureds, enrollees, annuitants, or group policy or contract owners with respect to group policies or contracts, 30 days' notice of the termination of the benefits provided; and

(3) with respect to individual policies or contracts, and with respect to individuals formerly an insured, enrollee, or annuitant under group policies or contracts who are not eligible for replacement group coverage, make available to each known insured, enrollee, annuitant, or policy or contract owner of an individual policy or contract if other than the insured, enrollee, or annuitant substitute coverage on an individual basis in accordance with the provisions of paragraph (4) of this subsection, if the insured, enrollee, or annuitant had a right under law or the terminated policy, contract or annuity to convert coverage to individual coverage or to continue an individual policy, contract, or annuity in force until a specified age or for a specified time, during which the member insurer, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization had no right unilaterally to make changes in any provision of the policy, contract, or annuity or had a right only to make changes in premium by class.

(4) (a) In providing the substitute coverage required by paragraph (3), the association may offer either to reissue the terminated coverage or to issue an alternative policy or contract at actuarially justified rates.

(b) Alternative or reissued policies or contracts shall be offered without requiring evidence of insurability, and shall not provide for any waiting period or exclusion that would not have applied under the terminated policy or contract.

(c) The association may reinsure any alternative or reissued policy or contract.

(5) (a) Alternative policies or contracts adopted by the association shall be subject to the approval of the commissioner.

(b) Alternative policies or contracts shall contain at least the minimum statutory provisions required in this State and provide benefits that shall not be unreasonable in relation to the premium charged under reasonable actuarial assumptions. The association shall set the premium in accordance with a table of rates which it shall adopt. The premium shall reflect the amount of insurance or coverage to be provided and the age and class of risk of each insured or enrollee.

(c) Any alternative policy or contract issued by the association shall provide coverage of a type similar to that of the policy or contract issued by the impaired or insolvent insurer, as determined by the association.

(6) If the association elects to reissue terminated coverage at a premium rate different from that charged under the terminated policy or contract, the premium shall be actuarially justified and set by the association in accordance with the amount of insurance or coverage provided and the age and class of risk, subject to approval of the commissioner.

(7) The association's obligations with respect to coverage under any policy or contract of the impaired or insolvent insurer or under any reissued or alternative policy or contract shall cease on the date that coverage, policy or contract is replaced by another similar coverage, policy or contract by the policy or contract owner, the enrollee, the association, or the insured.

e. When proceeding under subsection c. of this section with respect to any policy or contract carrying guaranteed minimum interest rates, the association shall assure the payment or crediting of a rate of interest at least equal to that specified in paragraph (3) of subsection c. of section 3 of P.L.1991, c.208 (C.17B:32A-3).

f. Nonpayment of premiums within 31 days after the date required, after effective notice shall have been given of the terms of any guaranteed, assumed, alternative or reissued policy or contract or substitute coverage, shall terminate the association's obligations under that policy, contract or coverage under P.L.1991, c.208 (C.17B:32A-1 et seq.) with respect to that policy, contract or coverage, except with respect to any claims incurred or any net cash surrender value which may be due in accordance with the provisions of P.L.1991, c.208 (C.17B:32A-1 et seq.).

g. Premiums due for coverage after entry of an order of receivership or liquidation of any insolvent insurer shall belong to, and be payable at the direction of, the association.

h. The protection provided by P.L.1991, c.208 (C.17B:32A-1 et seq.) shall not apply if any guaranty protection is provided to residents of this State by the law of the domiciliary state or jurisdiction of the impaired or insolvent insurer other than this State.

i. In carrying out its duties under subsections b. and c. of this section, the association may, subject to approval by the court:

(1) impose reasonable and necessary policy or contract liens in connection with any guaranty, assumption or reinsurance agreement, if the association finds that the amounts which can be assessed under this act are less than the amounts needed to assure full and prompt performance of the association's duties under P.L.1991, c.208 (C.17B:32A-1 et seq.), or that the economic or financial conditions as they affect member insurers are sufficiently adverse to render the imposition of those policy or contract liens, to be in the public interest; or

(2) impose temporary moratoriums or liens on payments of cash values and policy loans, or any other right to withdraw funds held in conjunction with policies or contracts, in addition to any contractual provisions for deferral of cash or policy loan value.

j. If the association fails to act within a reasonable period of time as provided in subsections b. and c. of this section, the commissioner shall have the powers and duties of the association provided by P.L.1991, c.208 (C.17B:32A-1 et seq.) with respect to impaired or insolvent insurers.

k. The association may render assistance and advice to the commissioner concerning the receivership, conservation, rehabilitation, liquidation, payment of claims, continuance of coverage, or the performance of other contractual obligations of any impaired or insolvent insurer.

l. The association shall have standing to appear before any court in this State with jurisdiction over an impaired or insolvent insurer with respect to which the association is or may become obligated under P.L.1991, c.208 (C.17B:32A-1 et seq.). That standing shall extend to all matters germane to the powers and duties of the association, including, but not limited to, proposals for reinsuring, reissuing, modifying or guaranteeing the policies or contracts of the impaired or insolvent insurer and the termination of the policies or contracts and contractual obligations. The association shall also have the right to appear or intervene before a court in another state with jurisdiction over an impaired or insolvent insurer for which the association is or may become obligated or with jurisdiction over any person or property against whom the association may have rights through subrogation or otherwise.

m. (1) Any person receiving benefits under P.L.1991, c.208 (C.17B:32A-1 et seq.) shall be deemed to have assigned the rights under, and any causes of action relating to, the covered policy or contract to the association to the extent of the benefits received pursuant to P.L.1991, c.208 (C.17B:32A-1 et seq.), whether the benefits are payments of or on account of contractual obligations, continuation of coverage or provision of substitute or alternative policies, contracts, or coverages. The association may require an assignment to it of such rights and causes of action by any payee, policy or contract owner, beneficiary, insured, enrollee, or annuitant as a condition precedent to the receipt of any right or benefits conferred by P.L.1991, c.208 (C.17B:32A-1 et seq.) upon that person.

(2) The subrogation rights of the association under this subsection shall have the same priority against the assets of the impaired or insolvent insurer as that possessed by the person entitled to receive benefits under P.L.1991, c.208 (C.17B:32A-1 et seq.).

(3) In addition to the rights of subrogation contained in paragraphs (1) and (2) of this subsection, the association shall have all common law rights of subrogation and any other equitable or legal remedy which would have been available to the impaired or insolvent insurer or policy or contract owner, beneficiary, enrollee, or payee with respect to that policy or contract.

(4) In addition to the rights contained in paragraphs (1), (2) and (3) of this subsection, in the case of any unallocated annuity contract for which benefits are paid by the association under P.L.1991, c.208 (C.17B:32A-1 et seq.), the association shall be deemed to have assigned to it the rights and causes of action of any employee or association of natural persons against the contract owner of such unallocated annuity contract for the amounts paid by the association under P.L.1991, c.208 (C.17B:32A-1 et seq.).

(5) If the preceding provisions of this subsection are invalid or ineffective with respect to any person or claim for any reason, the amount payable by the association with respect to the related covered obligations shall be reduced by the amount realized by any other person with respect to the person or claim that is attributable to the policies or contracts (or portion thereof) covered by the association.

(6) If the association has provided benefits with respect to a covered obligation and a person recovers amounts as to which the association has rights as described in the preceding paragraphs of this subsection, the person shall pay to the association the portion of the recovery attributable to the policies or contracts (or portion thereof) covered by the association.

n. The association may:

(1) enter into any contracts necessary or proper to carry out the provisions and purposes of P.L.1991, c.208 (C.17B:32A-1 et seq.);

(2) sue or be sued, including taking any legal actions necessary or proper to recover any unpaid assessments imposed pursuant to section 8 of P.L.1991, c.208 (C.17B:32A-8) and to settle claims or potential claims against it;

(3) borrow money to effectuate the purposes of P.L.1991, c.208 (C.17B:32A-1 et seq.). Any notes or other evidence of indebtedness of the association not in default shall be legal investments for domestic insurers and may be carried as admitted assets;

(4) employ or retain persons necessary to handle the financial transactions of the association, and to perform other functions as are necessary or proper under P.L.1991, c.208 (C.17B:32A-1 et seq.);

(5) take any legal action necessary to avoid payment of improper claims;

(6) exercise, for the purposes of P.L.1991, c.208 (C.17B:32A-1 et seq.) and to the extent approved by the commissioner, the powers of a domestic life insurer or health insurer, health service corporations, hospital service corporations, medical service corporations, or health maintenance organizations but in no case shall the association issue insurance policies or annuity contracts other than those issued to perform its obligations under P.L.1991, c.208 (C.17B:32A-1 et seq.);

(7) organize itself as a corporation or in other legal form permitted by the law of the State;

(8) request information from a person seeking coverage from the association in order to aid the association in determining its obligations under P.L.1991, c.208 (C.17B:32A-1 et seq.) with respect to the person, and the person shall promptly comply with the request;

(9) unless prohibited by law, in accordance with the terms and conditions of the policy or contract, file for actuarially justified rate or premium increases for any policy or contract for which it provides coverage under P.L.1991, c.208 (C.17B:32A-1 et seq.); and

(10) take other necessary or appropriate action to discharge its duties and obligations under P.L.1991, c.208 (C.17B:32A-1 et seq.) or to exercise its powers under P.L.1991, c.208 (C.17B:32A-1 et seq.).

o. The association may join an organization of one or more other state associations of similar purposes, to further the purposes and administer the powers and duties of the association.

p. (1) (a) At any time within 180 days of the date of the order of liquidation, the association may elect to succeed to the rights and obligations of the ceding member insurer that relate to policies, contracts, or annuities covered, in whole or in part, by the association, in each case under any one or more reinsurance contracts entered into by the insolvent insurer and its reinsurers and selected by the association. Any such assumption shall be effective as of the date of the order of liquidation. The election shall be effected by the association or the National Organization of Life and Health Insurance Guaranty Associations (NOLGHA) on its behalf sending written notice, return receipt requested, to the affected reinsurers.

(b) To facilitate the earliest practicable decision about whether to assume any of the contracts of reinsurance, and in order to protect the financial positions of the estate, the receiver and each reinsurer of the ceding member insurer shall make available upon request to the association or the NOLGHA on its behalf as soon as possible after commencement of formal delinquency proceedings:

(i) copies of in-force contracts of reinsurance and all related files and records relevant to the determination of whether such contracts should be assumed; and

(ii) notices of any defaults under the reinsurance contracts or any known event or condition which with the passage of time could become a default under the reinsurance contracts.

(c) The following subsubparagraphs shall apply to reinsurance contracts so assumed by the association:

(i) The association shall be responsible for all unpaid premiums due under the reinsurance contracts for periods both before and after the date of the order of liquidation, and shall be responsible for the performance of all other obligations to be performed after the date of the order of liquidation, in each case which relate to policies, contracts, or annuities covered, in whole or in part, by the association. The association may charge policies, contracts, or annuities covered in part by the association, through reasonable allocation methods, the costs for reinsurance in excess of the obligations of the association and shall provide notice and an accounting of these charges to the liquidator;

(ii) The association shall be entitled to any amounts payable by the reinsurer under the reinsurance contracts with respect to losses or events that occur in periods after the date of the order of liquidation and that relate to policies, contracts, or annuities covered, in whole or in part, by the association, provided that, upon receipt of those amounts, the association shall be obliged to pay to the beneficiary under the policy, contracts, or annuity on account of which the amounts were paid a portion of the amount equal to the lesser of (1) the amount received by the association; and (2) the excess of the amount received by the association over the amount equal to the benefits paid by the association on account of the policy, contracts, or annuity less the retention of the insurer applicable to the loss or event.

(iii) Within 30 days following the association's election (the "election date"), the association and each reinsurer under contracts assumed by the association shall calculate the net balance due to or from the association under each reinsurance contract as of the election date with respect to policies, contracts or annuities covered, in whole or in part, by the association, which calculation shall give full credit to all items paid by either the member insurer or its receiver or the reinsurer prior to the election date. The reinsurer shall pay the receiver any amounts due for losses or events prior to the date of the order of liquidation, subject to any set-off for premiums unpaid for periods prior to the date, and the association or reinsurer shall pay any remaining balance due the other, in each case within five days of the completion of the aforementioned calculation. Any disputes over the amounts due to either the association or the reinsurer shall be resolved by arbitration pursuant to the terms of the affected reinsurance contracts or, if the contract contains no arbitration clause, as otherwise provided by law. If the receiver has received any amounts due the association pursuant to subsubparagraph (ii) of this subparagraph, the receiver shall remit the same to the association as promptly as practicable.

(iv) If the association or receiver, on the association's behalf, within 60 days of the election date, pays the unpaid premiums due for periods both before and after the election date that relate to policies, contracts, or annuities covered, in whole or in part, by the association, the reinsurer shall not be entitled to terminate the reinsurance contracts for failure to pay premium insofar as the reinsurance contracts relate to policies, contracts, or annuities covered, in whole or in part, by the association, and shall not be entitled to set off any unpaid amounts due under other contracts, or unpaid amounts due from parties other than the association, against amounts due the association.

(2) During the period from the date of the order of liquidation until the election date (or, if the election date does not occur, until 180 days after the date of the order of liquidation):

(a) (i) the association and the reinsurer shall not have rights or obligations under reinsurance contracts that the association has the right to assume under paragraph (1) of this subsection, whether for period prior to or after the date of the order of liquidation; and

(ii) the reinsurer, the receiver and the association shall, to the extent, practicable, provide each other data and records reasonably requested.

(b) provided that once the association has elected to assume a reinsurance contract, the parties' rights and obligations shall be governed paragraph (1) of this subsection.

(3) If the association does not elect to assume a reinsurance contract by the election date pursuant to paragraph (1) of this subsection, the association shall have no rights or obligations, in each case for periods both before and after the date of the order of liquidation, with respect to the reinsurance contract.

(4) When policies, contracts, or annuities, or covered obligations with respect thereto, are transferred to an assuming insurer, reinsurance on the policies, contracts, or annuities may also be transferred by the association, in the case of contracts assumed under paragraph (1) of this subsection, subject to the following:

(a) unless the reinsurer and the assuming insurer agree otherwise, the reinsurance contract transferred shall not cover any new policies of insurance, contracts, or annuities in addition to those transferred;

(b) the obligations described in paragraph (1) of this subsection shall no longer apply with respect to matters arising after the effective date of the transfer; and

(c) notice shall be given in writing, return receipt requested, by the transferring party to the affected reinsurer not less than 30 days prior to the effective date of the transfer.

(5) The provisions of this subsection shall supersede the provisions of any State law or any affected reinsurance contract that provides for or requires any payment of reinsurance proceeds, on account of losses or events that occur in periods after the date of the order of liquidation, to the receiver of the insolvent insurer or any other person. The receiver shall remain entitled to any amounts payable by the reinsurer under the reinsurance contracts with respect to losses or events that occur in periods prior to the date of the order of liquidation, subject to applicable setoff provisions.

(6) Except as otherwise provided in this subsection, nothing in this subsection shall alter or modify the terms and conditions of any reinsurance contract. Nothing in this subsection shall abrogate or limit any rights of any reinsurer to claim that it is entitled to rescind a reinsurance contract. Nothing in this subsection shall give a policyholder, contract owner, enrollee, certificate holder, or beneficiary an independent cause of action against a reinsurer that is not otherwise set forth in the reinsurance contract. Nothing in this subsection shall limit or affect the association's rights as a creditor of the estate against the assets of the estate. Nothing in this subsection shall apply to reinsurance agreements covering property or casualty risks.

q. The board of directors of the association shall have discretion and may exercise reasonable business judgment to determine the means by which the association is to provide the benefits of P.L.1991, c.208 (C.17B:32A-1 et seq.) in an economical and efficient manner.

r. Where the association has arranged or offered to provide the benefits of P.L.1991, c.208 (C.17B:32A-1 et seq.) to a covered person under a plan or arrangement that fulfills the association's obligations under P.L.1991, c.208 (C.17B:32A-1 et seq.), the person shall not be entitled to benefits from the association in addition to or other than those provided under the plan or arrangement.

s. Venue in a suit against the association arising under P.L.1991, c.208 (C.17B:32A-1 et seq.) shall be in Monmouth County. The association shall not be required to give an appeal bond in an appeal that relates to a cause of action arising under P.L.1991, c.208 (C.17B:32A-1 et seq.).

t. In carrying out its duties in connection with guaranteeing, assuming, reissuing, or reinsuring policies or contracts under subsections a., b., c, or d. of this section, the association may issue substitute coverage for a policy or contract that provides an interest rate, crediting rate or similar factor determined by use of an index or other external reference stated in the policy or contract employed in calculating returns or changes in value by issuing an alternative policy or contract in accordance with the following provisions:

(1) in lieu of the index or external reference provided for in the original policy or contract, the alternative policy or contract provides for a fixed interest rate; payment of dividends with minimum guarantees; or a different method for calculating interest or changes in value;

(2) there is no requirement for evidence of insurability, waiting period or other exclusion that would not have applied under the replaced policy or contract; and

(3) the alternative policy or contract is substantially similar to the replaced policy or contract in all other material terms.

u. A deposit in this State, held pursuant to law or required by the commissioner for the benefit of creditors, including policy or contract owners, not turned over to the domiciliary liquidator upon the entry of a final order of liquidation or order approving a rehabilitation plan of a member insurer domiciled in this State or in a reciprocal state pursuant to section 57 of P.L.1992, c.65 (C.17B:32-87) shall be promptly paid to the association. The association shall be entitled to retain a portion of any amount so paid to it equal to the percentage determined by dividing the aggregate amount of policy or contract owners' claims related to that insolvency for which the association has provided statutory benefits by the aggregate amount of all policy or contract owners' claims in the State related to that insolvency and shall remit to the domiciliary receiver the amount so paid to the association less the amount retained pursuant to this subsection. Any amount so paid to the association and retained by it shall be treated as a distribution of estate assets pursuant to applicable State receivership law dealing with early access disbursements.

§ 17B:32A-8 Member insurers assessed to provide funding for association

8. a. For the purpose of providing the funds necessary to carry out the powers and duties of the association, the board of directors shall assess the member insurers, separately for each account, at such time and for such amounts as the board finds necessary. Assessments shall be due not less than 30 days after prior written notice to the member insurers and shall accrue interest at the percentage of interest prescribed in the Rules Governing the Courts of the State of New Jersey for judgments, awards and orders for the payment of money, on and after the due date.

b. There shall be two classes of assessments, as follows:

(1) Class A assessments shall be made for the purpose of meeting administrative and legal costs of the association which are not objected to by the commissioner and other expenses. Class A assessments shall also be made, upon the request of the commissioner, for the purpose of meeting costs incurred by or on behalf of the department in the administration of an insolvent insurer to the extent those costs exceed assets of the insolvent insurer available for that purpose. Class A assessments need not be related to a particular impaired or insolvent insurer. The amount of any Class A assessment shall be determined by the board.

(2) Class B assessments shall be made to the extent necessary to carry out the powers and duties of the association under section 7 of P.L.1991, c.208 (C.17B:32A-7) with respect to an impaired or an insolvent insurer. The amount of any Class B assessment, except for assessments related to long-term care insurance, shall be allocated for assessment purposes between the accounts and among subaccounts of the life insurance and annuity account, pursuant to an allocation formula which may be based on the premiums or reserves of the impaired or insolvent insurer or any other standard deemed by the board in its sole discretion as being fair and reasonable under the circumstances.

(3) The amount of Class B assessments for long-term care insurance written by the impaired or insolvent insurer shall be allocated according to a methodology included in the plan of operation and approved by the commissioner. The methodology shall provide for 50 percent of the assessment to be allocated to accident and health member insurers and 50 percent to be allocated to life and annuity member insurers.

c. (1) Class B assessments against member insurers for each account and subaccount shall be in the proportion that the premiums received on business in this State by each assessed member insurer on policies or contracts covered by each account for the three most recent calendar years for which information is available preceding the year in which the member insurer became impaired or insolvent, as the case may be, bears to such premiums received on business in this State for such calendar years by all assessed member insurers.

(2) Assessments for funds to meet the requirements of the association with respect to an impaired or insolvent insurer shall be made as necessary to implement the purposes of P.L.1991, c.208 (C.17B:32A-1 et seq.). Classification of assessments under subsection b. of this section and computation of assessments under this subsection c. shall be made with a reasonable degree of accuracy, recognizing that exact determinations may not always be possible.

d. The association shall abate or defer, in whole or in part, the assessment of a member insurer if, in the opinion of the commissioner, payment of the assessment would endanger the ability of the member insurer to fulfill its contractual obligations or places the member insurer in an unsafe or unsound financial condition. In the event an assessment against a member insurer is abated or deferred, in whole or in part, the amount by which that assessment is abated or deferred shall be assessed against the other member insurers in a manner consistent with the basis for assessments set forth in this section. Once the conditions that caused a deferral have been removed or rectified, the member insurer shall pay all assessments that were deferred pursuant to a repayment plan approved by the commissioner.

e. (1) The total of all assessments imposed under subsection b. of this section upon a member insurer for the life insurance and annuity account and for each subaccount thereunder shall not in any one calendar year exceed two percent and for the health account shall not in any one calendar year exceed two percent of that member insurer's average premiums, as reported in the annual statement in a form prescribed by the commissioner, received in this State on the policies and contracts covered by the account during the three calendar years preceding the year in which the member insurer became an impaired or insolvent insurer. If the maximum assessment, together with the other assets of the association in any account, does not provide in any one year in either account an amount sufficient to carry out the responsibilities of the association, the necessary additional funds shall be assessed as soon thereafter as permitted by P.L.1991, c.208 (C.17B:32A-1 et seq.).

(2) If a one percent assessment for any subaccount of the life insurance and annuity account in any one year does not provide an amount sufficient to carry out the responsibilities of the association, then pursuant to paragraph (1) of subsection c. of this section, the board shall assess all subaccounts of the life insurance and annuity account for the necessary additional amount, subject to the maximum stated in paragraph (1) of this subsection.

(3) The board may provide in the plan of operation a method of allocating funds among claims, whether relating to one or more impaired or insolvent insurers, when the maximum assessment will be insufficient to cover anticipated claims.

f. The board may, by an equitable method as established in the plan of operation, refund to member insurers, in proportion to the contribution of each member insurer to that account, the amount by which the assets of an account exceed the amount the board, with the concurrence of the commissioner, finds is necessary to carry out during the coming year the obligations of the association with respect to that account, including assets accruing from assignment, subrogation, net realized gains and income from investments. A reasonable amount may be retained in any account to provide funds for the continuing expenses of the association and for future losses.

g. Except for that portion of assessments that may be offset against premium taxes pursuant to section 18 of P.L.1991, c.208 (C.17B:32A-18), it shall be proper for any member insurer, in determining its premium rates and policy owner dividends as to any kind of insurance, health service corporation business, hospital service corporation business, medical service corporation business, or health maintenance organization business within the scope of P.L.1991, c.208 (C.17B:32A-1 et seq.), to consider the amount reasonably necessary to meet its assessment obligations under P.L.1991, c.208 (C.17B:32A-1 et seq.).

h. The association shall issue to each member insurer paying an assessment pursuant to P.L.1991, c.208 (C.17B:32A-1 et seq.), other than a Class A assessment, a certificate of contribution, in a form and manner prescribed by the commissioner, for the amount of the assessment so paid. All outstanding certificates shall be of equal dignity and priority without reference to amount or date of issue. A certificate of contribution may be shown by the member insurer in its financial statement as an asset in such form and manner and for such amount and period of time as the commissioner may approve.

i. (1) A member insurer that wishes to protest all or part of an assessment shall pay when due the full amount of the assessment as set forth in the notice provided by the association. The payment shall be available to meet association obligations during the pendency of the protest or any subsequent appeal. Payment shall be accompanied by a statement in writing that the payment is made under protest and setting forth a brief statement of the grounds for the protest.

(2) Within 60 days following the payment of an assessment under protest by a member insurer, the association shall notify the member insurer in writing of its determination with respect to the protest unless the association notifies the member insurer that additional time is required to resolve the issues raised by the protest.

(3) Within 30 days after a final decision has been made, the association shall notify the protesting member insurer in writing of that final decision. Within 60 days of receipt of notice of the final decision, the protesting member insurer may appeal that final action to the commissioner.

(4) In the alternative to rendering a final decision with respect to a protest based on a question regarding the assessment base, the association may refer protests to the commissioner for a final decision, with or without a recommendation from the association.

(5) If the protest or appeal on the assessment is upheld, the amount paid in error or excess shall be returned to the member insurer. Interest on a refund due a protesting member insurer shall be paid at the rate actually earned by the association.

j. The association may request information of member insurers in order to aid in the exercise of its power under this section and member insurers shall promptly comply with a request.

§ 17B:32A-9 Plan of operation

9. a. (1) The association shall submit to the commissioner a plan of operation and any amendments thereto necessary or suitable to assure the fair, reasonable, and equitable administration of the association. The plan of operation and any amendments thereto shall become effective upon the commissioner's written approval or at the expiration of 30 days after submission if it has not been disapproved.

(2) If the association fails to submit a suitable plan of operation within 120 days following the effective date of P.L.1991, c.208 (C.17B:32A-1 et seq.) or if at any time thereafter the association fails to submit suitable amendments to the plan, the commissioner shall adopt such plan or amendments necessary to effectuate the provisions of P.L.1991, c.208 (C.17B:32A-1 et seq.). The plan or amendments shall continue in force until modified by the commissioner or superseded by a plan submitted by the association and approved by the commissioner.

b. All member insurers shall comply with the plan of operation.

c. The plan of operation shall, in addition to requirements enumerated elsewhere in P.L.1991, c.208 (C.17B:32A-1 et seq.):

(1) establish procedures for handling the assets of the association;

(2) establish the amount and method of reimbursing members of the board of directors under subsection c. of section 6 of P.L.1991, c.208 (C.17B:32A-6);

(3) establish regular places and times for meetings, including telephone conference calls, of the board of directors;

(4) establish procedures for records to be kept of all financial transactions of the association, its agents, and the board of directors;

(5) establish the procedures whereby selections for the board of directors will be made and submitted to the commissioner;

(6) establish any additional procedures for the imposition of assessments under section 8 of P.L.1991, c.208 (C.17B:32A-8);

(7) contain additional provisions necessary or proper for the execution of the powers and duties of the association;

(8) establish procedures whereby a director may be removed for cause, including in the case where a member insurer director becomes an impaired or insolvent insurer; and

(9) require the board of directors to establish a policy and procedures for addressing conflicts of interests.

d. The plan of operation may provide for the delegation of any or all powers and duties of the association, except those set forth in paragraph (3) of subsection m. of section 7 of P.L.1991, c.208 (C.17B:32A-7) and section 8 of P.L.1991, c.208 (C.17B:32A-8), to a corporation, association, or other organization which performs or will perform functions similar to those of the association, or its equivalent, in two or more other states. Such a corporation, association, or organization shall be reimbursed for any payments made on behalf of the association and shall be paid for its performance of any function of the association. A delegation under this subsection d. shall take effect only with the approval of both the board of directors and the commissioner, and may be made only to a corporation, association, or organization which extends protection not substantially less favorable or effective than that provided by P.L.1991, c.208 (C.17B:32A-1 et seq.).

§ 17B:32A-10 Additional duties, powers of commissioner

10. a. In addition to the duties and powers enumerated elsewhere in P.L.1991, c.208 (C.17B:32A-1 et seq.), the commissioner shall:

(1) upon request of the board of directors, provide the association with a statement of the premiums in this State and any other appropriate states for each member insurer;

(2) when an impairment is declared and the amount of the impairment is determined, serve a demand upon the impaired insurer to make good the impairment within a reasonable time. Notice to the impaired insurer shall constitute notice to its shareholders, if any. The failure of the impaired insurer to promptly comply with a demand shall not excuse the association from the performance of its powers and duties under P.L.1991, c.208 (C.17B:32A-1 et seq.);

(3) in any liquidation or rehabilitation proceeding involving a domestic member insurer, be appointed as the liquidator or rehabilitator.

b. The commissioner may suspend or revoke, after notice and hearing, the certificate of authority to transact business in this State of any member insurer which fails to pay an assessment when due or fails to comply with the plan of operation. As an alternative, the commissioner may levy a penalty on any member insurer which fails to pay an assessment when due. That penalty shall not exceed five percent of the unpaid assessment per month, but no penalty shall be less than $100 per month.

c. Any action of the board of directors or the association may be appealed to the commissioner by any member insurer if that appeal is taken within 60 days of its receipt of notice of the final action being appealed. If a member insurer is appealing an assessment, the amount assessed shall be paid to the association and made available to meet association obligations during the pendency of an appeal. If the appeal of an assessment is upheld, the amount paid in error or excess shall be returned to the member insurer. Any final action or order of the commissioner shall be subject to judicial review in a court of competent jurisdiction.

d. The liquidator, rehabilitator, or conservator of any impaired insurer may notify all interested persons of the effect of P.L.1991, c.208 (C.17B:32A-1 et seq.).

§ 17B:32A-11 Detection, prevention of insurer insolvencies, impairments

11. a. To aid in the detection and prevention of member insurer insolvencies or impairments, the commissioner may:

(1) notify the commissioners of insurance or comparable officials of all the other states, territories of the United States and the District of Columbia within 30 days when he takes any of the following actions against a member insurer:

(a) revokes its certificate of authority or license;

(b) suspends its certificate of authority or license; or

(c) makes any formal order that the member insurer restrict its premium writing, obtain additional contributions to surplus, withdraw from this State, reinsure all or part of its business, or increase capital, surplus, or any other account for the security of policy or contract owners, certificate holders, or creditors.

Notice shall be made in any form the commissioner deems appropriate, including notification under the auspices of the National Association of Insurance Commissioners, hereinafter referred to as NAIC.

(2) report to the board of directors when he has taken any of the actions set forth in paragraph (1) of this subsection or has received notification from the commissioner of insurance or comparable official of any other jurisdiction that any such action has been taken in that jurisdiction. The report to the board of directors shall contain all significant details of the action taken or of any such notification received from another jurisdiction.

(3) report to the board of directors when he has reasonable cause to believe from any examination, whether completed or in process, of any member insurer that the member insurer may be an impaired or insolvent insurer. The report and the information therein shall be kept confidential by the board of directors.

(4) furnish to the board of directors the NAIC Insurance Regulatory Information System (IRIS) ratios and a list of companies not included in the ratios developed by the NAIC. The board may use the information contained therein in carrying out its duties and responsibilities under this section. The report and information contained therein shall be kept confidential by the board of directors until such time as made public by the commissioner or other lawful authority.

b. The commissioner may seek the advice and recommendations of the board of directors concerning any matter affecting the duties and responsibilities of the commissioner regarding the financial condition of member insurers and member insurers, health service corporations, hospital service corporations, medical service corporations, or health maintenance organizations seeking admission to transact business in this State.

c. The board of directors may, upon majority vote, make reports and recommendations to the commissioner upon any matter germane to the solvency, liquidation, rehabilitation, conservation or receivership of any member insurer or germane to the solvency of any insurer, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization seeking to do business in this State. Reports and recommendations made pursuant to this subsection shall not be considered public documents.

d. The board of directors may, upon majority vote, notify the commissioner of any information indicating any member insurer may be an impaired or insolvent insurer.

e. (Deleted by amendment, P.L.2022, c.98).

f. The board of directors may, upon majority vote, make recommendations to the commissioner for the detection and prevention of member insurer insolvencies.

g. (Deleted by amendment, P.L.2022, c.98).

§ 17B:32A-12 Liabilities of impaired, insolvent insurers

12. a. Nothing in P.L.1991, c.208 (C.17B:32A-1 et seq.) or P.L.2022, c.98 (C.17B:32A-2 et al.) shall be construed to reduce the liability for unpaid assessments of the insureds or enrollees of an impaired or insolvent insurer operating under a plan with assessment liability.

b. Records shall be kept of all negotiations and meetings in which the association or its representatives are involved to discuss the activities of the association in carrying out its powers and duties under section 7 of P.L.1991, c.208 (C.17B:32A-7). Records of those negotiations or meetings shall be made public only upon the termination of a liquidation, rehabilitation, or conservation proceeding involving an impaired or insolvent insurer, upon the termination of the impairment or insolvency of the member insurer, or upon the order of a court of competent jurisdiction.

c. For the purpose of carrying out its obligations under P.L.1991, c.208 (C.17B:32A-1 et seq.), the association shall be deemed to be a creditor of an impaired or insolvent insurer to the extent of assets attributable to covered policies or contracts reduced by any amounts to which the association is entitled as subrogee pursuant to subsection m. of section 7 of P.L.1991, c.208 (C.17B:32A-7). Assets of an impaired or insolvent insurer attributable to covered policies or contracts shall be used to continue all covered policies or contracts and pay all contractual obligations of the impaired or insolvent insurer as required by P.L.1991, c.208 (C.17B:32A-1 et seq.). For purposes of this subsection, assets attributable to covered policies or contracts are that proportion of the assets which the reserves that should have been established for such policies or contracts bears to the reserves that should have been established for all policies or contracts of insurance or health benefit plans written by the impaired or insolvent insurer.

d. As a creditor of the impaired or insolvent insurer as established in subsection c. of this section and consistent with section 33 of P.L.1992, c.65 (C.17B:32-63), the association and other similar associations shall be entitled to receive a disbursement of assets out of the marshaled assets, from time to time as the assets become available to reimburse it, as a credit against contractual obligations under P.L.1991, c.208 (C.17B:32A-1 et seq.). If the liquidator has not, within 120 days of a final determination of insolvency of a member insurer by the receivership court, made an application to the court for the approval of a proposal to disburse assets out of marshaled assets to guaranty associations having obligations because of the insolvency, then the association shall be entitled to make application to the receivership court for approval of its own proposal to disburse these assets.

(1) Prior to the termination of any receivership, liquidation, rehabilitation or conservation proceeding, the court may take into consideration the contributions of the respective parties, including the association, the shareholders, enrollees, certificate holders, and policy or contract owners of an insolvent insurer, and any other party with a bona fide interest in making an equitable distribution of the ownership rights of that insolvent insurer. In making such a determination, consideration shall be given to the welfare of the policy or contract owners, enrollees, and certificate holders, and to the reasonable requirements of a continuing or successor member insurer.

(2) No dividend or other distribution to stockholders or policyholders of an impaired or insolvent insurer shall be made until and unless the total amount of valid claims of the association with interest thereon for funds expended in carrying out its powers and duties under section 7 of P.L.1991, c.208 (C.17B:32A-7) with respect to that member insurer have been recovered by the association.

e. (1) If an order for liquidation or rehabilitation of a member insurer domiciled in this State has been entered, the receiver appointed under that order shall have a right to recover on behalf of the member insurer, from any affiliate that controlled it, the amount of distributions, other than stock dividends paid by the member insurer on its capital stock, made at any time during the five years preceding the petition for liquidation or rehabilitation subject to the limitations of paragraphs (2) through (4) of this subsection.

(2) No such distribution shall be recoverable if the member insurer shows that the distribution was lawful and reasonable when paid, and that the member insurer did not know and could not reasonably have known that the distribution might adversely affect the ability of the member insurer to fulfill its contractual obligations.

(3) Any person who was an affiliate that controlled the member insurer at the time the distributions were paid shall be liable up to the amount of distributions received. Any person who was an affiliate that controlled the member insurer at the time the distributions were declared, shall be liable up to the amount of distributions which would have been received if they had been paid immediately. If two or more persons are liable with respect to the same distributions, they shall be jointly and severally liable.

(4) The maximum amount recoverable under this subsection shall be the amount in excess of all other available assets of the insolvent insurer needed to pay the contractual obligations of the insolvent insurer.

(5) If any person liable under paragraph (3) of this subsection is insolvent, all its affiliates that controlled it at the time the distribution was paid shall be jointly and severally liable for any resulting deficiency in the amount recovered from the insolvent affiliate.

§ 17B:32A-13 Association subject to examination, regulation

13. The association shall be subject to examination and regulation by the commissioner. The board of directors shall submit to the commissioner each year, not later than 120 days after the close of the association's fiscal year, a financial report in a form approved by the commissioner and a report of its activities during the preceding fiscal year. Upon request of a member insurer, the association shall provide a copy of the report.

§ 17B:32A-14 Association exempt from fees, taxes

14. The association shall be exempt from payment of all fees and all taxes levied by this State or any of its subdivisions, except taxes levied on real property.

§ 17B:32A-15 Immunity from liability

15. a. There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member insurer or its agents or employees, the association or its agents or employees, members of the board of directors, or the commissioner or his representatives, for any action or omission by them in the performance of their powers and duties under P.L.1991, c.208 (C.17B:32A-1 et seq.). This immunity shall extend to the participation in any organization of one or more other state associations of similar purposes and to any such organization and its agents or employees.

b. With respect to any impairment or insolvency of a health service corporation created pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.), the association shall have no cause of action against any not-for-profit or nonprofit corporation that is regulated by a law governing the conduct of not-for-profit or nonprofit corporations, except in the event of willful or wanton conduct, unless the not-for-profit or nonprofit corporation is a provider of health care services as defined in section 1 of P.L.1985, c.236 (C.17:48E-1). For purposes of this subsection, "willful or wanton conduct" means a course of action which shows the actual or deliberate intent to cause harm.

§ 17B:32A-16 Stay of proceedings involving insolvent insurer

16. Upon application and notice, all proceedings in which an insolvent insurer is a party or is obligated to defend a party in any court in this State shall be stayed for 180 days and any additional time thereafter as may be determined by the court from the date the insolvency is determined or any ancillary proceeding is initiated in the State, whichever is later, to permit proper defense by the association of all pending causes of action. With respect to any covered claims arising from a judgment under any decision, verdict or finding based on the default of the insolvent insurer or its failure to defend an insured, the association either on its own behalf or on behalf of the insured may apply to have the judgment, order, decision, verdict or finding set aside by the court in which the judgment, order, decision, verdict or finding is entered and shall be permitted to defend against the claim on the merits.

§ 17B:32A-17 Association shall not be used to promote insurance sales

17. a. No person, including a member insurer, agent or affiliate of a member insurer or insurance producer shall make, publish, disseminate, circulate or place before the public or cause directly or indirectly, to be made, published, disseminated, circulated or placed before the public, in any newspaper, magazine or other publication or in the form of a notice, circular, pamphlet, letter or poster, or over any radio station or television station, or in any other way, any advertisement, announcement or statement, written or oral, which uses the existence of the association for the purpose of sales, solicitation, or inducement to purchase any form of insurance or other coverage covered by P.L.1991, c.208 (C.17B:32A-1 et seq.). This subsection shall not apply to the department or the association or to any other entity which does not sell or solicit insurance or coverage by a health service corporation, hospital service corporation, medical service corporation, or health maintenance organization.

b. Within 180 days of the effective date of P.L.1991, c.208 (C.17B:32A-1 et seq.), the association shall prepare a summary document describing the general purposes and current limitations of P.L.1991, c.208 (C.17B:32A-1 et seq.) which complies with subsection c. of this section. This document shall be submitted to the commissioner for approval. Sixty days after receiving that approval, no member insurer may deliver a policy or contract described in subsection b. of section 3 of P.L.1991, c.208 (C.17B:32A-3) to a policy or contract owner, certificate holder, or enrollee unless the document is delivered to the policy or contract owner, certificate holder, or enrollee prior to or at the time of delivery of the policy or contract. The document should also be available upon request by a policy or contract owner, certificate holder, or enrollee. The distribution, delivery, contents or interpretation of this document shall not mean that either the policy or the contract or the policy or contract owner, certificate holder, or enrollee thereof would be covered in the event of the impairment or insolvency of a member insurer. The document shall be revised by the association as amendments to the act may require. Failure to receive this document does not give the policy or contract owner, certificate holder, enrollee, or insured any greater rights than those stated in P.L.1991, c.208 (C.17B:32A-1 et seq.).

c. The document prepared pursuant to subsection b. of this section shall contain a clear and conspicuous disclaimer on its face. The commissioner shall promulgate a rule establishing the form and content of the disclaimer. The disclaimer shall:

(1) state the name and address of the association and the department;

(2) prominently warn the policy owner, contract owner, certificate holder, or enrollee that the association may not cover the policy or contract or, if coverage is available, it will be subject to substantial limitations and exclusions and conditioned on continued residence in this State;

(3) state that the member insurer and its producers are prohibited by law from using the existence of the association for the purpose of sales, solicitation or inducement to purchase any form of insurance, health service corporation coverage, hospital service corporation coverage, medical service corporation coverage, or health maintenance organization coverage;

(4) emphasize that the policy or contract owner, certificate holder, or enrollee should not rely on coverage under the association when selecting a member insurer, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization;

(5) state the types of policies or contracts for which guaranty funds will provide coverage;

(6) explain rights available and procedures for filing a complaint to allege a violation of any provisions of P.L.1991, c.208 (C.17B:32A-1 et seq.); and

(7) provide other information as directed by the commissioner, including, but not limited to, sources for information about the financial condition of member insurers provided that the information is not proprietary and is subject to disclosure under P.L.1963, c.73 (C.47:1A-1 et seq.).

d. A member insurer shall retain evidence of compliance with subsection b. of this section for so long as the policy or contract for which the notice is given remains in effect.

§ 17B:32A-18 Member insurer may offset assessments against premium tax liability

18. a. A member insurer may offset against its premium tax liability, attributable to premiums written in that year, and determined pursuant to section 1 of P.L.1945, c.132 (C.54:18A-1), any assessments for which a certificate of contribution has been issued, pursuant to subsection h. of section 8 of P.L.1991, c.208 (C.17B:32A-8) to the extent of 10% of the amount of those assessments for each of the five calendar years following the second year after the year in which those assessments were paid, except that no member insurer may offset its premium tax liability by more than 20% of its premium tax liability in any one year. If a member insurer should cease doing business in this State, any uncredited assessments may be offset against its premium tax liability for the year in which it ceases to do business in this State.

b. A member insurer that is exempt from taxes referenced in subsection a. of this section may recoup its assessments by a surcharge on its premiums or by a surcharge on its membership fees (as applicable) in a sum reasonably calculated to recoup the assessments over a reasonable period of time, as approved by the commissioner. Amounts recouped shall not be considered premiums for any other purpose, including the computation of gross premium tax, the medical loss ratio, or insurance producer commission. If a member insurer collects excess surcharges, the member insurer shall remit the excess amount to the association, and the excess amount shall be applied to reduce future assessments in the appropriate account.

c. Any sums which are acquired by member insurers as the result of a refund from the association pursuant to subsection f. of section 8 of P.L.1991, c.208 (C.17B:32A-8), and which have theretofore been offset against premium taxes as provided in subsection a. of this section, shall be paid by those member insurers to the State as the Director of the Division of Taxation may require. The association shall notify the commissioner and the Director of the Division of Taxation of any refunds made.

d. This section shall not apply in any way to the imposition or collection of, and no offset shall be permitted against, the surtax on premiums authorized pursuant to section 76 of P.L.1990, c.8 (C.17:33B-49).

§ 17B:32A-19 Provisions not applicable to certain insurers

19. a. The provisions of P.L.1991, c.208 (C.17B:32A-1 et seq.) prior to the effective date of P.L.2022, c.98 (C.17B:32A-2 et al.) shall apply to all matters relating to any impaired insurer or insolvent insurer as defined in section 4 of P.L.1991, c.208 (C.17B:32A-4) for which the association first became obligated under section 7 of P.L.1991, c.208 (C.17B:32A-7) in effect prior to the effective date of P.L.2022, c.98 (C.17B:32A-2 et al.).

b. The provisions of P.L.1991, c.208 (C.17B:32A-1 et seq.) in effect on and after the effective date of P.L.2022, c.98 (C.17B:32A-2 et al.) shall apply to all matters relating to any impaired insurer or insolvent insurer as defined in section 4 of P.L.1991, c.208 (C.17B:32A-4) for which the association first became obligated under section 7 of P.L.1991, c.208 (C.17B:32A-7) on or after the effective date of P.L.2022, c.98 (C.17B:32A-2 et al.).

Chapter 32B

§ 17B:32B-1 Short title.

1. This act shall be known and may be cited as the "New Jersey Insolvent Health Maintenance Organization Assistance Fund Act of 2000."

§ 17B:32B-2 Purpose of act.

2. The purpose of this act is to protect, subject to certain limitations, covered individuals and providers against the failure or inability of HIP Health Plan of New Jersey, Inc. and American Preferred Provider Plan, Inc. to perform certain contractual obligations due to their insolvency. The act creates a funding mechanism and authorizes this funding mechanism to pay certain unpaid contractual obligations of these insolvent health maintenance organizations incurred prior to the date of their insolvency. In addition, providers of health care services must agree to forgive one-third of those unpaid contractual obligations due them to receive payment from the funding mechanism.

This act is intended to provide only limited coverage of claims against HIP Health Plan of New Jersey, Inc. and American Preferred Provider Plan, Inc. This act is not intended to provide coverage for claims of creditors other than those of covered individuals or providers.

§ 17B:32B-3 Definitions relative to certain insolvent health maintenance organizations.

3. As used in this act:

"Association" means the New Jersey Insolvent Health Maintenance Organization Assistance Association created by section 5 of this act.

"Commissioner" means the Commissioner of Banking and Insurance.

"Contractual obligation" means an obligation, arising from an agreement, policy, certificate or evidence of coverage, to a covered individual or provider incurred prior to the declaration of insolvency of a covered health maintenance organization that remains unpaid at the time of its insolvency, but does not include claims by former employees, including medical professional employees for deferred compensation, severance, vacation or other employment benefits.

"Covered health maintenance organization contract" means a policy, certificate, evidence of coverage or contract for health care services issued in New Jersey by HIP Health Plan of New Jersey, Inc. or American Preferred Provider Plan, Inc., but shall not include any contract with an employer or other person to provide health care benefits on an administrative services only basis.

"Covered individual" means an enrollee or member of HIP Health Plan of New Jersey, Inc. or American Preferred Provider Plan, Inc.

"Department" means the Department of Banking and Insurance.

"Eligible claim" means a claim for a covered service or benefit under a contract or policy issued by an insolvent health maintenance organization and provided by a provider or to a covered individual prior to the declaration of insolvency of an insolvent organization, but shall not include any claim filed after the claims bar date established by the Superior Court of New Jersey supervising the insolvent organizations.

"Fund" means the New Jersey Insolvent Health Maintenance Organization Assistance Fund created pursuant to section 6 of this act.

"Insolvent organization" means HIP Health Plan of New Jersey, Inc. or American Preferred Provider Plan, Inc.

"Member organization" means a person who holds a certificate of authority to operate a health maintenance organization pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), and includes any person whose certificate of authority has been suspended, revoked or nonrenewed.

"Net written premiums received" means direct premiums as reported on the annual financial statement submitted pursuant to section 9 of P.L.1973, c.337 (C.26:2J-9).

"Provider" means a physician, hospital or other person which is licensed or otherwise authorized by this State, or licensed or otherwise authorized under similar laws of another state, to provide health care services, and which provided health care services to covered individuals. As used in this act, provider also includes persons who incurred a contractual obligation as defined by this act by providing home health care services, durable medical equipment, physical therapy services, medical transportation, ambulance services or laboratory services to covered individuals.

§ 17B:32B-4 Payment for eligible services, benefits.

4. This act shall provide payment for eligible services or benefits under a covered health maintenance organization contract on an equitable basis to any covered individual or provider who is entitled to receive payment from HIP Health Plan of New Jersey, Inc. and American Preferred Provider Plan, Inc. for an eligible claim that remains unpaid.

§ 17B:32B-5 New Jersey Insolvent Health Maintenance Organization Assistance Association.

5. There is created a nonprofit legal entity to be known as the New Jersey Insolvent Health Maintenance Organization Assistance Association. All health maintenance organizations authorized to transact business in this State shall be and remain members of the association as a condition of their authority to transact business in this State. The association shall perform its functions under the plan of operation established and approved pursuant to section 10 of this act and shall exercise its powers through a board of directors established pursuant to section 7 of this act. The association shall be supervised by the commissioner and is subject to the provisions of this act.

§ 17B:32B-6 New Jersey Insolvent Health Maintenance Organization Assistance Fund.

6. a. For purposes of administration and assessment, the New Jersey Insolvent Health Maintenance Organization Assistance Fund is created, and shall be held in trust and maintained by the association as provided in this act for the purposes specified in this act.

b. The New Jersey Insolvent Health Maintenance Organization Assistance Fund is created as a limited purpose trust fund consisting of not more than $100,000,000 as follows:

(1) $50,000,000 to be deposited in the fund pursuant to section 17 of this act; and

(2) an additional aggregate sum of not more than $50,000,000 collected through assessments over a three-year period as provided in section 9 of this act.

Moneys deposited in the fund pursuant to this section shall be deposited with the State Treasurer in the State of New Jersey Cash Management Fund established pursuant to section 1 of P.L.1977, c.281 (C.52:18A-90.4), pending disbursement for the payment of eligible claims as provided in this act.

c. Moneys deposited in the fund in accordance with this act shall be used by the association to pay eligible claims of the insolvent organizations and loss adjustment expenses associated with the claims, including the cost of claims adjudication.

§ 17B:32B-7 Board of directors.

7. a. The board of directors of the association shall consist of not less than five nor more than nine members, who shall be representative of the member organizations, serving terms as established in the plan of operation. The members of the board of directors shall be selected by a vote of the member organizations, subject to the approval of the commissioner, with each member organization entitled to one vote. Vacancies on the board of directors shall be filled for the remaining period of the term in the same manner as the initial appointment.

b. To allow for the selection of the initial board of directors and the organization of the association, the commissioner shall give notice to all member organizations of the time and place of an organizational meeting no later than 30 days following the effective date of this act. If the member organizations have not selected a suitable board of directors no later than 30 days following the organizational meeting, the commissioner may appoint the initial members of the board of directors.

c. In approving or appointing members to the board of directors, the commissioner shall consider, among other things, whether all member organizations are fairly represented. No representative of an association member that is exempt or becomes exempt from assessments pursuant to subsection e. of section 9 of this act shall be eligible for membership or remain on the board.

d. Members of the board of directors may be reimbursed from the assets of the association for reasonable expenses incurred by them as members of the board of directors, but shall not otherwise be compensated by the association for their services.

§ 17B:32B-8 Maximum liability of association.

8. a. The maximum liability of the association for all coverage provided under this act shall be limited to the amount available from the New Jersey Insolvent Health Maintenance Organization Assistance Fund created in section 6 of this act.

b. If the association fails to act within a reasonable period of time, the commissioner shall have the powers and duties of the association provided by this act with respect to the insolvent organizations.

c. The commissioner shall, in consultation with the association, oversee the payment of eligible claims reimbursable pursuant to this act.

d. The association shall have standing to appear before any court in this State with jurisdiction over the insolvent organizations. That standing shall extend to all matters germane to the powers and duties of the association, including, but not limited to, the payment of eligible claims as provided for in this act. The association shall also have the right to appear or intervene before a court in another state with jurisdiction over the insolvent organizations or with jurisdiction over a third party against whom the association may have rights through subrogation of the organization's enrollees.

e. (1) Any person receiving payment for eligible claims under this act shall be deemed to have assigned the rights under, and any causes of action relating to, the covered health maintenance organization contract to the association to the extent of the payment received pursuant to this act, whether the payments are in full, or on account of, contractual obligations. The association may require an assignment to it of those rights and causes of action by any payee, policy or contract owner, beneficiary, member or enrollee as a condition precedent to the receipt of any right or payment conferred by this act upon that person.

(2) The subrogation rights of the association under this subsection shall have the same priority against the assets of the insolvent organization as that possessed by the person entitled to receive payment under this act.

(3) In addition to the rights of subrogation contained in paragraphs (1) and (2) of this subsection, the association shall have all common law rights of subrogation and any other equitable or legal remedy which would have been available to the insolvent organization or holder of a policy or contract with respect to that policy or contract.

f. The association may:

(1) enter into any contracts necessary or proper to carry out the provisions and purposes of this act;

(2) sue or be sued, including taking any legal actions including a summary proceeding necessary or proper to recover any unpaid assessments imposed pursuant to section 9 of this act and to settle claims or potential claims against it;

(3) borrow money to effectuate the purposes of this act. Any notes or other evidence of indebtedness of the association not in default shall be legal investment for domestic insurers and may be carried as admitted assets;

(4) employ or retain persons necessary to handle the financial transactions of the association, and to perform other functions as are necessary or proper under this act, which may include, but shall not be limited to, the oversight of the adjudication of the claims of the insolvent organization in order to ensure conformance with subsection g. of this section and recommendations to the board with respect to any remedial action necessary for the adjudication of those claims; and

(5) take any legal action necessary to avoid payment of improper claims.

g. Claims shall be adjudicated in accordance with standard industry practice, subject to available documentation and information. The guidelines shall include, but shall not be limited to, the establishment of procedures to ensure that:

(1) the eligible claims or other obligations are paid in accordance with the contractual reimbursement rate payable by the insolvent organization to a covered individual or provider to whom the payment is to be made;

(2) claims submitted by providers or covered individuals for payment are for eligible services or benefits under the contract or policy issued by the insolvent organization, the persons receiving the eligible services or benefits were covered individuals, and the eligible services or benefits were rendered by an eligible provider;

(3) in the case of a provider not in the network of the insolvent organization, any payment made to the provider in accordance with the provisions of section 15 of this act is made on the basis of reasonable and customary reimbursement and shall not be made at a rate that is disproportionate to the reimbursement rates applicable to network providers; and is made only on that portion of the payment due to the provider by the insolvent organization, net of any coinsurance payment due under the insolvent organization's contract with the covered individual;

(4) eligible claims are paid in accordance with coordination of benefits regulations or contract provisions;

(5) no eligible claims are paid that are duplicative; and

(6) claims presented for payment are in compliance with the insolvent organization's utilization review requirements. Claims shall be deemed to be in compliance with respect to benefits or services reviewed by a representative that regularly conducted utilization review on behalf of the insolvent organization on the site of a provider prior to the date of insolvency.

h. (1) At the discretion of the commissioner, the association shall employ the services of a consulting organization with expertise in the adjudication and payment of health benefits claims, other than an organization that is responsible for the payment of claims of the insolvent organizations pursuant to this act, to audit the adjudicated claims of the insolvent organization payable by the association pursuant to this act to determine whether they have been adjudicated in accordance with subsection g. of this section. The consulting organization shall employ procedures for the audit consistent with industry standards and in accordance with standards established by the board and approved by the commissioner, to determine if the adjudication of the claims of the insolvent organizations payable by the association pursuant to this act meets the standards set forth in subsection g. of this section.

(2) The consulting organization shall recommend to the board and the commissioner any remedial measures that may be necessary to ensure the accurate and timely payment of eligible claims.

(3) The cost for the audit of claims provided for in this subsection shall be borne by the members of the association as provided for in the plan of operation and shall not exceed $2,000,000, for which an assessment shall be made on each association member that is required to pay an assessment pursuant to section 9 of this act in proportion to the share its net premiums bear to the aggregate net premiums of all association members writing business in this State.

§ 17B:32B-9 Assessment of member organizations.

9. a. For the purpose of providing the funds necessary to carry out the powers and duties of the association, the board of directors shall assess the member organizations an aggregate amount not to exceed $50,000,000, to be payable in installments, in a manner determined by the commissioner, and after notification to the board, over a period not to exceed three years, in amounts as may be sufficient to meet the periodic disbursements of the association as provided for in subsection b. of this section; provided, however, that the amount of the assessment for the twelve calendar months following the effective date of this act shall not be more than one-third of the aggregate assessment required to be paid pursuant to this subsection. Assessments shall be due not less than 30 days after prior written notice to the member organizations and shall accrue interest on and after the due date at the percentage of interest prescribed in the Rules Governing the Courts of the State of New Jersey for judgments, awards and orders for the payment of money.

b. Fund moneys as set forth in subsection b. of section 6 of this act shall be deposited in an account in the name of the fund in the State of New Jersey Cash Management Fund established pursuant to section 1 of P.L.1977, c.281 (C.52:18A-90.4) and shall be disbursed by the State Treasurer from time to time as needed to pay eligible claims of the insolvent organizations, upon request of the commissioner, after notification to the commissioner by the board of the amount of the disbursement needed by the association to carry out its functions under this act. The funds so disbursed from the State of New Jersey Cash Management Fund shall be deposited in an account or accounts which are in the name of, and shall remain in the custody of, the association, and which account or accounts may be drawn upon as needed by a person designated to disburse funds of the association to covered individuals and providers to pay the eligible claims of the insolvent organizations. Accounts shall be maintained in accordance with the "Governmental Unit Deposit Protection Act," P.L.1970, c.236 (C.17:9-41 et seq.). Disbursements shall be made in the name of the association by a person authorized to disburse association funds to pay eligible claims, which disbursements shall be made in accordance with the plan of operation. The commissioner may direct the association to make an interim partial payment or payments on a pro rata basis to eligible providers or covered individuals of a portion of the aggregate eligible claims payable pursuant to this act, pending any future claims audit or other verification of the eligibility of a claim. The person authorized to disburse association funds to providers shall, in the case of such partial payment, notify the provider that the claim may be subject to retrospective verification or audit and all or part of the disbursement may be reclaimed as a result of the findings. The commissioner may also direct the association to make payment, interim or otherwise, for loss adjustment expenses, including claims adjudication.

c. Assessments against member organizations shall be made in the proportion that the net written premiums received on health maintenance organization business in this State by each assessed member organization for the most recent calendar year for which premium information is available preceding the year in which the assessment is made bears to such premiums received on total health maintenance organization business in this State for that calendar year by all assessed member organizations. The net written premium paid to enroll Medicaid recipients in a Medicaid-contracting health maintenance organization, New Jersey Kid Care and similar State-sponsored programs, and Medicare Plus Choice plans shall not be used to calculate any assessment under this subsection.

d. The amount of each member organization's assessment necessary to meet the requirements of the association with respect to the insolvent organizations under this act shall be determined annually as necessary to implement the purposes of this act, and shall be payable in accordance with subsection a. of this section. Computations of assessments under this section shall be made with a reasonable degree of accuracy, recognizing that exact determinations may not always be possible.

e. The association shall exempt, abate or defer, in whole or in part, the assessment of a member organization if, in the opinion of the commissioner, payment of the assessment would endanger the ability of the member organization to fulfill its contractual obligations or place the member organization in an unsafe or unsound financial condition. If an assessment against a member organization is exempted, abated or deferred, in whole or in part, the amount by which that assessment is exempted, abated or deferred shall be assessed against the other member organizations in a manner consistent with the basis for assessments set forth in subsection c. of this section.

f. The board may provide in the plan of operation for a method of allocating funds among claims, whether relating to one or more insolvent organizations, when the funds available under this act as provided in subsection b. of section 6 of this act will be insufficient to cover anticipated eligible claims. If payment of an eligible claim or portion of a claim is delayed due to the insufficiency of funds available, the association shall not be required to pay, and shall have no liability to, any person for any interest or late charge for the period that the payment of that claim is delayed.

g. The board may, by an equitable method established in the plan of operation, refund to member organizations and the State in proportion to the contribution of each organization, the amount by which the assets of the fund exceed the amount the board, in accordance with subsection e. of section 10 of this act, with the concurrence of the commissioner, finds necessary to carry out the obligations of the association, including assets accruing from assignment, subrogation, net realized gains and income from investments.

h. In determining its schedule of charges or rates filed with the commissioner pursuant to subsection b. of section 8 of P.L.1973, c.337 (C.26:2J-8), or filed in accordance with any other law requiring such filing, no member organization shall include the amount paid or to be paid as assessments under this act, or any portion of that amount, unless the commissioner specifically determines after a separate filing by a member that exclusion of those assessments in determining its schedule of charges or rates will significantly and adversely affect the organization. Each member organization shall annually file a certification to the commissioner that demonstrates compliance with this subsection.

i. The association shall issue to each organization paying an assessment pursuant to this act a certificate of contribution, in a form and manner prescribed by the commissioner, for the amount of the assessment so paid. All outstanding certificates shall be of equal dignity and priority without reference to amount or date of issue. A certificate of contribution may be shown by the organization in its financial statement as an asset in that form and manner and for the amount and period of time as the commissioner may approve.

§ 17B:32B-10 Submission of plan of operation.

10. a. (1) The association shall submit to the commissioner a plan of operation, and any amendments thereto, necessary or suitable to assure the fair, reasonable and equitable administration of the association and the fund. The plan of operation and any amendments thereto shall become effective upon the commissioner's written approval or at the expiration of 30 days after submission if it has not been disapproved.

(2) If the association fails to submit a suitable plan of operation within 90 days following the effective date of this act, or if at any time thereafter the association fails to submit suitable amendments to the plan, the commissioner shall adopt a plan, or amendments as necessary, to implement the provisions of this act. The plan or amendments shall continue in force until modified by the commissioner or superseded by a plan submitted by the association and approved by the commissioner.

b. All member organizations shall comply with the plan of operation.

c. The plan of operation shall, in addition to any other requirements specified in this act:

(1) establish procedures for handling the assets of the association, in accordance with the provisions of this act;

(2) establish the method of reimbursing members of the board of directors under subsection d. of section 7 of this act;

(3) establish regular places and times for meetings, including telephone conference calls, of the board of directors;

(4) establish procedures for keeping records of all financial transactions of the association, its agents and the board of directors;

(5) establish procedures for selecting members of the board of directors and submitting their names to the commissioner;

(6) establish any additional procedures for the imposition of assessments under section 9 of this act; and

(7) contain additional provisions necessary or proper for the execution of the powers and duties of the association.

d. The plan of operation may provide for the delegation of any or all powers and duties of the association, except those set forth in paragraph (3) of subsection e. of section 8 and section 9 of this act, to a corporation, association or other organization which performs or will perform functions similar to those of the association, or its equivalent, in two or more other states. Such a corporation, association or organization shall be reimbursed for any payments made on behalf of the association and shall be paid for its performance of any function of the association. A delegation under this subsection shall take effect only with the approval of both the board of directors and the commissioner, and may be made only to a corporation, association or organization which extends protection not substantially less favorable or effective than that provided by this act.

e. The plan of operation shall provide for the orderly cessation of activity by the association upon the exhaustion of moneys in the New Jersey Insolvent Health Maintenance Organization Assistance Fund created in section 6 of this act, or upon the completion of the payment of eligible claims by the association pursuant to this act, whichever is earlier. Any moneys remaining in the fund upon the cessation of activity by the association shall be distributed to the State and to member organizations in proportion to their contributions to the fund pursuant to sections 6 and 9 of this act.

f. Moneys that are available or become available from the insolvent organization shall be used to make pro rata refunds to member organizations and the State, as appropriate, for the contractual obligations of the insolvent organizations paid by the association pursuant to this act, in accordance with and subject to the provisions of the "Life and Health Insurers Rehabilitation and Liquidation Act," P.L.1992, c.65 (C.17B:32-31 et seq.).

§ 17B:32B-11 Additional powers, duties of the commissioner.

11. a. In addition to the duties and powers enumerated elsewhere in this act, the commissioner shall, upon request of the board of directors, provide the association with a statement of the net written premiums received in this State and any other appropriate states for each member organization.

b. The commissioner may suspend or revoke, after notice and hearing, the certificate of authority to transact business in this State of any member organization which fails to pay an assessment when due or fails to comply with the plan of operation. As an alternative, the commissioner may levy a penalty on any member organization which fails to pay an assessment when due. That penalty shall not exceed five percent of the unpaid assessment per month, but no penalty shall be less than $100 per month.

c. Any action of the board of directors or the association may be appealed to the commissioner by a member organization if that appeal is taken within 30 days from the final action being appealed. If a member organization is appealing an assessment, the amount assessed shall be paid to the association and made available to meet association obligations during the pendency of an appeal. If the appeal of an assessment is successful, the amount paid in error or excess shall be returned to the member organization. Any determination of an appeal from an action of the board of directors shall be subject to review by the commissioner on the record below, and shall not be considered a contested case under the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The commissioner's determination shall be a final agency decision subject to review by the Appellate Division of the Superior Court.

§ 17B:32B-12 Tax credit permitted for member organizations.

12. a. A member organization shall be allowed a credit against the tax imposed pursuant to section 5 of P.L.1945, c.162 (C.54:10A-5), in an amount equal to 50 % of an assessment for which a certificate of contribution has been issued pursuant to subsection i. of section 9 of this act. One-fifth of that credit amount may be applied against the tax imposed pursuant to section 5 of P.L.1945, c.162 (C.54:10A-5) for each of the five privilege periods beginning on or after the third calendar year commencing after the assessment was paid, provided however, that no member organization may reduce that tax liability pursuant to this section by more than 20% of the amount (determined without regard to any other credits allowed pursuant to law) otherwise due for a privilege period. If a member organization should cease doing business in this State, any credit amounts not yet applied against its liability may be applied against its liability for tax imposed pursuant to section 5 of P.L.1945, c.162 (C.54:10A-5) for the privilege period that it ceases to do business in this State.

b. Any sums that are acquired by a member organization as the result of a refund from the association pursuant to subsection g. of section 9 of this act are deemed to be assessment amounts for which a credit was allowed pursuant to subsection a. of this section. If the member organization has applied any amounts of the credit allowed pursuant to subsection a. of this section, then 50% of the amount of any refund shall be paid by the member organization to the State as the Director of the Division of Taxation in the Department of the Treasury may require until the amounts paid equal the amounts applied as credit. The association shall notify the commissioner and the director of any refunds made.

§ 17B:32B-13 Examination, regulation.

13. a. The association shall be subject to examination and regulation by the commissioner. The board of directors shall submit to the commissioner each year, not later than 120 days after the close of the association's fiscal year, a financial report in a form approved by the commissioner and a report of its activities during the preceding fiscal year.

b. The commissioner shall report annually to the Chairman and the Ranking Minority member of the Assembly Appropriations Committee and the Chairman and the Ranking Minority member of the Senate Budget and Appropriations Committee regarding the administration of the fund, including the status of pending litigation, the amount of claims made and the amount of any distributions on those claims, as well as the effects of the assessments under this act on the operations of member organizations.

§ 17B:32B-14 Exemption of association from certain fees, taxes.

14. The association shall be exempt from the payment of all fees and all taxes levied by this State or any of its subdivisions, except those levied on real property.

§ 17B:32B-15 Condition for receipt by providers of payments.

15. As a condition of receiving payment directly from the association for an eligible claim against an insolvent organization, a provider shall agree to forgive that organization of one-third of the unpaid contractual obligation incurred prior to insolvency, which would otherwise be paid by the organization had it not been insolvent. The foregoing shall not apply to any portion of an eligible claim owed to a provider by another insurer, health maintenance organization, or other payer through a coordination of benefits provision. The association is not bound by an assignment of benefits executed with respect to the coverage provided by the insolvent organization. The association may aggregate all eligible claims owed providers when negotiating direct payment of eligible claims of all covered individuals. Nothing in this act shall be construed to preclude any provider from collecting moneys owing to the provider from a self-insured benefit plan that contracted with an insolvent organization to pay claims on an administrative services only basis.

§ 17B:32B-16 Immunity from liability for member organizations, etc.

16. There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member organization or its agents or employees, the association or its agents or employees, or the commissioner or his representatives, for any action or omission by them in the performance of their powers and duties under this act.

§ 17B:32B-17 Rules, regulations.

18. The commissioner shall promulgate such rules and regulations as may be necessary to effectuate the purposes of this act.

Chapter 33

§ 17B:33-1 Short title

This chapter shall be known as the Unauthorized Insurers' Process Act.

a. The purpose of this chapter is to subject unauthorized insurers to the jurisdiction of the commissioner and to the courts of this State in suits by or on behalf of insureds or beneficiaries under insurance contracts or when such insurers place or send into this State any advertising designed to induce residents of this State to purchase insurance. It is in the interest of the State and of those residents of this State who purchase insurance from insurers which solicit insurance business in this State in the manner set forth in the preceding sentence that such insurers be subject to the provisions of this chapter and also that those residents who hold policies issued or delivered in this State by unauthorized insurers not be subjected to the obstacle of resorting to distant forums for the purpose of asserting legal rights under any policies. In furtherance of such state interest, there is provided herein a method of substituted service of process upon such insurers which is declared to be in the exercise of a state's power to protect its residents pursuant to the powers and privileges available to the State by virtue of Public Law 15, 79th Congress of the United States, Chapter 20, 1st Session, s. 340, which declares that the business of insurance and every person engaged therein shall be subject to the laws of the several states; the authority provided herein to be in addition to any existing powers of this State.

b. The provisions of this act shall be liberally construed.

§ 17B:33-2 Acts constituting commissioner as process agent

Any of the following acts in this State by an unauthorized insurer, whether effected by mail or other means, shall be equivalent to and shall constitute an appointment of the commissioner and of any other person discharging the duties of his office to be the true and lawful attorney of such insurer for the service upon him of all lawful process and other papers required by the practice of this State to be served in any action or proceeding instituted by or on behalf of an insured or beneficiary arising out of any contracts of insurance of the kinds defined in sections 17B:17-3, 17B:17-4 and 17B:17-5 and any such act shall signify its agreement that the service of such process and other papers shall have the same legal force, validity and effect as personal service of the same in this State upon such insurer:

a. the issuance or delivery of contracts of insurance to residents of this State or to corporations authorized to do business therein;

b. the solicitation or negotiation of applications for such insurance;

c. the collection of premiums, membership fees or dues, assessments or other considerations for such contracts;

d. any other transaction of business in relation to such contracts of insurance.

§ 17B:33-3 Service of process on commissioner as process agent

Service of process and other papers upon the commissioner as the true and lawful attorney of an unauthorized insurer pursuant to this chapter may be effected by any person lawfully authorized to serve process and other papers in civil actions generally by delivering or by mailing by certified or registered mail, return receipt requested, 2 copies thereof, together with the fee prescribed by law, to the commissioner or to someone designated by him in his office. Such service shall be effective and valid notwithstanding that the county in which the court is situated or in which venue is laid is a county other than that in which the commissioner's office is located. Upon receipt of any such service, the commissioner shall within 2 days thereafter (excluding Saturdays, Sundays and holidays) mail one of said copies by certified or registered mail, return receipt requested to the defendant addressed to it at its principal place of business, or to its registered office or to a registered agent for service. The commissioner shall keep a record of all process and papers so served upon him and of the mailing thereof to defendant. Upon so giving notice to the defendant of the service made upon him on its behalf, the commissioner shall forward to the clerk of the court for filing his certificate of the service upon him and of the notice given by him.

§ 17B:33-4 Service of process on persons acting on behalf of unauthorized insurer

In addition to other methods authorized for the service of process and other papers upon an unauthorized insurer, such service may be made upon any agent, servant, employee or representative thereof within this State acting in the discharge of his duties. In addition to other forms of activity, any such person shall be deemed to be acting in this State on behalf of such insurer when he a. solicits or negotiates insurance, or b. makes, issues or delivers any contract of insurance, or c. collects or receives any premium, membership fees or dues, assessment or other consideration for insurance.

§ 17B:33-5 Service of process by other means

Nothing in this chapter shall be taken or construed to limit or abridge the means or methods by which any process or other papers may be served according to law or rules or orders of court now or hereafter provided.

§ 17B:33-6 Judgment by default

Whenever the service of process is effected by a method authorized by this chapter, the time within which the defendant shall be allowed to serve answer shall be the same as is otherwise provided in the case of service by mail or publication in civil actions generally, and no default or judgment based thereon shall be entered until after the expiration of such time.

§ 17B:33-7 Deposit of bond by unauthorized insurer

Before any unauthorized insurer shall file or cause to be filed any pleading or other paper in any action or proceeding instituted against it in any court of this State, such insurer shall either a. deposit with the clerk of the court cash or securities or file with such clerk a bond approved by the court as to the sureties and in an amount fixed by it sufficient to secure the payment of any final judgment which may be rendered; provided, however, that the court may, on notice and hearing, dispense with such deposit or bond upon being satisfied that the insurer maintains, in a State of the United States, funds or securities, in trust or otherwise, sufficient and available to satisfy any final judgment which may be entered; or b. procure a certificate of authority to transact the business of insurance in this State.

§ 17B:33-8 Damages for unjustified refusal to pay

In any action against an unauthorized foreign or alien insurer upon a contract of insurance issued or delivered in this State to a resident thereof or to a corporation authorized to do business therein, if it shall be shown that the insurer failed for 30 days after written demand accompanied by a copy of this section, all prior to the institution of the action, to make payment in accordance with the terms of the contract without presenting a colorable defense in law or fact, the plaintiff shall be entitled to recover consequential damages for such unjustified refusal as part of his cause of action, the said damages to be measured by the reasonable costs and expenses incurred by plaintiff, including costs and expenses for the services of counsel and for investigation, as well as interest, and the same shall be included in the damages set forth in the final judgment; but no item recoverable as costs in the action shall be included in such damages.

§ 17B:33-9 Misrepresentation by unauthorized insurer; notice to domiciliary supervisory official; action

No unauthorized insurer shall make, issue, circulate or cause to be made, issued or circulated, to residents of this State any estimate, illustration, circular, pamphlet, or letter, or cause to be made in any newspaper, magazine or other publication, any announcement or statement to such residents misrepresenting its financial condition or the terms of any contracts issued or to be issued or the benefits or advantages promised thereby, or the dividends or share of the surplus to be received thereon in violation of chapter 30 of Title 17B of the Revised Statutes and whenever the commissioner shall have reason to believe that any such insurer is engaging in such unlawful advertising, he shall give notice of such fact by registered or certified mail to such insurer and to the insurance supervisory official of the domiciliary State of such insurer. For the purpose of this section, the domiciliary State of an alien insurer shall be deemed to be the State of entry or the State of the principal office in the United States.

If after 30 days following the giving of notice, such insurer has failed to cease making, issuing, or circulating such false misrepresentations or causing the same to be made, issued or circulated in this State, and if the Commissioner has reason to believe that a proceeding by him in respect to such matters would be to the interest of the public, and that such insurer is issuing or delivering contracts of insurance to residents of this State or collecting premiums on such contracts or doing any of the acts enumerated in section 17B:33-2, the commissioner shall issue and serve upon such unauthorized insurer a statement of the charges in that respect and a notice of hearing pursuant to the Administrative Procedure Act (P.L.1968, c. 410) and any rules adopted thereunder for an order to cease and desist.

Chapter 34

§ 17B:34-1 Applicability of chapter

The provisions of this chapter shall apply to all matters in respect to which a particular section directs that proceedings shall be governed by this chapter, and to matters to be dealt with by the commissioner in respect to any person coming within the scope of this Code in those instances where and to the extent that the section or sections involved do not contain specific provisions for procedure, administration or the like.

§ 17B:34-2 General policy

Provisions for procedure, administration and the like, set out in this Code shall be construed and applied so as to aid in the operation of applicable law in a fashion compatible with the reasonable, flexible and efficient operation and conduct of the regulated activity and with the interests of the public. To that end, administrative action shall be prospective whenever feasible and appropriate; it shall provide a suitable period of time, and shall allow suitable and practicable means, for achieving and implementing the purposes of the action taken, either by provision in the step embodying the action taken or by proceedings supplementary thereto.

§ 17B:34-3 Subsequently enacted laws

Laws hereafter enacted by way of amendment or supplement to this Code shall be dealt with in respect to matters of procedure, administration and the like with the same effect as though they had been part of said Code when originally enacted, unless the same shall expressly provide otherwise. Any reference to the Revised Statutes or laws of New Jersey in this Code shall be deemed to refer to such Revised Statutes or laws of New Jersey as enacted and heretofore or hereafter amended or supplemented.

§ 17B:34-4 Filing

Whenever any matter is required to be filed with the commissioner, the same shall be deemed to have been filed on the date it is received by mail, addressed to the commissioner, or on which it is delivered by means other than mailing. The commissioner shall not return or refuse to file any matter required to be filed with him because of any technical defect of form or content, but in any such case he shall notify the person involved of the defect or defects and of a reasonable date by which a correction, amendment or supplement shall be supplied. Unless the commissioner states that intervening rights or interests are or may be affected, or unless the person making the same shall indicate otherwise, the correction, amendment or supplement shall relate back to the date of the initial filing of the matter. In the alternative, the person filing the matter may withdraw the defective filing.

§ 17B:34-5 Submission for approval or determination

Whenever any matter is required to be submitted, filed or otherwise presented so that it may be brought to the attention of the commissioner, then, unless a different time is specified in the applicable provision, the same shall be taken to have been approved upon the expiration of 30 days after the filing thereof if no notice of disapproval, or of suspension and inquiry, shall be issued and if the matter is not withdrawn, within such time. The commissioner may extend the 30 day period referred to in the preceding sentence for not more than 30 additional days by giving written notice of such extension before the expiration of the initial 30 day period. In the event of such extension, the provisions of this section, except the provision for extension, relating to the initial 30 day period, shall apply to the extended period instead of such initial 30 day period. Approvals taking effect pursuant to this section may be relied upon by all persons with like effect as though there had been an affirmative written approval, during such a period as may ensue thereafter prior to the making of a subsequent order of disapproval on notice and hearing.

§ 17B:34-6 Effect of withdrawals, approvals and the like

The withdrawal of any matter shall be without prejudice unless expressly stated to be with prejudice. Approvals resulting from the lapse of time shall not be a bar to subsequent disapproval or modified approval by order after notice and hearing unless the same be waived, but any such order shall be prospective only from a date specified therein or in an order on supplemental proceedings.

§ 17B:34-7 Number of copies

One copy of any paper or other matter to be filed, submitted or otherwise presented shall be sufficient. Additional copies if thereafter requested by the commissioner shall be furnished to him in a reasonable number in accordance with the needs of the matter but in any case where it is indicated to the commissioner that the furnishing of additional copies would be burdensome he may request, in lieu thereof, that a copy or copies be placed on deposit at a specified place or places, during stated hours and for a stated period, for the reasonable inspection thereof by persons having a proper interest therein.

§ 17B:34-8 Subpoenas

to witnesses shall be issued in the name of the commissioner by him or by any deputy commissioner or other employee designated by him at the request of any person interested in the proceeding, but no subpoena duces tecum shall be issued except for good cause shown. All subpoenas shall be subject to modification or cancellation on application and upon a showing that the same is oppressive or unreasonable, that the witness or evidence to be produced is not reasonably related to the matter, or on any other proper ground. Any person failing or refusing to comply with the command of a subpoena may be ordered by a judge of the Superior Court, on application made by the commissioner or by the person at whose instance the subpoena was issued, and to be proceeded upon in a summary manner, to comply with the terms of the subpoena or else to be punished by the court for contempt.

§ 17B:34-9 Orders pending hearing

In any formal proceeding, where the commissioner finds that the interests of the public require that immediate action be taken pending the completion of the hearings, the making of a determination thereon and the entry of a final order, he may enter an appropriate order to be effective pending the hearing and until the entry of a final order. Such orders may be entered on ex parte proofs where the proofs are strong and the need is great, but ex parte orders shall be subject to application to vacate on 2 days' notice, and a preliminary hearing on the ex parte order shall be held in any event within not more than 20 days after entry thereof. In the alternative, or in addition thereto, the commissioner shall be authorized to institute a proceeding in the Superior Court, to be conducted in a summary manner, for an injunction against specified acts or conduct in aid of the proceedings pending before him, including temporary injunctions and interim restraints, upon a showing that such remedy would be more effective and complete.

§ 17B:34-10 Judicial review; stay

Orders of the commissioner, whether temporary or final, shall be subject to judicial review. Any party intending to seek judicial review may request the commissioner to amend his order so that it will not take effect until such review has been completed, or to stay or suspend its taking effect, and the commissioner is authorized to do so as requested or on terms so long as it does not appear that the public interest will be prejudiced thereby. Any such action on the part of the commissioner shall be subject to modification or revocation.

§ 17B:34-11 Matters not otherwise provided for

In the administration of any matter, the procedure for which is not specified by any applicable provision of law or of any rule or regulation, a specific procedure may be authorized by the commissioner by analogy to any statute or rule of court calculated to achieve a fair, efficient and proper presentation, management and disposition of the matter involved.

§ 17B:34-12 Effect of Chapter

The enactment of the provisions of this Chapter shall provide an alternative method of action and shall in no way be deemed to repeal the provisions of Chapters 66 and 68 of the Laws of 1958 nor the provisions of Chapter 12 of the Laws of 1970.

Chapter 35

§ 17B:35-1 Certificate of authority existing prior to effective date of act; expiration; renewal

Every certificate of authority of an insurer in force immediately prior to the effective date of this act and existing under any law herein repealed shall be valid until midnight of the last day of April next following such effective date, unless earlier terminated in accordance with this act. Such certificate of authority upon first renewal under this act shall be replaced by a certificate of authority in form as consistent with this act, and shall thereafter be subject to continuance, suspension, revocation or termination as though originally issued under this act.

§ 17B:35-2 Licenses in force prior to effective date of act; continuance; expiration; renewal

Every license in force immediately prior to the effective date of this act and existing under any law herein repealed shall be valid until midnight of the day such license would have expired under such law, unless earlier suspended, revoked, or terminated in accordance with this act. Such license upon first renewal under this act shall be replaced by a license in form consistent with this act, and shall thereafter be subject to continuation, suspension, revocation, or termination as though originally issued under this act.

§ 17B:35-3 Form of insurance document, rate or filing lawfully used prior to effective date of act; continuance of use and effectiveness

Every form of insurance document and every rate or other filing lawfully in use immediately prior to the effective date of this act may continue to be so used or be effective until the commissioner otherwise prescribes pursuant to this act; except, that before expiration of one year from and after such effective date neither this act nor the commissioner shall prohibit the use of any such document, rate, or filing because of any power, prohibition, or requirement contained in this act which did not exist under laws in force immediately prior to such effective date, unless expressly otherwise provided in this act.

§ 17B:35-4 Deposits in compliance with condition precedent to or in connection with certificate of authority prior to effective date of act; use for similar purposes

Any deposit made in this State under any law repealed herein, with or through the Department of Insurance or the commissioner, or by any insurer in compliance with a condition precedent to or in connection with its certificate of authority to transact insurance in this State, and so on deposit immediately prior to the effective date of this act, shall be given full recognition as fulfillment, to the extent of such deposit, or any deposit so required for similar purposes under this act. The deposit shall hereafter be held for the purpose applicable thereto as specified in this act, and shall be subject in all respects to the provisions of this act applicable to similar deposits newly made under this act.

§ 17B:35-5 References to repealed provisions as references to provisions of this act

Any laws of New Jersey, other than this act, remaining in force after the effective date of this act which refer to certain provisions of law repealed under this act, shall be deemed to refer to those provisions of this act which are in substance the same or substantially the same as such repealed provisions.

§ 17B:35-6 Impairment or effect on acts, offenses, rights, penalties, etc., prior to effective date of act

This act shall not impair or affect any act done, offense committed, or right accruing, accrued, or acquired, or liability, penalty, forfeiture or punishment incurred, prior to the time this act takes effect, but the same may be enjoyed, asserted, enforced, prosecuted or inflicted, as fully and to the same extent as if this act had not been passed.

§ 17B:35-7 Insurer organized under any repealed act; continuance of existence and rights

The repeal by this code of the whole or any part of any act under which there was organized any insurer in existence on the effective date of this code shall not work a dissolution of such insurer, but the existence of such insurer and the tenure of its officers and directors shall be preserved and such insurer, its officers, directors and policyholders shall have the same rights and shall be subject to the same limitations, restrictions, liabilities and penalties as those prescribed by this code for insurers organized under this code, their officers, directors and policyholders.

Chapter 36

§ 17B:36-1 Sections and acts saved from repeal

The following sections, acts, and parts of acts, together with all amendments and supplements thereto, are saved from repeal.

a. The following sections of the Revised Statutes are saved from repeal:

17:17-13.

17:18-2.

17:20-5.

17:21-3.

17:24-1, 17:24-3, 17:24-5 through 17:24-12, both inclusive.

17:28-2.

17:29-7, 17:29-10 through 17:29-12, both inclusive.

17:32-4, 17:32-5, 17:32-8, 17:32-9, 17:32-10, 17:32-13.

b. The following acts are saved from repeal:

P.L.1951, Chapter 206 (C. 17:17-14).

P.L.1938, Chapter 289, s.s. 6, 7, 8 (C. 17:18-13, 17:18-14, 17:18-15).

P.L.1966, Chapter 50 (C. 17:22-6.2a).

P.L.1944, Chapter 175, s.s. 5, 15, 18, 19, 22, 23, 26, 27, 28 (C. 17:22-6.5, 17:22-6.15, 17:22-6.18, 17:22-6.19, 17:22-6.22, 17:22-6.23, 17:22-6.26, 17:22-6.27, 17:22-6.28).

P.L.1948, Chapter 462 (C. 17:22-6.35 and C. 17:22-6.36).

P.L.1960, Chapter 32, s.s. 6-33, both inclusive, 1, 2 (C. 17:22-6.40 to 17:22-6.67, both inclusive, 17:22-6.68 and 17:22-6.69).

P.L.1967, Chapter 201, s.s. 9, 10 (C. 17:24-25, 17:24-26).

P.L.1938, Chapter 259 (C. 17:27-5A).

P.L.1968, Chapter 385 (C. 17:28-1.1, 17:28-1.2).

P.L.1939, Chapter 74 (C. 17:28-4 through 17:28-7, both inclusive).

P.L.1950, Chapter 271, s. 2 (C. 17:28A-3).

P.L.1947, Chapter 379, s. 14 (C. 17:29B-14).

P.L.1968, Chapter 234, s. 7 (C. 17:32-22).

P.L.1968, Chapter 318, s. 14 (C. 17:35B-14).

P.L.1959, Chapter 168 (C. 17:38-1.1 and 17:38-1.2).

P.L.1951, Chapter 237, s. 13 (C. 17:38-13.12).

P.L.1970, Chapter 22 (C. 17:27A-1 to C. 17:27A-14, both inclusive).

§ 17B:36-2 Sections and acts repealed

The following sections, acts, and parts of acts, together with all amendments and supplements thereto, are hereby repealed.

a. The following sections of the Revised Statutes are repealed entirely:

17:24-4.

17:34-4 through 17:34-6, both inclusive; 17:34-8 through 17:34-17, both inclusive; 17:34-19 through 17:34-21, both inclusive.

17:34-22.

17:34-23 through 17:34-25.1, both inclusive.

17:34-26 and 17:34-27.

17:34-31 and 17:34-32.

17:34-33 through 17:34-43, both inclusive.

17:34-44 through 17:34-48, both inclusive.

17:38-1.

b. The following acts are repealed entirely:

P.L.1944, Chapter 175, s. 24 (C. 17:22-6.24).

P.L.1949, Chapter 248, s. 3 (C. 17:24-15).

P.L.1967, Chapter 201, s.s. 1 through 8, both inclusive, and 11 (C. 17:24-17 through C. 17:24-24, both inclusive, and C. 17:24-27).

P.L.1950, Chapter 276 (C. 17:28A-1).

P.L.1950, Chapter 271, s. 1 (C. 17:28A-2).

P.L.1943, Chapter 15 (C. 17:34-3.2 through C. 17:34-3.10, both inclusive).

P.L.1949, Chapter 198, s. 2 (C. 17:34-3.11).

P.L.1953, Chapter 156 (C. 17:34-3.12 through C. 17:34-3.22, both inclusive).

P.L.1943, Chapter 148, s.s. 1 and 2 (C. 17:34-21.1 and C. 17:34-25.2).

P.L.1946, Chapter 119 (C. 17:34-22.1).

P.L.1957, Chapter 62, s. 3 (C. 17:34-25.3).

P.L.1950, Chapter 301, s. 3 (C.17:34-32.2).

P.L.1969, Chapter 97 (C. 17:34-32.3).

P.L.1940, Chapter 208, s.s. 1 through 5, both inclusive, and 7 (C. 17:34-43.1 through C. 17:34-43.5 and C. 17:34-43.7).

P.L.1946, Chapter 154 (C. 17:34-49, C. 17:34-50 through C. 17:34-58).

P.L.1961, Chapter 82, s. 82 (C. 17:34-49.1).

P.L.1959, Chapter 122, s.s. 1 through 5 (C. 17:35A-1 through C. 17:35A-5).

P.L.1959, Chapter 123 (C. 17:35A-6 through C. 17:35A-13).

P.L.1968, Chapter 318, s.s. 1 through 13 (C. 17:35B-1 through C. 17:35B-13).

P.L.1951, Chapter 237, s.s. 2 through 4, 6 through 12 (C. 17:38-13.1 through C. 17:38-13.3, both inclusive, C. 17:38-13.5 through C. 17:38-13.11, both inclusive).

P.L.1967, Chapter 33 (C. 17:38-13.13).

P.L.1939, Chapter 305, s.s. 1, 2, 4, 5, 6 and 7 (C. 17:38-14, C. 17:38-15, C. 17:38-17 through C. 17:38-20).

P.L.1967, Chapter 35 (C. 17:38-20.1).

P.L.1967, Chapter 276 (C. 17:38-20.2).

P.L.1958, Chapter 169 (C. 17:38A-1 through C. 17:38A-15).

P.L.1949, Chapter 156 (C. 17:18-12.1).

§ 17B:36-3 Partial Repealers

a. The following sections of the Revised Statutes are hereby repealed insofar as they apply to the formation of and subsequent authorization of companies to do life insurance, health insurance or annuities business: 17:17-1 to 17:17-11, both inclusive.

b. The following sections of the Revised Statutes are hereby repealed insofar as they apply to any company authorized to do one or more of the following kinds of business as defined in Title 17B: life insurance, health insurance and annuities:

17:18-1, 17:18-3, 17:18-4, 17:18-5, 17:18-6, 17:18-8 through 17:18-10, both inclusive; 17:18-12 and 17:18-16.

17:20-1 through 17:20-4, both inclusive.

17:21-1 through 17:21-2, both inclusive.

17:23-1, 17:23-2, 17:23-4 and 17:23-5.

17:25-1 through 17:25-7, both inclusive.

17:26-1, 17:26-2 through 17:26-6, both inclusive.

17:27-1 through 17:27-5, both inclusive.

17:30-1 through 17:30-8, both inclusive.

17:32-1 through 17:32-3, both inclusive; and 17:32-14.

c. The following acts are hereby repealed insofar as they apply to any company authorized to do one or more of the following kinds of business as defined in Title 17B: life insurance, health insurance and annuities:

P.L.1948, Chapter 157 (C. 17:17A-1 to C. 17:17A-4, both inclusive).

P.L.1966, Chapter 85 (C. 17:20-6).

P.L.1958, Chapter 15 (C. 17:23-6 to C. 17:23-7, both inclusive).

P.L.1949, Chapter 248, s.s. 1, 2 and 4 (C. 17:24-13, C. 17:24-14, C. 17:24-16).

P.L.1943, Chapter 14 (C. 17:26-1.1).

P.L.1956, Chapter 149 (C. 17:27-5.1 to C. 17:27-5.4, both inclusive).

P.L.1947, Chapter 379, s.s. 1 through 13, both inclusive (C. 17:29B-1 to C. 17:29B-13, both inclusive).

P.L.1950, Chapter 231 (C. 17:32-15).

P.L.1968, Chapter 234, s.s. 1 through 6, inclusive (C. 17:32-16 to C. 17:32-21, both inclusive).

P.L.1952, Chapter 330 (C. 17:51-1 to C. 17:51-5, both inclusive).

d. The following act is hereby repealed as it applies to any company solely authorized to do one or more of the following kinds of business as defined in Title 17B: life insurance, health insurance and annuities: P.L.1970, Chapter 215 (C. 17:29D-1).

e. The following sections of the Revised Statutes are hereby repealed insofar as they apply to any company authorized to do one or more of the following kinds of business as defined in Title 17B: life insurance, health insurance and annuities, and insofar as said sections apply to the health insurance business of any company transacting any insurance not defined in Title 17B: 17:33-1 and 17:33-2.

f. The following acts are hereby repealed insofar as they apply to any aspect of the licensing of, business of or any other matter pertaining to any agent, solicitor or broker which aspect relates to life insurance, health insurance or annuities, and insofar as applicable to the health insurance business of any company transacting any insurance not defined in Title 17B:

P.L.1944, Chapter 175, s.s. 1, 2, 3, 4, 6 through 14, both inclusive, 16, 17, 20 and 25 (C. 17:22-6.1, C. 17:22-6.2, C. 17:22-6.3, C. 17:22-6.4, C. 17:22-6.6 through C. 17:22-6.14, both inclusive, C. 17:22-6.16, C. 17:22-6.17, C. 17:22-6.20 and C. 17:22-6.25).

P.L.1962, Chapter 211 (C. 17:22-6.16a).

P.L.1960, Chapter 32, s.s. 3, 4 and 5 (C. 17:22-6.37, C. 17:22-6.38 and C. 17:22-6.39).

g. The following section of the Revised Statutes is hereby repealed insofar as it applies to any company authorized to do one or more of the following kinds of business as defined in Title 17B: life insurance, health insurance and annuities, and insofar as it applies to any aspect of the licensing of, business of or any other matter pertaining to any agent, solicitor or broker which aspect relates to life insurance, health insurance or annuities; and insofar as it applies to the health insurance business of any company transacting any insurance not defined in Title 17B: 17:17-12.

h. The following section of the Revised Statutes is hereby repealed insofar as it applies to any aspect of the licensing of, business of or any other matter pertaining to any agent, solicitor or broker which aspect relates to life insurance, health insurance or annuities and insofar as applicable to the health insurance business of any company transacting any insurance not defined in Title 17B: 17:22-6.

i. The following sections of the Revised Statutes are hereby repealed as to life insurance, health insurance and annuities: 17:28-1 and 17:28-3.

§ 17B:36-4 Effective date

Except as otherwise expressly provided this act shall take effect January 1, 1972.

Chapter 37

§ 17B:37-1 Short title, findings, declarations.

1. a. This act shall be known and may be cited as the "Interstate Insurance Product Regulation Compact."

b. The Legislature finds and declares that the purposes of this act, through means of joint and cooperative action among the compacting states, are to:

(1) promote and protect the interests of consumers of individual and group annuity, life insurance, disability income, and long-term care insurance products;

(2) develop uniform standards for insurance products covered under this act;

(3) establish a central clearinghouse to receive and provide prompt review of insurance products covered under the compact and, in certain cases, advertisements related thereto, submitted by insurers authorized to do business in one or more compacting states;

(4) give appropriate regulatory approval to those product filings and advertisements satisfying the applicable uniform standard;

(5) improve coordination of regulatory resources and expertise between state insurance departments regarding the setting of uniform standards and the review of insurance products covered under the compact;

(6) create the Interstate Insurance Product Regulation Commission; and

(7) perform these and any other related functions as may be consistent with the State's regulation of the business of insurance.

§ 17B:37-2 Definitions relative to the "Interstate Insurance Product Regulation Compact."

2. For the purposes of this act:

"Advertisement" means any material designed to create public interest in an insurance product, or induce the public to purchase, increase, modify, reinstate, borrow on, surrender, replace or retain a policy, as more specifically defined in the rules and operating procedures of the Interstate Insurance Product Regulation Commission established by section 3 of this act.

"Bylaws" mean those bylaws established by the Interstate Insurance Product Regulation Commission for its governance, or for directing or controlling the commission's actions or conduct.

"Commission" means the Interstate Insurance Product Regulation Commission established by section 3 of this act.

"Commissioner" means the chief insurance regulatory official of a state including, but not limited to the commissioner, superintendent, director or administrator.

"Compact" means the "Interstate Insurance Product Regulation Compact" established by this act.

"Compacting state" means any state which has enacted this or similar compact legislation and which has not withdrawn or been terminated pursuant to section 14 of this act.

"Domiciliary state" means the state in which an insurer is incorporated or organized; or, in the case of an alien insurer, its state of entry.

"Insurer" means any entity licensed by a state to issue contracts of insurance for any of the lines of insurance covered by this act.

"Member" means the person chosen by a compacting state as its representative to the commission, or his designee.

"Non-compacting state" means any state which is not a compacting state.

"Operating procedures" means procedures promulgated by the commission implementing a rule, uniform standard, or a provision of this act.

"Product" means the form of a policy or contract, including any application, endorsement, or related form which is attached to and made a part of the policy or contract, and any evidence of coverage or certificate, for an individual or group annuity, life insurance, disability income, or long-term care insurance product that an insurer is authorized to issue.

"Rule" means a statement of general or particular applicability and future effect promulgated by the commission, including a uniform standard developed pursuant to section 7 of this act, designed to implement, interpret, or prescribe law or policy, or describing the organization, procedure, or practice requirements of the commission, which shall have the force and effect of law in the compacting states.

"State" means any state, district, or territory of the United States of America.

"Third party filer" means an entity that submits a product filing to the commission on behalf of an insurer.

"Uniform standard" means a standard adopted by the commission for a product line, pursuant to section 7 of this act, and shall include all of the product requirements in aggregate; provided, that each uniform standard shall be construed, whether express or implied, to prohibit the use of any inconsistent, misleading, or ambiguous provisions in a product, and the form of the product made available to the public shall not be unfair, inequitable, or against public policy as determined by the commission.

§ 17B:37-3 "Interstate Insurance Product Regulation Commission."

3. a. The compacting states hereby create and establish a joint public agency known as the "Interstate Insurance Product Regulation Commission." Pursuant to section 4 of this act, the commission shall develop uniform standards for product lines, receive and provide prompt review of products filed therewith, and give approval to those product filings satisfying applicable uniform standards; however, it is not intended for the commission to be the exclusive entity for receipt and review of insurance product filings. Nothing in this act shall prohibit an insurer from filing its product in any state in which the insurer is licensed to conduct the business of insurance, which filing shall be subject to the laws of the state where filed.

b. The commission is a body corporate and politic, and an instrumentality of the compacting states.

c. The commission is solely responsible for its liabilities except as otherwise specifically provided in this act.

d. Venue is proper and judicial proceedings by or against the commission shall be brought solely and exclusively in a court of competent jurisdiction where the principal office of the commission is located.

§ 17B:37-4 Powers of commission.

4. The commission shall have the following powers:

a. To promulgate rules, pursuant to section 7 of this act, which shall have the force and effect of law and shall be binding in the compacting states to the extent and in the manner provided in this act;

b. To exercise its rule-making authority and establish reasonable uniform standards for products covered under this act, and advertisements related thereto, which shall have the force and effect of law and shall be binding in the compacting states, but only for those products filed with the commission, provided, that a compacting state shall have the right to opt out of those uniform standards pursuant to section 7 of this act, to the extent and in the manner provided in this act, and, provided further, that any uniform standard established by the commission for long-term care insurance products may provide the same or greater protections for consumers as, but shall not provide less than, those protections set forth in the National Association of Insurance Commissioners' (NAIC) Long-Term Care Insurance Model Act and Long-Term Care Insurance Model Regulation, respectively, adopted as of 2001. The commission shall consider whether any subsequent amendments to the NAIC Long-Term Care Insurance Model Act or Long-Term Care Insurance Model Regulation adopted by the NAIC require amendment of the uniform standards established by the commission for long-term care insurance products;

c. To receive and review in an expeditious manner, products filed with the commission, and rate filings for disability income and long-term care insurance products, and give approval of those products and rate filings that satisfy the applicable uniform standard, which approval shall have the force and effect of law and be binding on the compacting states to the extent and in the manner provided in this act;

d. To receive and review in an expeditious manner, advertisements relating to long-term care insurance products for which uniform standards have been adopted by the commission, and give approval to all advertisements that satisfy the applicable uniform standard. For any product covered under the compact, other than long-term care insurance products, the commission shall have the authority to require an insurer to submit all or any part of its advertisement with respect to that product for review or approval prior to use, if the commission determines that the nature of the product is such that an advertisement of the product could have the capacity or tendency to mislead the public. The actions of the commission as provided in this section shall have the force and effect of law, and shall be binding in the compacting states to the extent and in the manner provided in this act;

e. To exercise its rule-making authority and designate products and advertisements that may be subject to a self-certification process without the need for prior approval by the commission;

f. To promulgate operating procedures, pursuant to section 7 of this act, which shall be binding in the compacting states to the extent and in the manner provided in this act;

g. To bring and prosecute legal proceedings or actions in its name as the commission; however, the standing of any state insurance department to sue or be sued under applicable law shall not be affected;

h. To issue subpoenas requiring the attendance and testimony of witnesses and the production of evidence;

i. To establish and maintain offices;

j. To purchase and maintain insurance and bonds;

k. To borrow, accept, or contract for services of personnel, including, but not limited to, employees of a compacting state;

l. To hire employees, professionals, or specialists, and elect or appoint officers, and to fix their compensation, define their duties, and give them appropriate authority to carry out the purposes of this act, and determine their qualifications; and to establish the commission's personnel policies and programs relating to, among other things, conflicts of interest, rates of compensation, and qualifications of personnel;

m. To accept any appropriate donations and grants of money, equipment, supplies, materials, and services, and to receive, utilize, and dispose of the same; provided, at all times the commission shall strive to avoid any appearance of impropriety;

n. To lease, purchase, accept appropriate gifts or donations of, or otherwise own, hold, improve, or use, any property, real, personal, or mixed; provided, at all times the commission shall strive to avoid any appearance of impropriety;

o. To sell, convey, mortgage, pledge, lease, exchange, abandon, or otherwise dispose of any property, real, personal or mixed;

p. To remit filing fees to compacting states as may be set forth in the bylaws, rules, or operating procedures;

q. To enforce compliance by compacting states with rules, uniform standards, operating procedures and bylaws;

r. To provide for dispute resolution among compacting states;

s. To advise compacting states on issues relating to insurers domiciled or doing business in non-compacting jurisdictions, consistent with the purposes of this act;

t. To provide advice and training to those personnel in state insurance departments responsible for product review, and to be a resource for state insurance departments;

u. To establish a budget and make expenditures;

v. To borrow money;

w. To appoint committees, including advisory committees comprising members, state insurance regulators, state legislators or their representatives, insurance industry and consumer representatives, and any other interested persons as may be designated in the bylaws;

x. To provide and receive information from, and to cooperate with, law enforcement agencies;

y. To adopt and use a corporate seal; and

z. To perform any other functions as may be necessary or appropriate to achieve the purposes of this act consistent with the state regulation of the business of insurance.

§ 17B:37-5 Membership of commission; organization; bylaws.

5. a. (1) Each compacting state shall have and be limited to one member of the commission. Each member shall be qualified to serve in that capacity pursuant to the applicable law of the compacting state. Any member may be removed or suspended from office as provided by the law of the state from which he shall be appointed. Any vacancy occurring in the commission shall be filled in accordance with the laws of the compacting state wherein the vacancy exists. Nothing herein shall be construed to affect the manner in which a compacting state determines the election or appointment and qualification of its own commissioner.

(2) Each member shall be entitled to one vote and shall have an opportunity to participate in the governance of the commission in accordance with the bylaws. Notwithstanding any provision herein to the contrary, no action of the commission with respect to the promulgation of a uniform standard shall be effective unless two-thirds of the members vote in favor thereof.

(3) The commission shall, by a majority of the members, prescribe bylaws to govern its conduct as may be necessary or appropriate to carry out the purposes, and exercise the powers, of this act, including, but not limited to:

(a) establishing the fiscal year of the commission;

(b) providing reasonable procedures for appointing and electing members, as well as holding meetings, of the management committee;

(c) providing reasonable standards and procedures for the establishment and meetings of other committees, and governing any general or specific delegation of any authority or function of the commission;

(d) providing reasonable procedures for calling and conducting meetings of the commission that consist of a majority of commission members, ensuring reasonable advance notice of each meeting, and providing for the right of citizens to attend each meeting, with enumerated exceptions designed to protect the public's interest, the privacy of individuals, and insurers' proprietary information, including trade secrets. The commission may meet in executive or closed session only after a majority of the entire membership votes to close a meeting, in whole or in part. As soon as practicable, the commission shall make public a copy of the vote to close the meeting revealing the vote of each member with no proxy votes allowed, and votes taken during the meeting;

(e) establishing the titles, duties and authority, and reasonable procedures for the election, of the officers of the commission;

(f) providing reasonable standards and procedures for the establishment of the personnel policies and programs of the commission. Notwithstanding any civil service or other similar laws of any compacting state, the bylaws shall exclusively govern the personnel policies and programs of the commission;

(g) promulgating a code of ethics to address permissible and prohibited activities of commission members and employees; and

(h) providing a mechanism for winding up the operations of the commission and the equitable disposition of any surplus funds that may exist after the termination of the compact established by this act, after the payment and reserving of all of its debts and obligations.

(4) The commission shall publish its bylaws in a convenient form and file a copy thereof, and a copy of any amendment thereto, with the appropriate agency or officer in each of the compacting states.

b. (1) A management committee comprising no more than 14 members shall be established as follows:

(a) One member from each of the six compacting states with the largest premium volume for individual and group annuities, life, disability income, and long-term care insurance products, determined from the records of the NAIC for the prior year;

(b) Four members from those compacting states with at least two percent of the market based on the premium volume as described in subparagraph (a) of this paragraph, other than the six compacting states with the largest premium volume, selected on a rotating basis as provided in the bylaws; and

(c) Four members from those compacting states with less than two percent of the market, based on the premium volume as described in subparagraph (a) of this paragraph, with one selected from each of the four zone regions of the NAIC as provided in the bylaws.

(2) The management committee shall have that authority and those duties as may be set forth in the bylaws, including but not limited to:

(a) managing the affairs of the commission in a manner consistent with the bylaws and purposes of the commission;

(b) establishing and overseeing an organizational structure within, and appropriate procedures for, the commission to provide for the creation of uniform standards and other rules, receipt and review of product filings, administrative and technical support functions, review of decisions regarding the disapproval of a product filing, and the review of elections made by a compacting state to opt out of a uniform standard; however, a uniform standard shall not be submitted to the compacting states for adoption unless approved by two-thirds of the members of the management committee;

(c) overseeing the offices of the commission; and

(d) planning, implementing, and coordinating communications and activities with other state, federal and local government organizations in order to advance the goals of the commission.

(3) The commission shall elect annually officers from the management committee, with each having the authority and duties as may be specified in the bylaws.

(4) The management committee may, subject to the approval of the commission, appoint or retain an executive director for a period, upon those terms and conditions, and for that compensation, which the commission deems appropriate. The executive director shall serve as secretary to the commission, but shall not be a member of the commission. The executive director shall hire and supervise additional staff as authorized by the commission.

c. (1) A legislative committee comprised of state legislators or their designees, provided in a manner of selection and for terms as shall be set forth in the bylaws, shall be established to monitor the operations of, and make recommendations to, the commission, including the management committee; provided that the manner of selection and term of any legislative committee member shall be as set forth in the bylaws. Prior to the adoption by the commission of any uniform standard, revision to the bylaws, annual budget, or other significant matter as may be provided in the bylaws, the management committee shall consult with and report to the legislative committee.

(2) The commission shall establish two advisory committees, one of which shall be comprised of consumer representatives independent of the insurance industry, and the other comprised of insurance industry representatives.

(3) The commission may establish additional advisory committees as provided in the bylaws for carrying out its functions.

d. The commission shall maintain its corporate books and records in accordance with the bylaws.

e. (1) The members, officers, executive director, employees, and representatives of the commission shall be immune from suit and liability, either personally or in their official capacity, for any claim for damage to or loss of property or personal injury or other civil liability caused by or arising out of any actual or alleged act, error, or omission that occurred, or that the person against whom the claim is made had a reasonable basis for believing occurred, within the scope of commission employment, duties, or responsibilities; however, nothing in this paragraph shall be construed to protect any person from suit and liability for any damage, loss, injury, or liability caused by the intentional or willful and wanton misconduct of that person.

(2) The commission shall defend any member, officer, executive director, employee, or representative of the commission in any civil action seeking to impose liability arising out of any actual or alleged act, error, or omission that occurred within the scope of commission employment, duties or responsibilities, or that the person against whom the claim is made had a reasonable basis for believing occurred within the scope of commission employment, duties, or responsibilities, so long as that actual or alleged act, error, or omission did not result from that person's intentional or willful and wanton misconduct; however, nothing herein shall be construed to prohibit that person from retaining his own counsel.

(3) The commission shall indemnify and hold harmless any member, officer, executive director, employee, or representative of the commission for the amount of any settlement or judgment obtained against that person arising out of any actual or alleged act, error, or omission that occurred within the scope of commission employment, duties, or responsibilities, or that the person had a reasonable basis for believing occurred within the scope of commission employment, duties, or responsibilities, so long as that actual or alleged act, error, or omission did not result from the intentional or willful and wanton misconduct of that person.

§ 17B:37-6 Meetings, actions.

6. a. The commission shall meet and take those actions consistent with the provisions of this act and the bylaws.

b. Each member of the commission shall have the right and power to cast a vote to which that compacting state is entitled, and to participate in the business and affairs of the commission. A member shall vote in person or by other means as provided in the bylaws. The bylaws may provide for members' participation in meetings by telephone or other means of communication.

c. The commission shall meet at least once during each calendar year. Additional meetings shall be held as set forth in the bylaws.

§ 17B:37-7 Rules, uniform standards, operating procedures.

7. a. The commission shall promulgate reasonable rules, including uniform standards and operating procedures, in order to effectively and efficiently achieve the purposes of this act. Notwithstanding the foregoing, if the commission exercises its rulemaking authority in a manner that is beyond the scope of the purposes of this act, or the powers granted hereunder, that action by the commission shall be invalid and have no force and effect.

b. Rules and operating procedures shall be made pursuant to a rulemaking process that conforms to the Model State Administrative Procedure Act of 1981 adopted by the National Conference of Commissioners on Uniform State Laws, as amended, as may be appropriate to the operations of the commission. Before the commission adopts a uniform standard, the commission shall give written notice to the relevant state legislative committee or committees in each compacting state responsible for insurance issues of its intention to adopt the uniform standard. The commission, in adopting a uniform standard, shall consider fully all submitted materials and issue a concise explanation of its decision.

c. A uniform standard shall become effective 90 days after its promulgation by the commission, or a later date determined by the commission; however, a compacting state may opt out of a uniform standard as provided in subsection d. of this section. As used in this section, "opt out" means any action by a compacting state to decline to adopt or participate in a promulgated uniform standard. All other rules and operating procedures, and amendments thereto, shall become effective as of the date specified in each rule, operating procedure, or amendment.

d. (1) A compacting state may opt out of a uniform standard, either by legislation or regulation, duly promulgated by the insurance department under the compacting state's administrative procedure act. If a compacting state elects to opt out of a uniform standard by regulation, it shall give written notice to the commission no later than 10 business days after the uniform standard is promulgated, or at the time the state becomes a compacting state and finds that the uniform standard does not provide reasonable protections to the citizens of the state, given the conditions in that state. The commissioner shall make specific findings of fact and conclusions of law, based on a preponderance of the evidence, detailing the conditions in the state which warrant a departure from the uniform standard and determining that the uniform standard would not reasonably protect the citizens of that state. The commissioner shall consider and balance the following factors, and find that the conditions in the state and needs of the citizens of the state outweigh:

(a) the intent of the legislature to participate in, and the benefits of, an interstate agreement to establish national uniform consumer protections for the products subject to this act; and

(b) the presumption that a uniform standard adopted by the commission provides reasonable protections to consumers of the relevant product.

(2) Notwithstanding the provisions of paragraph (1) of this subsection, a compacting state may, at the time of its enactment of the compact, prospectively opt out of all uniform standards involving long-term care insurance products by expressly providing therefor in the act, and that opt out shall not be treated as a material variance in the offer or acceptance of any state to participate in the compact. Such an opt out shall be effective at the time of enactment of the compact by the compacting state, and shall apply to all existing uniform standards involving long-term care insurance products and those subsequently promulgated.

(3) In accordance with the provisions of paragraph (2) of this subsection, this State prospectively opts out of all uniform standards involving long-term care insurance products promulgated by the commission, as this State has previously enacted the "New Jersey Long-Term Care Insurance Act," P.L.2003, c.207 (C.17B:27E-1 et seq.), which facilitates flexibility and innovation in the development of long-term care insurance coverage.

e. If a compacting state elects to opt out of a uniform standard, the uniform standard shall remain applicable in the compacting state electing to opt out until the opt out legislation is enacted into law or the regulation opting out becomes effective.

Once the opt out of a uniform standard by a compacting state becomes effective as provided under the laws of that state, the uniform standard shall have no further force and effect in that state unless the legislation or regulation implementing the opt out is repealed or otherwise becomes ineffective under the laws of the state. If a compacting state opts out of a uniform standard after the uniform standard has been made effective in that state, the opt out shall have the same prospective effect as provided pursuant to section 14 of this act for withdrawal from the compact.

f. If a compacting state has formally initiated the process of opting out of a uniform standard by regulation, and while the regulatory opt out is pending, the compacting state may petition the commission, at least 15 days before the effective date of the uniform standard, to stay the effectiveness of the uniform standard in that state. The commission may grant a stay if it determines that the regulatory opt out is being pursued in a reasonable manner and there is a likelihood of success. If a stay is granted or extended by the commission, the stay or extension thereof may postpone the effective date by up to 90 days, unless affirmatively extended by the commission; however, a stay may not be permitted to remain in effect for more than one year unless the compacting state can show extraordinary circumstances which warrant a continuance of the stay, including, but not limited to, the existence of a legal challenge which prevents the compacting state from opting out. A stay may be terminated by the commission upon notice that the rulemaking process has been terminated.

g. Not later than 30 days after a rule or operating procedure is promulgated, any person may file a petition for judicial review of the rule or operating procedure; however, the filing of that petition shall not stay or otherwise prevent the rule or operating procedure from becoming effective unless the court finds that the petitioner has a substantial likelihood of success. The court shall give deference to the actions of the commission consistent with applicable law and shall not find the rule or operating procedure to be unlawful if the rule or operating procedure represents a reasonable exercise of the commission's authority.

§ 17B:37-8 Rules establishing conditions, procedures for public inspection, copying of information and official records.

8. a. The commission shall promulgate rules establishing conditions and procedures for public inspection and copying of its information and official records, except for information and records involving the privacy of individuals and insurers' trade secrets. The commission may promulgate additional rules under which it may make available to federal and state agencies, including law enforcement agencies, records and information otherwise exempt from disclosure, and may enter into agreements with those agencies to receive or exchange information or records subject to nondisclosure and confidentiality provisions.

b. Except as to privileged records, data and information, the laws of any compacting state pertaining to confidentiality or nondisclosure shall not relieve any compacting state commissioner of the duty to disclose any relevant records, data or information to the commission; however, disclosure to the commission shall not be deemed to waive or otherwise affect any confidentiality requirement, and further, except as otherwise expressly provided in this act, the commission shall not be subject to the compacting state's laws pertaining to confidentiality and nondisclosure with respect to records, data, and information in its possession. Confidential information of the commission shall remain confidential after that information is provided to any commissioner.

c. The commission shall monitor compacting states for compliance with duly adopted bylaws, rules, including uniform standards, and operating procedures. The commission shall notify any non-complying compacting state in writing of its noncompliance with commission bylaws, rules, or operating procedures. If a non-complying compacting state fails to remedy its noncompliance within the time specified in the notice of noncompliance, the compacting state shall be deemed to be in default as provided in section 14 of this act.

d. The commissioner of any state in which an insurer is authorized to do business, or is conducting the business of insurance, shall continue to exercise the commissioner's authority to oversee the market regulation of the activities of the insurer in accordance with the provisions of the state's law. The commissioner's enforcement of compliance with the compact is governed by the following provisions:

(1) With respect to the commissioner's market regulation of a product or advertisement that is approved or certified to the commission, the content of the product or advertisement shall not constitute a violation of the provisions, standards, or requirements of the compact except upon a final order of the commission, issued at the request of a commissioner after prior notice to the insurer and an opportunity for hearing before the commission.

(2) Before a commissioner may bring an action for violation of any provision, standard, or requirement of the compact relating to the content of an advertisement not approved or certified to the commission, the commission, or an authorized commission officer or employee, shall authorize the action. However, authorization pursuant to this paragraph does not require notice to the insurer, opportunity for hearing, or disclosure of requests for authorization or records of the commission's action on such requests.

§ 17B:37-9 Resolution of disputes, issues subject to compact.

9. The commission shall attempt, upon the request of a member, to resolve any disputes or other issues that are subject to the compact and which may arise between two or more compacting states, or between compacting states and non-compacting states, and the commission shall promulgate an operating procedure providing for resolution of those disputes.

§ 17B:37-10 Approval process for product.

10. a. Insurers and third party filers seeking to have a product approved by the commission shall file the product with, and pay applicable filing fees to, the commission. Nothing in this act shall be construed to restrict or otherwise prevent an insurer from filing its product with the insurance department in any state wherein the insurer is licensed to conduct the business of insurance, and that filing shall be subject to the laws of the states where filed.

b. The commission shall establish appropriate filing and review processes and procedures pursuant to commission rules and operating procedures. Notwithstanding any provision in this act to the contrary, the commission shall promulgate rules to establish conditions and procedures under which the commission will provide public access to product filing information. In establishing these rules, the commission shall consider the interests of the public in having access to that information, as well as protection of personal medical and financial information and trade secrets, which may be contained in a product filing or supporting information.

c. Any product approved by the commission may be sold or otherwise issued in those compacting states for which the insurer is legally authorized to do business.

§ 17B:37-11 Disapproved product or advertisement; appeal.

11. a. Not later than 30 days after the commission has given notice of a disapproved product or advertisement filed with the commission, the insurer or third party filer whose filing was disapproved may appeal the determination to a review panel appointed by the commission. The commission shall promulgate rules to establish procedures for appointing those review panels and provide for notice and hearing. An allegation that the commission, in disapproving a product or advertisement filed with the commission, acted arbitrarily, capriciously, or in a manner that is an abuse of discretion or otherwise not in accordance with the law, is subject to judicial review in accordance with subsection d. of section 3 of this act.

b. The commission shall have the authority to monitor, review, and reconsider products and advertisements subsequent to their filing or approval upon a finding that the product does not meet the relevant uniform standard. Where appropriate, the commission may withdraw or modify its approval after proper notice and hearing, subject to the appeal process pursuant to subsection a. of this section.

§ 17B:37-12 Payment of reasonable expenses of establishment, organization.

12. a. The commission shall pay or provide for the payment of the reasonable expenses of its establishment and organization. To fund the cost of its initial operations, the commission may accept contributions and other forms of funding from the NAIC, compacting states, and other sources. Contributions and other forms of funding from other sources shall be of a nature that the independence of the commission concerning the performance of its duties shall not be compromised.

b. The commission shall collect a filing fee from each insurer and third party filer filing a product with the commission to cover the cost of the operations and activities of the commission and its staff in a total amount sufficient to cover the commission's annual budget.

c. The commission's budget for a fiscal year shall not be approved until it has been subject to notice and comment as set forth in section 7 of this act.

d. The commission shall be exempt from all taxation in and by the compacting states.

e. The commission shall not pledge the credit of any compacting state, except by and with the appropriate legal authority of that compacting state.

f. The commission shall keep complete and accurate accounts of all its internal receipts, including grants and donations, and disbursements of all funds under its control. The internal financial accounts of the commission shall be subject to the accounting procedures established under its bylaws. The financial accounts and reports, including the system of internal controls and procedures of the commission, shall be audited annually by an independent certified public accountant. Upon the determination of the commission, but no less frequently than every three years, the review of the independent auditor shall include a management and performance audit of the commission. The commission shall make an annual report to the governor and legislature of the compacting states, which shall include a report of the independent audit. The commission's internal accounts shall not be confidential and may be shared with the commissioner of any compacting state upon request, except that any work papers related to any internal or independent audit and any information regarding the privacy of individuals and insurers' proprietary information, including trade secrets, shall remain confidential.

g. No compacting state shall have any claim to or ownership of any property held by or vested in the commission, or to any commission funds held pursuant to the provisions of this act.

§ 17B:37-13 Eligibility of states to join compact.

13. a. Any state is eligible to become a compacting state.

b. The compact shall become effective and binding upon legislative enactment of the compact into law by two compacting states; however, the commission shall become effective for purposes of adopting uniform standards for, reviewing, and giving approval or disapproval of, products filed with the commission that satisfy applicable uniform standards only after 26 states are compacting states or, alternatively, by states representing greater than 40% of the premium volume for life insurance, annuity, disability income, and long-term care insurance products, based on records of the NAIC for the prior year. Thereafter, the compact shall become effective and binding as to any other compacting state upon enactment of the compact into law by that state.

c. Amendments to the compact may be proposed by the commission for enactment by the compacting states. No amendment shall become effective and binding upon the commission and the compacting states unless all compacting states enact the amendment into law.

§ 17B:37-14 Withdrawal, termination, reinstatement.

14. a. (1) Once effective, the compact shall continue in force and remain binding upon each compacting state; however, a compacting state may withdraw from the compact by repealing the statute which enacted the compact into law.

(2) The effective date of withdrawal is the effective date of the repealing statute. However, the withdrawal shall not apply to any product filings approved or self-certified, or any advertisement of those products, prior to or on the date the repealing statute becomes effective, except by mutual agreement of the commission and the withdrawing state unless the approval is rescinded by the withdrawing state as provided in paragraph (5) of this subsection.

(3) The commissioner of the withdrawing state shall immediately notify the management committee in writing upon the introduction of legislation repealing this compact in the withdrawing state.

(4) The commission shall notify the other compacting states of the introduction of such legislation within 10 days after its receipt of notice thereof.

(5) The withdrawing state is responsible for all obligations, duties, and liabilities incurred through the effective date of withdrawal, including any obligations, the performance of which extend beyond the effective date of withdrawal, except to the extent those obligations may have been released or relinquished by mutual agreement of the commission and the withdrawing state. The commission's approval of products and advertisements prior to the effective date of withdrawal shall continue to be effective and be given full effect in the withdrawing state, unless formally rescinded by the withdrawing state in the same manner as provided by the laws of the withdrawing state for the prospective disapproval of products or advertisements previously approved under state law.

(6) Reinstatement following withdrawal of any compacting state shall occur upon the effective date of the withdrawing state reenacting the compact.

b. (1) If the commission determines that any compacting state has at any time defaulted in the performance of any of its obligations or responsibilities under the compact, the bylaws, or duly promulgated rules or operating procedures, then, after notice and hearing as set forth in the bylaws, all rights, privileges, and benefits conferred by the compact on the defaulting state shall be suspended from the effective date of default as fixed by the commission. The grounds for default include, but are not limited to, failure of a compacting state to perform its obligations or responsibilities, and any other grounds designated in commission rules. The commission shall immediately notify the defaulting state in writing of the defaulting state's suspension pending a cure of the default. The commission shall stipulate the conditions and the time period within which the defaulting state shall cure its default. If the defaulting state fails to cure the default within the time period specified by the commission, the defaulting state shall be terminated from the compact and all rights, privileges, and benefits conferred by the compact shall be terminated from the effective date of termination.

(2) Product approvals by the commission or product self-certifications, or any advertisement in connection with that product, that are in force on the effective date of termination shall remain in force in the defaulting state in the same manner as if the defaulting state had withdrawn voluntarily pursuant to subsection a. of this section.

(3) Reinstatement following termination of any compacting state shall require a reenactment of the compact.

c. (1) The compact shall dissolve effective upon the date of the withdrawal or default of the compacting state which reduces membership in the compact to one compacting state.

(2) Upon the dissolution of the compact, the compact shall become void and shall be of no further effect, and the business and affairs of the commission shall be completed, and any surplus funds shall be distributed in accordance with the bylaws.

§ 17B:37-15 Severability; liberal construction.

15. a. The provisions of this act shall be severable; and if any phrase, clause, sentence, or provision is deemed unenforceable, the remaining provisions of this act shall be enforceable.

b. The provisions of this act shall be liberally construed to effectuate its purposes.

§ 17B:37-16 Enforcement of laws of compacting state unaffected.

16. a. (1) Nothing herein shall prevent the enforcement of any other law of a compacting state, except as provided in subsection b. of this section.

(2) For any product approved or certified by the commission, the rules, uniform standards, and any other requirements of the commission shall constitute the exclusive provisions applicable to the content, approval, and certification of that product. For any advertisement that is subject to the commission's authority, any rule, uniform standard, or other requirement of the commission which governs the content of the advertisement shall constitute the exclusive provision that a commissioner may apply to the content of the advertisement. Notwithstanding the foregoing, no action taken by the commission shall abrogate or restrict:

(a) the access of any person to state courts;

(b) remedies available under state law related to breach of contract, tort, or other laws not specifically directed to the content of the product;

(c) state law relating to the construction of insurance contracts; or

(d) the authority of the attorney general of the state, including, but not limited to, maintaining any actions or proceedings, as authorized by law.

(3) All insurance products filed with individual states shall be subject to the laws of those states.

b. (1) All lawful actions of the commission, including all rules and operating procedures promulgated by the commission, are binding upon the compacting states.

(2) All agreements between the commission and the compacting states are binding in accordance with their terms.

(3) Upon the request of a party to a conflict over the meaning or interpretation of commission actions, and upon a majority vote of the compacting states, the commission may issue advisory opinions regarding the meaning or interpretation in dispute.

(4) In the event any provision of the compact exceeds the constitutional limits imposed on the legislature of any compacting state, the obligations, duties, powers, or jurisdiction sought to be conferred by that provision upon the commission shall be ineffective as to that compacting state, and those obligations, duties, powers, or jurisdiction shall remain in the compacting state and shall be exercised by the agency thereof to which those obligations, duties, powers, or jurisdiction are delegated by law in effect at the time the compact becomes effective.

§ 17B:37-17 Report to Legislature.

17. The Commissioner of Banking and Insurance shall report to the Legislature, as provided pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), within one year of the effective date of this act or within one year of the operational date of the compact for the long-term care insurance products, whichever is later, the commissioner's non-binding recommendation as to whether the State should participate in the compact with respect to all uniform standards involving long-term care insurance products under the compact.