New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 1 - NEW JERSEY INSOLVENT HEALTH MAINTENANCE ORGANIZATION ASSISTANCE ASSOCIATION
Section 11:4-1.2 - Definitions

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

"Applicant" means the member organization seeking an exemption, abatement or deferral of its obligation to pay assessments pursuant to section 17B:32B-1 et seq.

"Association" means the New Jersey Insolvent Health Maintenance Organization Assistance Association created by 17B:32B-5.

"Commissioner" means the Commissioner of the Department of Banking and Insurance.

"Contractual obligation" means an obligation, arising from a written agreement, policy, certificate or other written evidence of coverage, to a covered individual or provider incurred prior to the declaration of insolvency of a covered health maintenance organization that remains unpaid at the time of its insolvency, but does not include claims by former employees, including medical professional employees for deferred compensation, severance, vacation or other employment benefits.

"Covered health maintenance organization contract" means a written agreement, policy, certificate, or other written evidence of coverage for health care services issued in New Jersey by an insolvent organization to a covered individual, or a written contract between an insolvent organization and a participating provider, but shall not include any contract with an employer or other person to provide health care benefits on an administrative services only basis.

"Covered individual" means an enrollee or member of HIP Health Plan of New Jersey, Inc. or American Preferred Provider Plan, Inc.

"Covered service" means a health care service, supply or benefit, including prescription drugs, provided to a covered individual under a covered health maintenance organization contract.

"Department" means the Department of Banking and Insurance.

"Eligible claim" means a claim for a covered service under a covered health maintenance organization contract and provided by a provider or to a covered individual prior to the declaration of insolvency of an insolvent organization, but shall not include any claim filed after the claims bar date established by the Superior Court of New Jersey supervising the insolvent organizations.

"Fund" means the New Jersey Insolvent Health Maintenance Organization Assistance Fund created pursuant to 17B:32B-6.

"Hazardous financial condition" is as defined in 11:2-27.2.

"Insolvent organization" means HIP Health Plan of New Jersey, Inc. or American Preferred Provider Plan, Inc.

"Member organization" means a person who holds a certificate of authority to operate a health maintenance organization pursuant to 26:2J-1 et seq., and includes any person whose certificate of authority has been suspended, revoked or nonrenewed.

"Net written premiums received" means direct premiums as reported on the annual financial statement submitted pursuant to 26:2J-9, but shall not include net written premiums paid to enroll Medicaid recipients in a Medicaid-contracting health maintenance organization, New Jersey KidCare, or Medicare Plus Choice Plans, premiums received under the Federal Employees Health Benefits Program pursuant to 5 U.S.C. § 8909 or premiums received under the TRICARE program pursuant to 32 C.F.R. 199.17.

"Provider" means a physician, hospital or other person who is licensed or otherwise authorized by this State, or licensed or otherwise authorized under similar laws of another state, to provide covered services, and which provided covered services to covered individuals under a covered health maintenance organization contract. "Provider" also includes persons who incurred a contractual obligation as defined by 17B:32B-1 et seq. by providing home health care services, durable medical equipment, physical therapy services, medical transportation, ambulance services or laboratory services to covered individuals.

"Relief" means an exemption, abatement or deferral of the obligation to pay assessments pursuant to 17B:32B-9.