N.J. Stat. tit. 17, ch. 35C

in effect

N.J. Stat. § 17:35C-1 Definitions

1. For the purposes of this act: a. "Applicant" means: (1) In the case of an individual medicare supplement subscriber contract, the person who seeks to contract for service corporation benefits, and (2) In the case of a group medicare supplement subscriber contract, the person eligible for service corporation benefit coverage. b. "Certificate" means any certificate issued under an individual or group medicare supplement contract, which certificate has been delivered or issued for delivery in this State. c. "Commissioner" means the Commissioner of Insurance. d. "Medicare" means the program established by the "Health Insurance for the Aged Act," Title XVIII of the "Social Security Act," Pub.L.89-97, as then constituted or later amended (42 U.S.C. s.1395 et seq.). e. "Medicare supplement contract" means a group or individual subscriber contract or certificate which is advertised, marketed, designed primarily as, or is otherwise held out to be, a supplement to reimbursements under medicare for the hospital, medical or surgical expenses of persons eligible for medicare, other than a contract issued pursuant to a contract under 42 U.S.C. s.1395l or 42 U.S.C. s.1395mm or a contract issued under a demonstration project authorized pursuant to the "Health Insurance for the Aged Act," 42 U.S.C. s.1395 et seq. The term does not include a contract issued to one or more employers or labor organizations, or to the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees or combination thereof or for members or former members, or combination thereof, of the labor organizations. f. "Service corporation" means any medical service corporation operating pursuant to the provisions of P.L.1940, c.74 (C.17:48A-1 et seq.), any hospital service corporation operating pursuant to the provisions of P.L.1938, c.366 (C.17:48-1 et al.), any health service corporation operating pursuant to the provisions of P.L.1985, c.236 (C.17:48E-1 et al.), or any similar organization which is authorized by law to provide health care services and supplies. g. "Service corporation contract" means any group or individual subscriber contract issued by a service corporation. L.1982, c.95, s.1; amended 1992,c.144,s.2.

N.J. Stat. § 17:35C-2 Contract provisions; regulations

The commissioner shall issue regulations to establish specific standards for contract provisions of medicare supplement contracts, which shall be in addition to and in accordance with applicable laws of this State, and may cover, but shall not be limited to: a. Terms of renewability; b. Initial and subsequent conditions of eligibility; c. Nonduplication of coverage; d. Probationary periods; e. Benefit limitations, exceptions and reductions; f. Elimination periods; g. Requirements for replacement; h. Recurrent conditions; and i. Definition of terms. L.1982, c. 95, s. 2.

N.J. Stat. § 17:35C-3 Prohibited provisions

3. a. No medicare supplement contract shall contain benefits which duplicate any benefits provided by medicare. b. The commissioner may issue regulations that specify prohibited contract provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person covered or proposed for coverage under a medicare supplement contract. L.1982,c.95,s.3; amended 1992,c.144,s.3.

N.J. Stat. § 17:35C-4 Preexisting condition; denial of claim

Notwithstanding any other provision of law of this State to the contrary, a medicare supplement contract may not deny a claim for losses incurred more than 6 months from the effective date of coverage for a preexisting condition. The contract may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage. L.1982, c. 95, s. 4.

N.J. Stat. § 17:35C-5 Regulations

5. The commissioner shall promulgate regulations to effectuate and enforce the provisions of P.L.1982, c.95 (C. 17:35C-1 et seq.) and any regulations which are necessary to conform medicare supplement contracts and certificates with federal law. These regulations shall include, but not be limited to: a. Establishment of minimum standards for benefits, claim payments, marketing and reporting practices and compensation arrangements; b. Establishment of a uniform methodology for calculating and reporting loss ratios, and requiring refunds or credits if the contracts or certificates do not meet loss ratio requirements; c. Establishment of a process for filing of all requests for premium increases and rate changes, which may include public hearings as determined appropriate by the commissioner prior to approval of any premium increases; d. Assurance of access by the public to contract, premium and loss ratio information; and e. Establishment of standards for Medicare Select contracts and certificates at such time as this State is authorized under federal law to authorize Medicare Select contracts and certificates. L.1982,c.95,s.5; amended 1992,c.144,s.4.

N.J. Stat. § 17:35C-6 Requirements for medicare supplement contract forms, rates

6. a. No service corporation shall deliver or issue for delivery to a resident of this State a medicare supplement contract unless it has filed with the commissioner a copy of the contract or certificate and a copy of any application, rider and endorsement for use in connection with the issuance or renewal thereof. (1) The commissioner may, at any time, notify the service corporation of his disapproval of any form filed pursuant to the provisions of this section on the ground that the form contains provisions which are unjust, unfair, inequitable, misleading, or contrary to law or to the public policy of this State and no service corporation shall use any form in this State which has been disapproved pursuant to this paragraph. (2) Any disapproval shall be subject to review in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). (3) The disapproval or the withdrawal of any form by the commissioner shall state in writing the grounds therefor in such detail as is reasonable to inform the service corporation of the reasons for withdrawal or disapproval. b. Any service corporation providing medicare supplement benefits in this State shall file annually with the commissioner its rates, rating schedule and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this State. All filings of rates and rating schedules shall demonstrate that the actual and expected losses in relation to premiums comply with the requirements of P.L.1982, c.95 (C.17:35C-1 et seq.) and any rule or regulation promulgated thereunder. c. Medicare supplement contracts shall be expected to return to subscribers benefits which are reasonable in relation to the premium charged. The commissioner shall issue regulations to establish minimum standards for loss ratios of medicare supplement contracts on the basis of paid claim experience and written premiums in accordance with accepted actuarial principles and practices. L.1982,c.95,s.6; amended 1992,c.144,s.5.

N.J. Stat. § 17:35C-7 Outline of coverage

7. a. In order to provide for full and fair disclosure in the sale of medicare supplement contracts, no medicare supplement contract or certificate shall be delivered or issued for delivery in this State, unless an outline of coverage is delivered to the applicant at the time application is made. b. The commissioner shall prescribe the format and content of the outline of coverage required by subsection a. of this section. For the purposes of this section, "format" means style, arrangement and overall appearance, including such items as the size, color and prominence of the font used, paper size and weight and the arrangement of text and captions. The outline of coverage shall include: (1) A description of the principal benefits and coverage provided in the contract; (2) (Deleted by amendment, P.L.1992, c.144). (3) A statement of the renewal provisions, including any reservation by the service corporation of a right to change premiums, and disclosure of the existence of any automatic renewal premium increases based on the subscriber's age; and (4) A statement that the outline of coverage is a summary of the contract issued or applied for and that the contract should be consulted to determine governing contractual provisions. c. The commissioner may require by regulation the publication of forms and an informational brochure with a standardized format and content, to serve as an aid in the selection of appropriate coverage, if any, by those eligible for medicare, and to aid the consumer in improving his understanding of medicare benefits. Except in the case of direct response solicitation service corporation contracts, the commissioner may require by regulation that the informational brochure be provided, concurrently with delivery of the outline of coverage, to all prospective subscribers eligible for medicare. With respect to direct response solicitation service corporation contracts, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective subscribers eligible for medicare, but in no event later than the time of contract delivery. d. The commissioner may promulgate regulations for captions or notice requirements for all service corporation contracts sold to persons eligible for medicare, other than for medicare supplement contracts, to inform those prospective subscribers that the particular service corporation contract is not a medicare supplement contract. e. The commissioner may further promulgate regulations to govern the full and fair disclosure of the information in connection with the replacement of service corporation contracts by persons eligible for medicare. L.1982,c.95,c.7; amended 1992,c.144,s.6.

N.J. Stat. § 17:35C-8 30-day examination period; refunds

8. Medicare supplement contracts or certificates shall have a notice prominently printed on the first page of the contract or certificate or attached thereto stating in substance that the applicant shall have the right to return the contract or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the contract or certificate, the applicant is not satisfied for any reason. Refunds made pursuant to this section shall be made in a timely manner and shall be paid directly to the applicant. L.1982,c.95,s.8; amended 1992,c.144,s.7.

N.J. Stat. § 17:35C-9 Application to hospital service corporations

Notwithstanding the provisions of section 17 of P.L. 1938, c. 366 (C. 17:48-17), the provisions of this act shall apply to hospital service corporations established pursuant to P.L. 1938, c. 366 (C. 17:48-1 et seq.). L.1982, c. 95, s. 9.

N.J. Stat. § 17:35C-10 Applicability of C.17:35C-1 et seq.

1. Except as otherwise specifically provided: a. The provisions of P.L.1982, c.95 (C.17:35C-1 et seq.) shall apply to all medicare supplement contracts and subscriber certificates delivered or issued for delivery in this State. b. The provisions of P.L.1982, c.95 (C.17:35C-1 et seq.) shall not apply to subscriber certificates, including group conversion contracts, provided to medicare eligible persons that are not advertised, marketed, designed primarily as, or otherwise held out to be medicare supplement contracts. L.1992,c.144,s.1.

N.J. Stat. § 17:35C-11 Filing of copy of advertising materials promoting medicare supplement contracts

8. a. Every service corporation shall file with the Department of Insurance a copy of all advertising materials to be used in promoting medicare supplement contracts to which residents of this State will have access, and through which the service corporation intends, or by implication purports to the reasonable, targeted consumer its intent, to make such contracts available for purchase or enrollment in this State. The requirements of this section shall apply to all advertisements in any medium whether in print or by means of television or radio broadcast. Filings shall be made at least 30 days prior to the date on which the advertisement is to be used in this State, or made accessible to residents of this State. b. The commissioner may, in the public interest, promulgate regulations governing medicare supplement contract advertising including, but not limited to, specific filing procedures, standards upon which review may be based, celebrity endorsements, unfair practices and review and disapproval procedures. c. Notwithstanding the provisions of subsection b. of this section, the commissioner may disapprove any advertisement at any time if he determines that the advertisement misrepresents the product, misleads the targeted consumer, uses a strategy which involves scare tactics, unnecessarily confusing data or representation, false or fraudulent statements or otherwise violates any applicable laws of this State or regulations promulgated thereunder. L.1992,c.144,s.8.

N.J. Stat. § 17:35C-12 Penalties

9. In addition to any other applicable penalties for violation of the provisions of R.S.17:17-1 et seq., the commissioner may require service corporations violating the provisions of P.L.1982, c.95 (C.17:35C-1 et seq.) to cease marketing any medicare supplement contract or certificate in this State which is related directly or indirectly to the violation, require that service corporation to take such action as is necessary to comply with the provisions of that act, or both. L.1992,c.144,s.9.

Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://www.njleg.state.nj.us/legislative-activity/statutesFetched: 10/17/2026