N.J. Admin. Code § Tit. 11, ch. 20, APPENDIX, exh. G

Current through Register Vol. 57, No. 1, January 6, 2025

Exhibit G

[Carrier]

Plan Update Rider

This rider amends [the] standard [indemnity] [PPO][HMO deductible and coinsurance] individual health benefits plan [A/50] [B] [C] [D].

Effective Date:

1. The Deductible Credit provision of the [BENEFIT] [COVERAGE] PROVISION section is deleted and replaced with the following:

Deductible Credit: For the first Calendar Year of this [Policy] [Contract], a [Covered Person] [Member] will receive credit for any Deductible amounts satisfied under previous coverage within the same Calendar Year that Your first Calendar Year starts under this [Policy] [Contract] provided there has been no lapse in coverage between the previous coverage and this [Policy] [Contract].

This credit will be applied only if Your previous coverage was under a plan with Us and the new [Policy] [Contract] is being issued as a result of Our decision to convert the previous plan.

2. A new provision entitled Coinsurance Credit is added to the BENEFIT [COVERAGE] PROVISION section immediately following the Deductible Credit provision.

[Coinsurance Credit: A [Covered Person] [Member] will receive credit for any Coinsurance amounts the [Covered Person] [Member] satisfied from January 1 of the Calendar Year in which this [Policy] [Contract] is issued.

As of the Effective Date of this [Policy] [Contract], and for the balance of the first Calendar Year, the Coinsurance amounts the [Covered Person] [Member] paid during the same Calendar Year that were accumulating toward the satisfaction of the Maximum Out of Pocket under the prior coverage will be applied toward the satisfaction of the Maximum Out of Pocket under this [Policy] [Contract].

Except as stated below, once the Maximum Out of Pocket has been reached, the Covered Person has no further obligation to pay any amounts as Deductible and Coinsurance for covered services and supplies for the remainder of the Calendar Year.

Exception: Coinsurance paid for covered Prescription Drugs does not count toward the Maximum Out of Pocket. Such coinsurance must continue to be paid even after the Maximum Out of Pocket has been reached.]

This Rider terminates as of December 31 of the Calendar Year in which it was issued.

N.J. Admin. Code Tit. 11, ch. 20, APPENDIX, exh. G

Amended by R.1995 d.51, effective 12/23/1994 (operative January 1, 1995).
See: 26 N.J.R. 4884(a), 27 N.J.R. 565(a).
Amended by R.1997 d.279, effective 7/7/1997 (operative September 1, 1997).
See: 29 N.J.R. 1011(a), 29 N.J.R. 2854(a).
Amended by R.1997 d.477, effective 1/1/1998.
See: 29 N.J.R. 4381(a), 29 N.J.R. 5023(b).
Amended by R.1998 d.443, effective 8/7/1998.
See: 30 N.J.R. 2581(a), 30 N.J.R. 3289(a).
Amended by R.1998 d.503, effective 9/16/1998 (operative November 1, 1998).
See: 30 N.J.R. 3235(b), 30 N.J.R. 3838(a).
Amended by R.1999 d.131, effective 3/25/1999.
See: 31 N.J.R. 834(a), 31 N.J.R. 1104(a).
Amended by R.2002 d.95, effective 3/18/2002 (operative August 1, 2002).
See: 33 N.J.R. 4057(a), 34 N.J.R. 1277(a).
Amended by R.2002 d.331, effective 10/7/2002.
See: 34 N.J.R. 1786(a), 34 N.J.R. 3527(a).
Amended by R.2003 d.91, effective 1/28/2003.
See: 35 N.J.R. 73(a), 35 N.J.R. 1290(a).
Expired, effective 7/4/2005.
See: 37 N.J.R. 2994(a).
New Rule, R.2006 d.119, effective 2/24/2006 (operative July 1, 2006).
See: 38 N.J.R. 1306(a), 38 N.J.R. 1459(a).
Amended by R.2009 d.45, effective 12/29/2008.
See: 40 N.J.R. 6904(a), 41 N.J.R. 799(b).
Repealed by R.2018 d.197, effective 6/12/2018.
See: 50 N.J.R. 1412(a), 50 N.J.R. 2329(a).