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| Home > Statutes > USA New Jersey |
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USA Statutes : new_jersey
Title : TITLE 17 CORPORATIONS AND INSTITUTIONS FOR FINANCE AND INSURANCE
Chapter : 17:48C-18.
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17:48C-18. Written group contracts required; provisions; additional payment
Every group contract entered into by a dental 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 dental service corporation by or on behalf of the policyholder for the original period of coverage, the time or times at which, 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 dental 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 dental services to be paid for and the period during which such payments will be made, 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.
Any such group contract may contain a provision that all dental services paid for by a dental service corporation shall be in accordance with the accepted dental practices in the community at the time, but the corporation shall not be liable for injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or malpractice on the part of any officer or employee or on the part of any dentist or others engaged by him in the course of rendering dental services to persons covered.
Any dental service corporation may classify persons covered whereby under specified circumstances a covered person may pay a participating dentist for dental services an amount in addition to that payable by the corporation for dental services and the group contract shall contain the provisions thereof and specify such circumstances.
L.1968, c. 305, s. 18, eff. Sept. 26, 1968.
17:48C-18.1. Alternative dental coverage; original coverage restricted to limited number of providers
Each employer or other organization which employs or has 25 or more employees or members during the full preceding calendar year and which contributes to a dental service corporation contract which restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers, shall also offer its employees and their eligible dependents and members and members@ eligible dependents at the time a dental benefits plan is offered or renewed the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist.
L.1983, c. 144, s. 1, eff. April 20, 1983.
17:48C-18.2. Employer contribution
An employer or other organization shall be required to pay for or contribute towards the provision of alternative coverage an amount equal to the premium or cost which it pays or contributes to the dental service corporation contract which limits the number of providers of dental services.
L.1983, c. 144, s. 2, eff. April 20, 1983.
17:48C-18.3. Rules and regulations
Within 120 days of the effective date of this act, the Commissioner of the Department of Insurance shall promulgate rules and regulations necessary to effectuate the purpose of this act, including procedures for notice to covered persons, employers and other organizations of the provisions of this act.
L.1983, c. 144, s. 3, eff. April 20, 1983.
17:48C-19.1 Adjustment of rate of premium for dental service corporations, certain circumstances.
1. a. A group contract covering at least 10 employees or members may provide for the adjustment of the rate of premium based on past or projected experience, and may include those claim costs and utilization trend factors which the dental service corporation deems necessary in its discretion. No dental service corporation shall use any form of prospective or retrospective experience rating plan until it shall have filed with the Commissioner of Banking and Insurance the formulas to be used and the classes or groups to which they are to apply. The commissioner may disapprove the formulas or classes at any time if the commissioner 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 coverage under contracts with the dental service corporation which are not subject to experience rating.
b. An experience rating formula used pursuant to this section may provide for the allowance of an equitable discount if the policyholder agrees to perform certain administrative and recordkeeping functions in connection with the routine maintenance of the group contract.
c. Nothing in this section shall preclude a dental service corporation from incorporating in the rating formulas those claim cost and utilization trend factors which it deems necessary in its discretion, so long as the rates produced are self-supporting in the aggregate, not excessive, and the formulas for classes do not prejudice the interests of persons who are eligible for coverage under contracts with the dental service corporation which are not subject to experience rating.
d. The commissioner may, by regulation, prohibit or limit the experience rating of contracts covering groups of fewer than 50 employees or members if the commissioner determines that experience rating of those contracts is not in the public interest.
L.2003,c.154,s.1.
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