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

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

Exhibit H

In accordance with N.J.A.C. 11:20-3.1(e) each carriers shall file this Identification of Standard Plans no later than July 1, 2009 and an amended Identification of Standard Plans within 60 days of any change in the plans being offered by the carrier.

Identification of Standard Plans

1. INFORMATION ABOUT THE CARRIER AND RESPONDENT

Carrier Name:_________________________________________ NAIC #:________________

Respondent Information:

Name:________________________________ Title:__________________________________

Address________________________________________________________________________ _______________________________________________________________________________

Telephone:____________ FAX:____________ Email Address:_______________________

Is Carrier a Federally Qualified HMO? _______________ If yes, attach evidence.

2. INFORMATION ABOUT THE FILING

Date of Filing: ___________________________________

If the filing is being made after a change in the plans offered to individual consumers:

Date plan change(s) made: ___________________________________

Date of withdrawal pursuant to NJAC 11:20-18, if applicable: ___________________________________

Date of conversion pursuant to NJAC 11:20-24.7, if applicable: __________________________________

3. IDENTIFICATION OF PLANS BEING OFFERED

Place a check next to each standard plan being offered.

[ ] Plan A/50 (Must be offered unless carrier is Federally Qualified HMO)
Delivery System (Check all that apply)
[ ] Indemnity	[ ] PPO	[ ] POS
Deductible Options (Check all that apply)
[ ] $ 2,500	[ ] $ 1,000	[ ] $ 5,000	[ ] $ 10,000	[ ] amount to
(must offer)	qualify as a HDHP
Copayment Options (Check all that apply)
[ ] $ 15	[ ] $30	[ ] $ 40	[ ] $ 50

[ ] Plan B
Delivery System (Check all that apply)
[ ] Indemnity	[ ] PPO	[ ] POS
Deductible Options (Check all that apply)
[ ] $ 2,500	[ ] $ 1,000	[ ] $ 5,000	[ ] $ 10,000	[ ] amount to
(must offer)	qualify as a HDHP
Copayment Options (Check all that apply)
[ ] $ 15	[ ] $30	[ ] $ 40	[ ] $ 50

[ ] Plan C
Delivery System (Check all that apply)
[ ] Indemnity	[ ] PPO	[ ] POS
Deductible Options (Check all that apply)
[ ] $ 2,500	[ ] $ 1,000	[ ] $ 5,000	[ ] $ 10,000	[ ] amount to
(must offer)	qualify as a HDHP
Copayment Options (Check all that apply)
[ ] $ 15	[ ] $30	[ ] $ 40	[ ] $ 50

[ ] Plan D
Delivery System (Check all that apply)
[ ] Indemnity	[ ] PPO	[ ] POS
Deductible Options (Check all that apply)
[ ] $ 2,500	[ ] $ 1,000	[ ] $ 5,000	[ ] $ 10,000	[ ] amount to
(must offer)	qualify as a HDHP
Copayment Options (Check all that apply)
[ ] $ 15	[ ] $30	[ ] $ 40	[ ] $ 50

[ ] Plan HMO
Copayment Options (Check all that apply)
[ ] $15	[ ] $ 30 (must offer)	[ ] $ 40	[ ] $ 50
Deductible and Coinsurance (list the combinations below.)
_________________________________________________________
_________________________________________________________
Referral (Check all that apply)
[ ] Required	[ ] Not Required

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

Expired, effective 7/4/2005.
See: 37 N.J.R. 2994(a).
New Rule, 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).