New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM
Appendix - APPENDIX
Exhibit FF
Current through Register Vol. 56, No. 24, December 18, 2024
STATE OF NEW JERSEY
SEH PROGRAM PREMIUM COMPARISON SURVEY
Submit this completed survey no later than December 1 of each year to:
| Part 1 |
| COMPANY AND RESPONDENT INFORMATION |
| CERTIFICATION |
I certify that the information set forth in this SEH Premium Comparison Survey is true and accurate, and hereby further certify that I am authorized to execute this certification on behalf of the above-named carrier.
| Part 2 |
| TOLL-FREE INFORMATION |
| Part 3 |
| DIRECTIONS FOR COMPLETING THE PREMIUM SURVEY |
A. Give monthly premium, rounded to the nearest dollar, for a standard policy issued on the next January 1 to an employer described in paragraph C below, for each plan in accordance with paragraph D below. The following abbreviations and instructions apply:
-- SCA: Selective Contracting Arrangement (An arrangement for the payment of predetermined fees or reimbursement levels for covered services by the carrier to preferred providers or preferred provider organizations (see N.J.A.C. 11:4-37.2)) offered in conjunction with Plan(s) B, C, D, or E.
-- POS: A standard HMO Point of Service Plan (HMO/POS plan) (N.J.A.C. 11:21-3.1(h) ) or standard non-HMO Point of Service Plan (POS plan) (N.J.A.C. 11:21-3.1(g) ).
-- Standard Premium: The standard plan is offered or purchased without optional riders. This premium must include all standard benefits, including standard prescription drug (Rx) benefits, and must not reflect any non-standard riders which increase or decrease benefits. The standard Rx plan for any plan other than an in-network only HMO plan is Rx covered subject to the indemnity or out-of-network cost sharing.
-- Rx: For HMO (in-network-only) Plan, the standard Rx benefit is 50%. (Pursuant to N.J.A.C. 11:21-3.1(c)3 iii carriers are allowed the option of a $ 15 copay, but this option does not appear to be used.)
B. Use "NA" to indicate when any plan variation is not being offered.
C. For purposes of completing the survey, assume the policyholder is a small employer, located in one of the following counties: Bergen, Camden, and Middlesex, with six employees as follows:
D. Follow instruction on Page 10 to describe all delivery systems
E. If any of plans A - E are available on both an Indemnity and PPO (or POS) basis, give a PPO (or POS) premium on that Plan Page. If plans C or D are available on both a PPO and POS basis, give the PPO premium on the Plan C or D page, and the POS premium on the POS page.
F. The survey no longer requests information on premium guarantee periods.
| Part 4 |
| PREMIUM SURVEY |
| PLAN A |
| SEH PROGRAM PREMIUM COMPARISON SURVEY |
| PLAN A PREMIUM 1/1/____ |
| PLAN B |
| SEH PROGRAM PREMIUM COMPARISON SURVEY |
| PLAN B PREMIUM 1/1/____ |
| PLAN C |
| SEH PROGRAM PREMIUM COMPARISON SURVEY |
| PLAN C PREMIUM 1/1/____ |
| PLAN D |
| SEH PROGRAM PREMIUM COMPARISON SURVEY |
| PLAN D PREMIUM 1/1/_____ |
| PLAN E |
| SEH PROGRAM PREMIUM COMPARISON SURVEY |
| PLAN E PREMIUM 1/1/____ |
| HMO PLAN |
| SEH PROGRAM PREMIUM COMPARISON SURVEY |
| HMO PLAN PREMIUM 1/1/_____ |
| HMO/POS or POS PLAN |
| SEH PROGRAM PREMIUM COMPARISON SURVEY |
| POS PLAN PREMIUM 1/1/____ |
DELIVERY SYSTEMS (Plans A through E and HMO/POS or POS)
Indicate below the Delivery System used for the Plans used in answering the survey. For example, if the rates provided for Plan D are for a PPO, then complete the columns labeled "PPO" for that plan and leave the columns labeled "Traditional" and "POS" blank. Use a similar method for a Plan that is a POS. If the rates provided are not for POS or PPO plans, check the appropriate space under the column labeled "Traditional" and leave the "PPO" and "POS" columns blank. Check "Yes" under "Other Delivery Systems" if more than one delivery system is available; otherwise check "No."
| Sample Tiered Premiums |
Carriers should submit additional information about the premium for the following plans of benefits in Middlesex County: a) $ 1000 Deductible Plan C PPO; b) $ 20 Copay HMO; and c) $ 500 Deductible, $ 20 Copay Plan C POS. For these plans only, the carrier should provide a detailed calculation of the premium shown in the PCS in the same format as the sample calculation in the Carrier's SEH rating filing pursuant to N.J.A.C. 11:21-9.1 et seq. the detailed calculations should be attached to this survey.
The results of this detailed calculation should be summarized in a table:
BbsehbpnewFF/inoregs
