New_jersey Statute | Act | Code |Title 17 Corporations And Institutions For Finance And Insurance| US Code - US Statute

17:48-6ee. Hospital service corporation, coverage for prescription female contraceptives. 1. A hospital service corporation that provides hospital or medical expense benefits for expenses incurred in the purchase of outpatient prescription drugs under a contract shall provide coverage under every such contract delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives. For the purposes of this section, ~prescription female contraceptives~ means any drug or device used for contraception by a female, which is approved by the federal Food and Drug Administration for that purpose, that can only be purchased in this State with a prescription written by a health care professional licensed or authorized to write prescriptions, and includes, but is not limited to, birth control pills and diaphragms. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section if the required coverage conflicts with the religious employer@s bona fide religious beliefs and practices. A religious employer that obtains such an exclusion shall provide written notice thereof to prospective subscribers and subscribers. The provisions of this section shall not be construed as authorizing a hospital service corporation to exclude coverage for prescription drugs that are prescribed for reasons other than contraceptive purposes or for prescription female contraceptives that are necessary to preserve the life or health of a subscriber. For the purposes of this section, ~religious employer~ means an employer that is a church, convention or association of churches or an elementary or secondary school that is controlled, operated or principally supported by a church or by a convention or association of churches as defined in 26 U.S.C.s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C.s.501(c)(3). The benefits shall be provided to the same extent as for any other outpatient prescription drug under the contract. This section shall apply to those contracts in which the hospital service corporation has reserved the right to change the premium. L.2005,c.251,s.1. 17:48-6.1. Group contracts issued by hospital service corporation 2. A hospital service corporation may issue to a policyholder a group contract, covering at least two employees or members at the date of issue, if it conforms to the following description: (a) A contract issued to an employer or to the trustees of a fund established by one or more employers, or issued to a labor union, or issued to an association formed for purposes other than obtaining such contract, or issued to the trustees of a fund established by one or more labor unions, or by one or more employers and one or more labor unions, covering employees and members of associations or labor unions. (b) A contract issued to cover any other group which the Commissioner of Insurance determines may be covered in accordance with sound underwriting principles. Benefits may be provided for one or more members of the families or one or more dependents of persons who may be covered under a group contract referred to in (a) or (b) above. Family type contracts shall provide that the services applicable for children shall be payable with respect to a newly-born child of the subscriber, or his or her spouse from the moment of birth. The services for newly-born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and abnormalities. If a subscription payment is required to provide services for a child, the contract may require that notification of birth of a newly-born child and the required payment must be furnished to the service corporation within 31 days after the date of birth in order to have the coverage continue beyond such 31-day period. Group contracts which provide for services to the subscriber but not to family members or dependents of that subscriber, other than contracts which provide no dependent coverage whatsoever for the subscriber@s class, shall also provide services to newly-born children of the subscriber which shall commence with the moment of birth of each child and shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and abnormalities, provided that application therefor and payment of the required subscription amount are made to include in said contract the coverage described in the preceding paragraph of this section within 31 days from the date of birth of a newborn child. A contract under which coverage of such a dependent terminates at a specified age shall, with respect to an unmarried child, covered by the contract prior to attainment of age 19, who is incapable of self-sustaining employment by reason of mental retardation or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon the covered employee or member for support and maintenance, not so terminate while the coverage of the employee or member remains in force and the dependent remains in such conditions, if the employee or member has within 31 days of such dependent@s attainment of the termination age submitted proof of such dependent@s incapacity as described herein. The foregoing provisions of this paragraph shall not apply retrospectively or prospectively to require a hospital service corporation to insure as a covered dependent any mentally retarded or physically handicapped child of the applicant where the contract is underwritten on evidence of insurability based on health factors required to be set forth in the application. In such cases any contract heretofore or hereafter issued may specifically exclude such mentally retarded or physically handicapped child from coverage. Any group contract which contains provisions for the payment by the insurer of benefits for members of the family or dependents of a person in the insured group shall provide that, subject to payment of the appropriate premium, such family members or dependents be permitted to have coverage continued for at least 180 days after the death of the person in the insured group. The contract may provide that the term ~employees~ shall include as employees of a single employer the employees of one or more subsidiary corporations and the employees, individual proprietors and partners of affiliated corporations, proprietorships and partnerships if the business of the employer and such corporations, proprietorships or partnerships is under common control through stock ownership, contract or otherwise. The contract may provide that the term ~employees~ shall include the individual proprietor or partners of an individual proprietorship or a partnership. The contract may provide that the term ~employees~ shall include retired employees. A contract issued to trustees may provide that the term ~employees~ shall include the trustees or their employees, or both, if their duties are principally connected with such trusteeship. A contract issued to the trustees of a fund established by the members of an association of employers may provide that the term ~employees~ shall include the employees of the association. L.1964,c.104,s.2; amended 1966,c.236,ss.2,3; 1975,c.109,s.2; 1976,c.101,s.2; 1993,c.162,s.24. 17:48-6.2. Provisions applicable to group contracts; subscriber defined The provisions of the act to which this act is a supplement shall apply to group contracts except that sections 6 and 9 of such act shall not apply. The word ~subscriber~ as used in said act means the policyholder under a group contract where the context so requires. L.1964, c. 104, s. 3. 17:48-6.3. Group contract form Every group contract entered into by a hospital service corporation with any policyholder shall be in writing and a contract form stating the terms and conditions thereof shall be furnished to the policyholder to be kept by him. No group contract form shall be used unless it contains the following provisions: (a) A statement of the contract rate payable to the hospital service corporation by or on behalf of the policyholder for the original period of coverage, the time or times at which, and the manner in which, the contract rate due is to be paid, and the basis, if any, on which the rate may subsequently be adjusted; (b) A provision that all contract rates due under the contract shall be paid by the policyholder, or by the designated representative of the policyholder, to the hospital service corporation on or before the due date thereof or within such period of grace as may be specified therein; (c) A statement of the nature of the services to be furnished and the period during which they will be furnished, and if there are any services to be excepted, a detailed statement of such exceptions; (d) A provision that the contract, any endorsements or riders thereto, the application of the policyholder in whose name the contract is issued, a copy of which shall be attached to the contract, and the individual applications, if any, of the employees or members shall constitute the entire contract between the parties and that all statements contained in any such application for coverage shall be deemed representations and not warranties; (e) A provision that there shall be issued to the policyholder, for delivery to the employee or member, a certificate or other document which sets forth or summarizes the essential features of the coverage including the time, place and method for making claims for benefits; (f) A provision that all new employees or new members, as the case may be, in the groups or classes eligible for the coverage must be added to the eligible groups or classes; (g) A statement of the terms and conditions, if any, upon which the contract may be terminated or amended. Any notice to the policyholder shall be effective if sent by mail to the policyholder@s address as shown at the time on the corporation@s records. The notice to the policyholder as herein required shall be sent at least 30 days before the termination or amendment of the contract takes effect. L.1964, c. 104, s. 4. 17:48-6.4. Participation agreements A hospital service corporation of this State may enter into agreements to participate with other corporations in the issuance of group contracts to policyholders whose employees or members are located in more than one state. Such agreements may provide for experience rating, for a sharing of the premiums, claims, and expenses by the participating corporations or for acceptance or ceding of the whole or portions of group risks on a reinsurance basis. Such agreements shall be filed with and approved by the commissioner before becoming effective. L.1964, c. 104, s. 5. 17:48-6.5. Schedule of rates No hospital service corporation shall issue group contracts which are not experience rated pursuant to section 5 of this act, until it shall have filed with the commissioner a full schedule of the rates which are to apply to such contracts. The commissioner may disapprove such schedule at any time if he finds that such rates are excessive, inadequate or unfairly discriminatory. It shall be unlawful for any corporation to effect any such group contract according to such rates thereafter. L.1964, c. 104, s. 6. Amended by L.1967, c. 286, s. 3, eff. Jan. 23, 1968. 17:48-6.6. Combined hospital-medical contracts A hospital service corporation and a medical service corporation authorized to do business in this State may issue a combined contract providing for hospital care and medical care but no one of such corporations shall issue any such combined contract. Any one of such corporations may act as agent for the other without being required to obtain a license as an agent. L.1964, c. 104, s. 7. 17:48-6.7. Review of determinations of commissioner of banking and insurance All determinations of the Commissioner of Banking and Insurance made under the provisions of this act, or of the act to which this act is a supplement, shall be subject to review by the Superior Court in a proceeding in lieu of prerogative writ. L.1964, c. 104, s. 8. 17:48-6.8. Review of practices, rules and procedures of hospital service corporation All practices, rules and procedures of a hospital service corporation, involving termination or refusal to renew coverage, modification of coverage or rates in the case of persons classified as left-group, selection of risks, and underwriting classifications, shall be subject to review at any time by the commissioner and upon his request for information relative to any such practice, rule, or procedure the hospital service corporation shall furnish such information in writing without delay. If in the opinion of the commissioner, any such practice, rule, or procedure, is unjust, unfair, or inequitable, taking into consideration the nonprofit and tax-exempt status of the hospital service corporation, he shall so notify the hospital service corporation and fix a time and place for hearing before him or his designated representative at which the hospital service corporation may be heard. Following such hearing, the commissioner may make an order based on the record of the proceeding. If such order be one of disapproval, it shall be unlawful for the corporation to continue such practice, rule, or procedure. Such disapproval by the commissioner shall be subject to review by the Superior Court in a proceeding in lieu of prerogative writ. L.1964, c. 104, s. 9. 17:48-6.9. Adjustment of rates; experience rating formulas; approval Any group contract, covering at least 50 employees or members, may provide for the adjustment of the rate of premium at the end of the first year or any subsequent year of insurance thereunder based on the experience thereunder both past and contemplated. No hospital service corporation shall use any form of experience rating plan until it shall have filed with the commissioner the formulas to be used and the classes of groups to which they are to apply. The commissioner may disapprove the formulas or classes at any time if he finds that the rates produced thereby are excessive, inadequate or unfairly discriminatory or that the formulas or classes are such as to prejudice the interests of persons who are eligible for hospital services under contracts with the hospital service corporation which are not subject to experience rating. Excluding those rating formulas applicable to groups the employees or members of which are located in more than one state and which are underwritten in participation with other corporation(s) of other state(s), no rating formula shall be approved by the commissioner unless it provides that the experience rated groups will be assessed a reasonable community charge. Any such rating formula may provide for the allowance of an equitable discount in the event the policyholder agrees to perform certain administrative and record keeping functions in connection with the routine maintenance of the group account. Nothing in this section shall preclude the hospital service corporation from incorporating in the rate formula such claim cost and utilization trend factors as it deems necessary in its discretion so long as the rates produced are self-supporting and the formulas for classes do not prejudice the interests of persons who are eligible for hospital services under contracts with the hospital service corporation which are not subject to experience rating. For experience rated groups of 50 to 99 employees or members, the commissioner will have the authority to determine that rates charged depart from community rates in such a way as to assure continuity of rating principles with the community rated and experience rated groups of 100 or more. L.1970, c. 111, s. 1, eff. June 26, 1970. Amended by L.1978, c. 94, s. 2, eff. Aug. 2, 1978. 17:48-6.10. Definitions As used in this act: a. ~Group policy~ means a group contract or individual group certificate delivered or issued for delivery by a hospital service corporation, medical service corporation or similar corporation or organization. b. ~Insurer~ means the entity issuing a group contract or an individual group certificate. c. ~Insurance~ , ~Insurers~ and ~Insured~ refer to coverage under a group contract or individual group certificate on a premium-paying basis. d. ~Premium~ includes any premium or other consideration payable for coverage under a group contract or individual group certificate. e. ~Medicare~ means Title XVIII of the United States Social Security Act as amended or superseded. f. ~Total disability of an employee or member~ exists only while the employee or member (1) is not engaged in any gainful occupation, and (2) is completely unable, due to sickness or injury or both, to engage in any and every gainful occupation for which the person is reasonably fitted by education, training, or experience. L.1981, c. 455, s. 1. 17:48-6.11. Group contract or individual group certificate; total disability of employee or member; continuation of coverage; conditions A group contract or individual group certificate delivered or issued for delivery in this State which covers employees or members and their dependents for hospital, medical-surgical or major medical coverage on an expense incurred or service basis, other than for specific diseases or for accidental injuries only, shall provide that employees or members whose coverage under the group contract or individual group certificate would otherwise terminate because of termination of employment or membership due to total disability of the employee or member shall be entitled to continue their hospital, medical-surgical and major medical coverage under that group contract or individual group certificate for themselves and their eligible dependents, subject to all of the group contract@s or individual group certificate@s terms and conditions applicable to those forms of coverage and subject to the following conditions: a. Continuation shall only be available to any employee or member who has been continuously covered under the group contract or individual group certificate during the entire 3-months period ending with such termination. b. Continuation shall be available for any person who is covered by or eligible for Medicare, subject to any nonduplication of benefits provisions of the group contract or individual group certificate. c. In addition to hospital, medical-surgical, or major medical benefits, continuation shall include any other health care expense benefit, including dental, vision care, or prescription drug benefits available through the insured group. d. An employee or member electing continuation shall pay to the group contract holder or his employer, on a monthly basis in advance, the amount of contribution required by the contract holder or employer, but not more than the group rate for the coverage being continued under the group contract or individual group certificate on the due date of each payment. The employee@s or member@s written election for continuation, together with the first contribution required to establish contributions on a monthly basis in advance, shall be given to the contract holder or employer within 31 days of the date the employee@s or member@s coverage would otherwise terminate. e. Continuation of coverage under the group contract or individual group certificate for any person shall terminate at the first to occur of the following: (1) Failure of the former employee or member to make timely payment of a required contribution. Termination shall occur at the end of the period for which contributions were made. (2) The date the employee again becomes employed and eligible for benefits under another group plan providing health care expense benefits, or in the case of a qualified eligible dependent, the date such dependent becomes employed and eligible for such benefits. (3) The date on which the group contract or individual group certificate is terminated or, in the case of an employee, the date his employer terminates participation under the group contract or individual group certificate, provided that (a) the employee or member shall have the right to become covered under any new group contract or individual group certificate contracted for by the employer, for the balance of the period that he would have remained covered under the prior group contract or individual group certificate in accordance with this act had a termination of a group not occurred; (b) the minimum level of benefits to be provided by the other group contract or individual group certificate shall be the applicable level of benefits of the prior group contract or individual group certificate reduced by any benefits payable under that prior group contract or individual group certificate, and (c) the prior group contract or individual group certificate shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits, but only when replacement occurred. f. A notification of the continuation privilege shall be included in any individual group certificate or employee booklet. L.1981, c. 455, s. 2. 17:48-6.12. Inapplicability of act if insurer not have right to terminate contract or certificate without consent of insured The provisions of this act shall not apply to any contract or individual group certificate in which the insurer does not have the right to terminate the contract or individual group certificate without the consent of the insured. L.1981, c. 455, s. 3. 17:48-6.13. Hospital service corporation to offer basic health care contracts Every hospital service corporation authorized to do business in this State shall offer for sale individual and group basic health care contracts in accordance with accepted underwriting standards for payment of benefits to each person covered thereunder. L.1991,c.187,s.50. 17:48-6.14. Basic health care contract; provisions 51. a. A basic health care contract offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13) shall provide: (1) Basic hospital expense coverage for a period of 21 days in a benefit year for each covered person for expenses incurred for medically necessary treatment and services rendered as a result of injury or sickness, including: (a) Daily hospital room and board, including general nursing care and special diets; (b) Miscellaneous hospital services, including expenses incurred for charges made by the hospital for services and supplies which are customarily rendered by the hospital and provided for use only during any period of confinement; (c) Hospital outpatient services consisting of hospital services on the day surgery is performed; hospital services rendered within 72 hours after accidental injury; and X-ray and laboratory tests to the extent that benefits for such services would have been provided if rendered to an inpatient of the hospital; (2) Basic medical-surgical expense coverage for each covered person for expenses incurred for medically necessary services for treatment of injury or sickness for the following: (a) Surgical services; (b) Anesthesia services consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical services rendered by a physician other than the physician performing the surgical services; (c) In-hospital services rendered to a person who is confined to a hospital for treatment of injury or sickness other than that for which surgical care is required; (3) Maternity benefits, including cost of delivery and prenatal care; (4) Out-of-hospital physical examination, including related X-rays and diagnostic tests, on the following basis: (a) For covered minors of less than two years of age, up to six examinations during the first two years of life; for covered minors of two years of age or older, one examination at age 3, 6, 9, 12, 15 and 18 years; (b) For covered adults of less than 40 years of age, one examination every five years; for covered adults 40 or more years of age but less than 60 years of age, one examination every three years; and for covered adults 60 years of age or older, one examination every two years. Notwithstanding the provisions of this section to the contrary, a hospital service corporation may provide alternative benefits or services from those required by this subsection if they are approved by the Commissioner of Insurance and are within the intent of this act. b. (1) No person who is eligible for coverage under Medicare pursuant to Pub. L. 89-97 (42 U.S.C. s.1395 et seq.) shall be a covered person under a contract required to be offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13). (2) A hospital service corporation shall not sell a contract required to be offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13) to a group which was covered by health benefits or health insurance any time during the 12-month period immediately preceding the effective date of coverage. c. (1) Contracts required to be offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13) 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 family unit during any benefit year, no coinsurance shall be payable in excess of a total of $500 by an individual or family unit during any benefit year, and neither coinsurance nor deductibles shall apply to physical examinations or maternity benefits covered pursuant to paragraphs (3) or (4) of subsection a. of this section. (2) Managed care systems may be utilized for coverages required to be offered pursuant to this section, subject to the review and approval of the Commissioner of Insurance. d. Notwithstanding any other law to the contrary, a hospital service corporation shall file copies of all forms of contracts required to be offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13) for approval with the Commissioner of Insurance in accordance with the provisions of section 4 of P.L.1995, c.73, (C.17:48-8.2), provided, however, that contract forms shall be effective only with respect to those contract form filings which are accompanied by an explanation and identification of the changes being made on a form prescribed by the commissioner. Contract forms shall not be unfair, inequitable, misleading or contrary to law, nor shall they produce rates that are excessive, inadequate or unfairly discriminatory. e. Notwithstanding any other law to the contrary, a hospital service corporation shall file all rates and supplementary rate information and all changes and amendments thereof for the contracts required to be offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13) for approval with the commissioner at least 60 days prior to becoming effective. Unless disapproved by the commissioner prior to their effective date specifying in what respects the filing is not in compliance with the standards set forth in this subsection, any such rates, supplementary rate information, changes or amendments filed with the commissioner shall be deemed approved as of their effective date. In his discretion, the commissioner may waive the 60-day waiting period or any portion thereof. Rates shall not be excessive, inadequate or unfairly discriminatory. f. The commissioner shall issue regulations to establish minimum standards for loss ratios under contracts required to be offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13). g. Notwithstanding any provision of law to the contrary, a hospital service corporation shall not be required, in regard to contracts required to be offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13), to provide mandatory health care benefits or provide benefits for services rendered by providers of health care services as otherwise required by law. h. The commissioner shall, pursuant to the provisions of the ~Administrative Procedure Act,~ P.L.1968, c.410 (C.52:14B-1 et seq.), adopt rules and regulations necessary to effectuate the purposes of this section and section 50 of P.L.1991, c.187 (C.17:48-6.13), including standards for terms and conditions of contracts required to be offered pursuant to this section and section 50 of P.L.1991, c.187 (C.17:48-6.13) and schedules of benefits for coverages provided for in subsection a. of this section. i. Every hospital service corporation shall report annually on or before March 1 to the Department of Insurance the number of individual and group contracts required to be offered pursuant to section 50 of P.L.1991, c.187 (C.17:48-6.13) that were sold in the preceding calendar year and the number of persons covered under each type of contract. The department shall compile and analyze this information and shall report annually on or before July 1 its findings and any recommendations it may have to the Governor and the Legislature. L.1991,c.187,s.51; amended 1995,c.73,s.6. 17:48-6.15. Coverage provided by hospital service corporation for subscriber@s child 1. a. A hospital service corporation contract which provides hospital or medical expense benefits under which dependent coverage is available shall not deny coverage for a subscriber@s child on the grounds that: (1) The child was born out of wedlock; (2) The child is not claimed as a dependent on the subscriber@s federal tax return; or (3) The child does not reside with the subscriber or in the hospital service corporation@s service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the contract with respect to the use of specified providers. b. If a child has coverage through a hospital service corporation contract of a noncustodial parent, the hospital service corporation shall: (1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child@s noncustodial parent@s coverage; (2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and (3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate. c. When a parent who is the subscriber is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the hospital service corporation shall: (1) Permit the parent to enroll his child as a dependent, without regard to any enrollment season restrictions; (2) Permit the child@s other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the contract if the parent who is the subscriber fails to enroll the child; and (3) Not terminate coverage of the child unless the parent who is the subscriber provides the hospital service corporation with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage. L.1995,c.288,s.1. 17:48-6.16. Requirements applicable to State Medicaid 2. A hospital service corporation shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other subscriber. L.1995,c.288,s.2. 17:48-6.17. Eligibility for enrollment in hospital service corporation 1. Notwithstanding any other provision of law to the contrary, a hospital service corporation shall not consider a person@s eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the equivalent statute in another state, when determining the person@s eligibility for enrollment in, or the provision of benefits under, a hospital service corporation contract providing hospital or medical expense benefits delivered, issued or executed in this State, or approved for issuance in this State by the Commissioner of Insurance. L.1995,c.291,s.1. 17:48-6.18. Hospital service corporation contract, exclusion, rates, terms based on genetic information prohibited 11. Every individual or group hospital service corporation contract providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall not exclude any person or eligible dependent and shall not establish any rates or terms therefor on the basis of an actual or expected health condition or on the basis of any genetic characteristic. For the purposes of this section, ~genetic characteristic~ means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with statistically increased risk of development of a disease, disorder or syndrome. L.1996,c.126,s.11. 17:48-6.19 Coverage for certain dependents until age 30 by hospital service corporation. 1. a. As used in this section, ~dependent~ means a subscriber@s child by blood or by law who: (1) is less than 30 years of age; (2) is unmarried; (3) has no dependent of his own; (4) is a resident of this State or is enrolled as a full-time student at an accredited public or private institution of higher education; and (5) is not actually provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan or health benefits plan, or entitled to benefits under Title XVIII of the Social Security Act, Pub.L.89-97 (42 U.S.C. s.1395 et seq.). b. (1) A hospital service corporation contract that provides coverage for a subscriber@s dependent under which coverage of the dependent terminates at a specific age before the dependent@s 30th birthday, and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this section, shall, upon application of the dependent as set forth in subsection c. of this section, provide coverage to the dependent after that specific age, until the dependent@s 30th birthday. (2) Nothing herein shall be construed to require: (a) coverage for services provided to a dependent before the effective date of this section; or (b) that an employer pay all or part of the cost of coverage for a dependent as provided pursuant to this section. c. (1) A dependent covered by a subscriber@s contract, which coverage under the contract terminates at a specific age before the dependent@s 30th birthday, may make a written election for coverage as a dependent pursuant to this section, until the dependent@s 30th birthday: (a) within 30 days prior to the termination of coverage at the specific age provided in the contract; (b) within 30 days after meeting the requirements for dependent status as set forth in subsection a. of this section, when coverage for the dependent under the contract previously terminated; or (c) during an open enrollment period, as provided pursuant to the contract, if the dependent meets the requirements for dependent status as set forth in subsection a. of this section during the open enrollment period. (2) For 12 months after the effective date of this section, a dependent who qualifies for dependent status as set forth in subsection a. of this section, but whose coverage as a dependent under a subscriber@s contract terminated under the terms of the contract prior to the effective date of this section, may make a written election to reinstate coverage under that contract as a dependent pursuant to this section. d. (1) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall consist of coverage which is identical to the coverage provided to that dependent prior to the termination of coverage at the specific age provided in the contract. If coverage is modified under the contract for any similarly situated dependents for coverage prior to the termination of coverage at the specific age provided in the contract, the coverage shall also be modified in the same manner for the dependent. (2) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall not be conditioned upon, or discriminate on the basis of, lack of evidence of insurability. e. (1) The subscriber@s contract may require payment of a premium by the subscriber or dependent, as appropriate, subject to the approval of the Commissioner of Banking and Insurance, for any period of coverage relating to a dependent@s written election for coverage pursuant to subsection c. of this section. The payment shall not exceed 102% of the applicable portion of the premium previously paid for that dependent@s coverage under the contract prior to the termination of coverage at the specific age provided in the contract. (2) The applicable portion of the premium previously paid for the dependent@s coverage under the contract shall be determined pursuant to regulations promulgated by the Commissioner of Banking and Insurance, based upon the difference between the contract@s rating tiers for adult and dependent coverage or family coverage, as appropriate, and single coverage, or based upon any other formula or dependent rating tier deemed appropriate by the commissioner which provides a substantially similar result. (3) Payments of the premium may, at the election of the payor, be made in monthly installments. f. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following: (1) the dependent is disqualified for dependent status as set forth in subsection a. of this section; (2) the date on which coverage ceases under the contract by reason of a failure to make a timely payment of any premium required under the contract by the subscriber or dependent for coverage provided pursuant to this section. The payment of any premium shall be considered to be timely if made within 30 days after the due date or within a longer period as may be provided for by the contract; or (3) the date upon which the employer under whose contract coverage is provided to a dependent ceases to provide coverage to the subscriber. Nothing herein shall be construed to permit a hospital service corporation to refuse a written election for coverage by a dependent pursuant to subsection c. of this section, based upon the dependent@s prior disqualification pursuant to paragraph (1) of this subsection. g. Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to a subscriber: (1) in the certificate of coverage prepared for subscribers by the hospital service corporation on or about the date of commencement of coverage; and (2) by the subscriber@s employer: (a) on or before the coverage of a subscriber@s dependent terminates at the specific age as provided in the contract; (b) at the time coverage of the dependent is no longer provided pursuant to this section because the dependent is disqualified for dependent status as set forth in subsection a. of this section, except this employer notice shall not be required when a dependent no longer qualifies based upon paragraph (1) or (3) of subsection a. of this section; (c) before any open enrollment period permitting a dependent to make a written election for coverage pursuant to subsection c. of this section; and (d) immediately following the effective date of this section, with respect to information concerning a dependent@s opportunity, for 12 months after the effective date of the section, to make a written election to reinstate coverage under a contract pursuant to paragraph (2) of subsection c. of this section. h. This section shall apply to those contracts in which the hospital service corporation has reserved the right to change the premium. L.2005,c.375,s.1.

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