N.J. Admin. Code § 11:4-23.4

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:4-23.4 - Policy definitions and terms

(a) No policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this section.

1. "Accident," "accidental injury," or "accidental means" shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.

i. "Injury" shall not be defined more restrictively than as a bodily injury sustained by the covered person as a result of an accident, which injury is the direct cause of the loss, independent of disease, bodily infirmity or any other cause, and which occurs while coverage is in force.

ii. The definition may provide that injuries shall not include injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, mandatory motor vehicle no-fault plan, unless prohibited by law.

2. "Benefit period" or "Medicare benefit period" shall not be defined more restrictively than as defined in the Medicare program.

3. "Convalescent nursing home," "extended care facility," or "skilled nursing facility" shall not be defined more restrictively than as defined by the Medicare program.

4. "Health care expenses" means, for purposes of N.J.A.C. 11:4-23.1 1, expenses of health maintenance organizations which expenses are associated with the delivery of health care services and are analogous to incurred losses of insurers. Expenses shall not include the following costs:

i. Home office and overhead costs;

ii. Advertising costs;

iii. Commissions and other acquisition costs;

iv. Taxes;

v. Capital costs;

vi. Administrative costs; and

vii. Claims processing costs.

5. "Hospital" may be defined in relation to its status, facilities, and available services or to reflect accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined by the Medicare program.

6. "Medicare" shall be defined in the policy and certificate. Medicare may be substantially defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I of Public Laws 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof," or words of similar import.

7. . "Medicare eligible expense" shall mean expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

8. "Physician" shall not be defined more restrictively than as defined by the Medicare program.

9. "Preexisting condition" shall not be defined more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.

10. "Sickness" shall not be defined more restrictively than a sickness or disease which causes loss commencing while the insurance or coverage is in force and which is not excluded under a preexisting condition limitation. The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers' compensation, occupational disease, employer's liability, or similar law.

11. "Totally disabled" shall not be defined more restrictively than as:

i. An injury or sickness that continuously confines an individual in a hospital or skilled nursing facility; or

ii. A continuous disability resulting from an injury or sickness not requiring confinement of an individual in a hospital or skilled nursing facility, but which a physician certifies as preventing that individual from engaging in the normal activities of a person of like age and sex in good health.

N.J. Admin. Code § 11:4-23.4

Amended by R.1991 d.345, effective 7/1/1991.
See: 23 New Jersey Register 1264(a), 23 New Jersey Register 2014(a).
Deleted "group insurance", "or individual or group subscriber contract", "Supplement", "or subscriber contract" in (a).
Deleted "the definition of injury", "an accidental", "insurance or service corporation"; added "Injury", "defined", "as a result of an accident", "injury" in (a)1i.
Deleted ", or injuries occurring while the covered person is engaged in any activity pertaining to any trade, or business, employment, or occupation for wage or profit" in (a)1ii.
Deleted "or hospital or medical service corporations", "may", "as are applicable to Medicare claims"; added "shall", "as are applicable to Medicare claims" in (a)1ii6.
Deleted "or hospital or medical service corporation" in (a)1ii8 and 9.
Added (a)1ii12.
Amended by R.1993 d.26, effective 1/4/1993.
See: 24 New Jersey Register 12(a), 25 New Jersey Register 141(a).
Added definition for health care expenses and references to Medicare standards.
Amended by R.1996 d.295, effective 7/1/1996.
See: 28 New Jersey Register 1647(a), 28 New Jersey Register 3462(a).
Amended by R.2005 d.291, effective 9/6/2005.
See: 37 New Jersey Register 1428(a), 37 New Jersey Register 3376(a).
In (a)4, added ", for purposes of N.J.A.C. 11-4-23.11," following "means"; in (a)7, added "Part A and B" following "by Medicare".