17B:27A-1. Filing of paid hospital expense claims; definitions
483 words·~2 min read·
/nj/title-17b/chapter-27a/17b-27a-1·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
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.
L.1992,c.160,s.18.