17B:27A-3 Individual health benefits plans, applicability of act.

747 words·~3 min read·/nj/title-17b/chapter-27a/17b-27a-3·

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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.

(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).

L.1992, c.161, s.2; amended 1993, c.164, s.2; 1997, c.146, s.2; 2008, c.38, s.10.