N.J. Admin. Code § 11:10-1.9

Current through Register Vol. 56, No. 23, December 2, 2024

Section 11:10-1.9 - Expense limitation

(a) To achieve compliance with the expense limits set forth in 17:48D-14, every DPO shall:

1. Use at least 70 percent of its New Jersey premium in the first calendar year of operation, 75 percent in the second calendar year, and 80 percent in all subsequent calendar years for the direct provision of professional dental services to covered persons;

2. Set its per covered person retention in conformity with the statutory limits in constructing its schedule of premiums.

(b) Expenditures for the direct provision of professional dental services are, in general, that portion of the DPO's total expenses which would exist if the DPO were simply a dental practice and if covered persons were the patients of that practice. Monies paid to dentists for their time, for the cost of their assistants, hygienists, and other support personnel, for their laboratory costs, malpractice insurance, and for all other necessary costs of offices and equipment which are not required for the non-dental care delivery activities of a DPO are examples of such dental expenditures.

(c) Portions of expenditures such as rent, utilities, building maintenance, accounting, real estate taxes, payroll taxes, depreciation, amortization, employee benefits, interest and bad debts, which a dentist or dental group incurs in delivering dental care, may also be counted as expenditures for dental services as long as a reasonable method of allocating these expenditures to the dental and non-dental functions is used.

(d) Premium not needed for the direct provision of dental care shall be considered as retention and will be subject to the limitations of 17:48D-14. Two examples of items of retention are profits and marketing costs.

(e) For purposes of determining the applicable expense limitation pursuant to 17:48D-14, the DPO's first year of operation shall be the year the DPO obtains its initial certificate of authority.

(f) For purposes of determining the expense limitation pursuant to N.J.S.A. 17:48D-14, Federal fees, taxes, and/or assessments that are required by the Federal Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the Health Care and Education Reconciliation Act, Public Law 111-152 are excluded from the calculation of premiums.

N.J. Admin. Code § 11:10-1.9

Amended by 49 N.J.R. 3359(c), effective 10/2/2017