26:2J-48 Health maintenance organization, aggregate benefits.
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/nj/title-26/chapter-2j/26-2j-48A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
5. a. Beginning with the calendar year starting on January 1, 2020, and in each calendar year thereafter, a health maintenance organization providing health benefits plans to a large employer shall return, in the form of aggregate benefits for all large group health benefits plans offered by the health maintenance organization, at least 85 percent of the aggregate premiums collected for all of those plans.
b. A health maintenance organization shall annually report to the Commissioner of Banking and Insurance, no later than August 1 of each year, the loss ratio calculated for all health benefits plans for the previous calendar year. In each case in which the loss ratio fails to substantially comply with the 85 percent loss ratio requirement, the health maintenance organization shall issue a dividend or credit against future premiums for all contract holders in an amount sufficient to assure that the aggregate benefits paid in the previous calendar year plus the amount of the dividends and credits shall equal 85 percent of the premiums collected.
The health maintenance organization shall distribute all dividends and credits by December 31 of the year following the calendar year in which the loss ratio requirements were not satisfied. The health maintenance organization's annual report shall include the health maintenance organization's calculation of the dividends and credits applicable to all health benefits plans, as well as an explanation of the health maintenance organization's plan to issue dividends or credits.
c. The commissioner shall specify by regulation:
(1)any informational filings required to be submitted by a health maintenance organization to the commissioner in order to determine whether the health maintenance organization is in compliance with the loss ratio requirements;
(2)the instructions and format for calculating and reporting loss ratios and issuing dividends or credits;
(3)procedures for the distribution of a dividend or credit in the event of cancellation or termination by a contract holder; and
(4)the instructions and format for submitting annual reports.
d. As used in this section, "large employer" means an employer with more than 50 employees, who is not a small employer as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17).
L.2019, c.358, s.5.