17B:27A-4 - Offering of individual health benefits required by issuer of small employer health benefits plans
17B:27A-4 Offering of individual health benefits required by issuer of small employer health benefits plans.
3. a. No later than 180 days after the effective date of this section of P.L.2008, c.38, a carrier shall, as a condition of issuing small employer health benefits plans in this State, also offer individual health benefits plans. The plans shall be offered on an open enrollment, modified community rated basis, pursuant to the provisions of this act and P.L.2008, c.38. Every carrier that issues small employer health benefits plans pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) shall make a good faith effort to market individual health benefits plans.
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). One plan shall be a basic health benefits plan. A carrier may elect to convert any individual contract or policy forms in force on the effective date of P.L.2008, c.38 to any of the benefit plans, except that the carrier may not convert more than 25% of existing contracts or policies each year, and the replacement plan shall be of no less actuarial value than the policy or contract being replaced.
Notwithstanding the provisions of this subsection 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 a basic health benefits plan in accordance with the provisions of that law in lieu of the plans required pursuant to this subsection.
c. (1) A basic health benefits plan shall provide the benefits set forth in section 55 of P.L.1991, c.187 (C.17:48E-22.2), section 57 of P.L.1991, c.187 (C.17B:26B-2) or section 59 of P.L.1991, c.187 (C.26:2J-4.3), as the case may be.
(2)Notwithstanding the provisions of this subsection or any other law to the contrary, a carrier may, with the approval of the board, modify the coverage 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, respectively) or provide alternative benefits or services from those required by this subsection if they are within the intent of this act or if the board changes the benefits included in the basic health benefits plan.
(3)A contract or policy for a basic health benefits plan provided for in this section may contain or provide for coinsurance or deductibles, or both, except that no deductible shall be payable in excess of a total of $250 by an individual or $500 by a family unit during any benefit year; and no coinsurance shall be payable in excess of a total of $500 by an individual or by a family unit during any benefit year.
(4)Notwithstanding the provisions of paragraph (3) of this subsection or any other law to the contrary, a carrier may provide for increased deductibles or coinsurance for a basic health benefits plan if approved by the board or if the board increases deductibles or coinsurance included in the basic health benefits plan.
(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 this act.
(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 this act.
d.Every group conversion contract or policy issued after the effective date of this act 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.In addition to the rider packages provided for in subsection c. of section 6 of P.L.1992, c.161 (C.17B:27A-7), every carrier may offer, in connection with the health benefits plans required to be offered by this section, any number of riders which may add benefits or increase the actuarial value of any of the plans. Any such rider or amendment thereof shall be filed with the board for informational purposes before the rider may be sold. The added premium for each rider 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, contrary to law or the public policy of this State. The commissioner's determination shall be in writing and shall be appealable.
L.1992, c.161, s.3; amended 1993, c.164, s.3; 1994, c.102, s.1; 2008, c.38, s.11.