Words and terms contained in the Act, when used in this
chapter, shall have the meanings as defined in the Act, unless the context
clearly indicates otherwise, or as such words and terms are further defined by
this chapter.
"Act" means P.L. 1992, c.162, as adopted and subsequently
amended (N.J.S.A. 17B:27A-17 et seq.), also
referred to herein as the Small Employer Health Benefits Act.
"Affiliated carrier" means a carrier that directly or
indirectly through one or more intermediaries, controls or is controlled by, or
is under common control with, another carrier.
"Affiliated company" means a person that directly or
indirectly through one or more intermediaries, controls or is controlled by, or
is under common control with, another person. 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. §
414) shall be treated as one
employer.
"Allowed charge" means an amount that is not more than the
lesser of the allowance for the service or supply as determined by the standard
approved by the Board as set forth at
N.J.A.C. 11:21-7.1 3 or the negotiated fee
schedule.
"Board" means the Board of Directors of the New Jersey Small
Employer Health Benefits Program established by the Act.
"Carrier" means any entity subject to the insurance laws and
regulations of this State, or subject to the jurisdiction of the Commissioner,
that contracts or offers to contract to provide, deliver, arrange for, pay for,
or reimburse any of the costs of health care services, including 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 chapter, 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.
"Carrier coinsurance" means the percentage of a covered
charge paid by a carrier.
"Cash deductible" or "deductible" means the amount of covered
charges that a covered person must pay before the health benefits plan pays any
benefits for such charges.
"Coinsurance" means the percentage of a covered charge that
must be paid by a covered person. Coinsurance does not include cash
deductibles, copayment, or non-covered charges.
"Commissioner" means the Commissioner of the New Jersey
Department of Banking and Insurance.
"Copayment" or "copay" means a specified dollar amount a
covered person must pay for specified covered charges.
"Department" means the New Jersey Department of Banking and
Insurance.
"Dependent" means the spouse or child of a full-time employee
subject to applicable terms of the employee's health benefits plan. For
purposes of dependent eligibility only, the reference to "spouse" includes a
civil union partner pursuant to
P.L.
2006, c. 103, and same
sex relationships recognized in other jurisdictions if such relationships
provide substantially all of the rights and benefits of marriage, except that
spouse shall be limited to spouses of a marriage as marriage is defined in
Federal law with respect to the provisions of the Policy regarding continuation
rights required by the Federal Consolidated Omnibus Budget Reconciliation Act
of 1986 (COBRA), Pub. L. 99-272, as subsequently amended, and the provisions of
the policy or contract regarding Medicare Eligibility by Reason of Age and
Medicare Eligibility by Reason of Disability. At the option of the small
employer, "spouse" includes a domestic partner pursuant to
P.L.
2003, c. 246.
"Eligible employee" means a full-time, bona fide employee who
works a normal work week of 25 or more hours. The term excludes a sole
proprietor, a partner of a partnership, or an independent contractor and 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
pursuant to a collective bargaining agreement.
"Employee" means an individual who is an employee under the
common law standard as described in 26 CFR 31.3401(c) -1. For
purposes of determining whether an employer is a small employer, employee
excludes an individual and his or her spouse when the business is owned by the
individual or by the individual and his or her spouse, a sole proprietor, a
partner in a partnership, and a two percent shareholder in a Subchapter S
corporation as well as immediate family members of such individuals. Employee
also excludes a leased employee.
"Employee open enrollment period" means the 30-day period
each year designated by the small employer during which:
1. Employees and dependents who are eligible under the small
employer's plan but who are late enrollees may enroll for coverage under the
small employer's plan; and
2. Employees and dependents who are covered under the small
employer's plan may elect coverage under a different policy, if any, offered by
the small employer.
"Employer open enrollment period" means the period from
November 15 through December 15 each year during which minimum participation
and contribution requirements do not apply in accordance with 45 CFR
147.104.
"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. If an employee changes plans or if the employer transfers
coverage to another carrier, the covered person's enrollment date does not
change.
"Full-time employee" as used to determine eligibility for
coverage under a small employer health benefits plan and satisfaction of
participation requirements means an employee who works a normal work week of 25
or more hours per week. Note that the determination of small employer status in
N.J.A.C. 11:21-7.2 uses a
different definition of full-time employee.
"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. §
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 services
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 the Act
(N.J.S.A. 17B:27A-19), or any other
similar contract, policy or plan issued to a small employer not explicitly
excluded from the definition of health benefits plan. 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 plans shall not include
the following benefits if they are provided under a separate policy,
certificate or contract of insurance or are otherwise not an integral part of
the plan: limited scope dental or vision benefits; benefits for long-term care,
nursing home care, home health care, community-based care, or any combination
thereof; and such other similar, limited benefits as are specified in Federal
regulations. Health benefits plan shall not include hospital confinement
indemnity coverage if the benefits are provided under a separate policy,
certificate or contract of insurance, there is no coordination between the
provision of the benefits and any exclusion of benefits under any group health
benefits plan maintained by the same plan sponsor, and those benefits are paid
with respect to an event without regard to whether benefits are provided with
respect to such an event under any group health plan maintained by the same
plan sponsor. Health benefits plan shall not include the following if it is
offered as a separate policy, certificate or contract of insurance: Medicare
supplemental health insurance as defined under section 1882(g)(1) of the
Federal Social Security Act (42 U.S.C. §
1395(g)(1)); and coverage
supplemental to the coverage provided under chapter 55 of Title 10, United
States Code (10 U.S.C. §
1071 et seq.); and similar supplemental
coverage provided to coverage under a group health plan.
"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 a full-time 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.
"Maximum out of pocket" means the annual maximum dollar
amount that a covered person must pay as copayment, deductible, and coinsurance
for all covered services and supplies in a calendar year. All amounts paid as
copayment, deductible, and coinsurance shall count toward the maximum out of
pocket. Once the maximum out of pocket has been reached, the covered person has
no further obligation to pay any amounts as copayment, deductible, and
coinsurance for covered services and supplies for the remainder of the calendar
year.
"Medicaid" means the program administered by the New Jersey
Division of Medical Assistance and Health Services Program in the New Jersey
Department of Human Services, providing medical assistance to qualified
applicants, in accordance with P.L. 1968, c.413 (N.J.S.A. 30:4D-1 et seq.) and amendments
thereto.
"Medical care" means amounts paid:
1. For the diagnosis, care, mitigation, treatment, or
prevention of 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 paragraph 1 above.
"Medicare" means coverage provided pursuant to Title XVIII of
the Federal Social Security Act, Pub. L. 89-97 (42 U.S.C. §
1395 et seq.) and amendments thereto.
"Member" means a carrier that issues health benefits plans in
New Jersey on or after November 30, 1992.
"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.
"Network maximum out of pocket" means the annual maximum
dollar amount that a covered person must pay as copayment, deductible, and
coinsurance for all services and supplies provided by network providers in a
calendar year. All amounts paid as copayment, deductible, and coinsurance shall
count toward the network maximum out of pocket. Once the network maximum out of
pocket has been reached, the covered person has no further obligation to pay
any amounts as copayment, deductible, and coinsurance for services and supplies
provided by network providers for the remainder of the calendar year. If a
carrier wishes to use a common maximum out of pocket provision in a plan that
has both network and non-network benefits, the network maximum out of pocket
shall mean the annual maximum dollar amount that a covered person must pay as
copayment, deductible, and coinsurance for all services and supplies provided
by network providers and non-network providers in a calendar year. All amounts
paid as copayment, deductible, and coinsurance for both network and non-network
services and supplies shall count toward the network maximum out of pocket.
Once the network maximum out of pocket has been reached, the covered person has
no further obligation to pay any amounts as copayment, deductible, and
coinsurance for services and supplies provided by network or non-network
providers for the remainder of the calendar year.
"Non-network maximum out of pocket" means the annual maximum
dollar amount that a covered person must pay as deductible and coinsurance for
all services and supplies provided by non-network providers in a calendar year.
All amounts paid as deductible and coinsurance shall count toward the
non-network maximum out of pocket. Once the non-network maximum out of pocket
has been reached, the covered person has no further obligation to pay any
amounts as copayment, deductible and coinsurance for services and supplies
provided by non-network providers for the remainder of the calendar
year.
"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. §
1002(16)(B)).
"Program" means the New Jersey Small Employer Health Benefits
Program established pursuant to the Act.
"Public health plan" means any plan established or maintained
by a state, the U.S. government, a foreign country, or any political
subdivision of a state, the U.S. government, or a foreign country that provides
health coverage to individuals who are enrolled in the plan.
"Small employer" means in connection with a group health plan
with respect to a calendar year and a plan year, an employer with a business
location in the State of New Jersey who employed an average of at least one but
not more than 50 employees on business days during the preceding calendar year;
and who employs at least one employee on the first day of the plan year.
Any person 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. §
414) shall be treated as one
employer. Additionally, small employer includes an employer that employs more
than 50 full-time employees if the employer's workforce exceeds 50 full-time
employees for no more than 120 days during the calendar year and the employees
in excess of 50 who were employed during such 120-day or fewer period were
seasonal workers. As used in the definition of small employer, full-time means
an employee works 30 or more hours per week.
"Small employer carrier" means any carrier that offers health
benefits plans covering full-time employees of one or more small
employers.
"Small employer health benefits plan" means a health benefits
plan issued to small employers pursuant to
N.J.S.A. 17B:27A-19.
"Standard health benefits plan" means a health benefits plan
promulgated by the SEH Board, described at
N.J.A.C. 11:21-3.1, and set forth in the
Appendix to this chapter.
"State" means the State of New Jersey.
"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 purposes of the Small Employer Health Benefits Act, the policy shall
establish a per person attachment point or retention or aggregate attachment
point or retention, or both, which meet the following requirements:
1. If the policy establishes a per person attachment point or
retention, that specific attachment point or retention shall not be less than $
20,000 per covered person per plan year; and
2. If the policy establishes an aggregate attachment point or
retention, that aggregate attachment point or retention shall not be less than
125 percent of expected claims per plan year.
"Supplemental limited benefit insurance" means insurance that
is provided in addition to a health benefits plan on an indemnity nonexpense
incurred basis.