26:2J-44 - Contract forms; certification memorandum
26:2J-44. Contract forms; certification memorandum
26. a. Pursuant to the provisions of this section, a health maintenance organization authorized to do business in this State may file with the Commissioner of Insurance and use, in accordance with subsection d. of this section, any health maintenance organization contract, evidence of coverage or related form that is stipulated by the Commissioner of Insurance 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 health maintenance organization 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 of Insurance. If the Commissioner of Insurance determines that the form being filed does not conform with the law or regulation applicable to that type or kind of form, the Commissioner of Insurance shall notify the health maintenance organization of his objections in writing and may disapprove that form for further use in New Jersey.
b. Contracts and evidence of coverage 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 and group health maintenance organization contracts and evidences of coverage which the Commissioner of Insurance shall define by regulation.
c. The certification memorandum shall be signed and acknowledged by a responsible officer of the health maintenance organization. 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 of Insurance by regulation from time to time.
d. Upon receipt of an acknowledgment from the Commissioner of Insurance 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 health maintenance organization.
e. (1) Improper certification shall subject a health maintenance corporation submitting such improper certification to a fine not to exceed $50,000 and, in addition, a maximum penalty of $1,000 per contract or evidence of coverage issued on a form determined to be improperly certified pursuant to the provisions of this section. The Commissioner of Insurance 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 of Insurance 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.), a health maintenance organization is found by the Commissioner of Insurance to be in violation of this section, the form may be disapproved, and in addition to any other penalties that may be imposed pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), the Commissioner of Insurance may bar that health maintenance organization from participating in the certification process pursuant to this section for a period not to exceed one year.
f. The Commissioner of Insurance 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 health maintenance organization" means a corporate officer of the level of vice president or higher, or of equivalent title within the health maintenance organization's structure, who is either the actuary of the health maintenance organization with responsibility for the type of form filed, or the individual with responsibility for managing the form filing process for the health maintenance organization 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.
L.1995,c.73,s.26.