New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE
Section 11:4-23.15 - Required disclosure provisions
Universal Citation: NJ Admin Code 11:4-23.15
Current through Register Vol. 56, No. 18, September 16, 2024
(a) General rules concerning required disclosure provisions include the following:
1. Medicare supplement policies and
certificates shall include a renewal or continuation provision. The language or
specification of such provision shall be consistent with the type of policy or
certificate to be issued. Such provision shall appear on the first page of
policies and certificates, and shall include any reservation by the carrier of
a right to change premiums and any automatic renewal premium increases based on
the policyholder's or certificateholder's age.
2. Except for riders or endorsements by which
the carrier effectuates a request made in writing by the insured, exercises a
specifically reserved right under a Medicare supplement policy or certificate,
or is required to reduce or eliminate benefits to avoid duplication of Medicare
benefits:
i. All riders or endorsements added
after the date of issue or at reinstatement or renewal which reduce or
eliminate benefits or coverage shall require signed acceptance by the
insured;
ii. After the date of the
policy or certificate issue, any rider or endorsement which increases benefits
or coverage with a concomitant increase in premium or subscription charges
during the policy or certificate term, shall be agreed to in writing signed by
the insured, except if the increased benefits or coverage are required by the
minimum standards of this State for Medicare supplement coverage, or if
required by other law. Where a separate additional premium is charged for
benefits provided in connection with riders or endorsements, the premium charge
shall be set forth clearly.
3. A Medicare supplement policy or
certificate shall not provide for the payment of benefits based on standards
described as "usual and customary," "reasonable and customary," or words of
similar import.
4. If a Medicare
supplement policy or certificate contains any limitations with respect to
preexisting conditions, such limitation shall appear as a separate paragraph in
the policy or certificate and be labeled as "Preexisting Condition
Limitations."
5. Medicare
supplement policies and certificates shall have a notice prominently printed on
the first page or attached thereto stating in substance that the insured shall
have the right to return the policy or certificate within 30 days of its
delivery and to have the premium or subscription charge or fees refunded if,
after examination of the policy or certificate, the insured is not satisfied
for any reason.
6. Carriers issuing
policies or certificates which provide hospital or medical expense coverage on
an expense incurred, indemnity, or service benefit basis to persons eligible
for Medicare shall provide to all applicants an informational brochure entitled
"Guide to Health Insurance for People with Medicare," hereinafter referred to
as "the Guide," in the form developed jointly by the National Association of
Insurance Commissioners and the Centers for Medicare and Medicaid Services. The
Guide is intended to improve the buyer's understanding of Medicare and ability
to select the most appropriate coverage. Delivery of the Guide shall be made
whether or not policies or certificates are advertised, solicited or issued as
Medicare supplement policies or certificates as set forth by this
subchapter.
7. To ensure uniformity
in content, form and printing, the Guide has been made available through the
Publications Department of the National Association of Insurance Commissioners,
Kansas City, MO.
8. Except in the
case of direct response carriers, delivery of the Guide shall be made to the
applicant at the time of application, and acknowledgment of receipt of the
Guide shall be obtained by the carrier. Direct response carriers shall deliver
the Guide to the applicant upon request but in no instance shall delivery of
the Guide occur later than the time of policy or certificate
delivery.
9. Except as provided in
(c) below, the terms "Medicare Supplement," "Medigap," and words of similar
import shall not be used unless the policy or certificate is issued in
compliance with N.J.S.A. 11:4-23.8 and all other sections of this
subchapter.
(b) Outline of Coverage requirements for Medicare supplement policies and certificates shall include:
1. Carriers issuing Medicare
supplement policies or certificates for delivery in this State shall provide an
outline of coverage to all applicants at the time the application is presented
to the prospective applicant. Except for direct response policies or
certificates, acknowledgment of receipt of such outline shall be obtained by
the carrier from the applicant.
2.
If an outline of coverage is provided at the time of application and the
Medicare Supplement policy or certificate is issued on a basis which would
require revision of the outline, a substitute outline of coverage properly
describing the policy or certificate actually issued must accompany such policy
or certificate when it is delivered and contain the following statement, in no
less than 12 point type, immediately above the company name: "NOTICE: Read this
outline of coverage carefully. It is not identical to the outline of coverage
provided upon application and the coverage originally applied for has not been
issued."
3. The outline of coverage
provided to applicants pursuant to (b)1 above shall be in the language and
format prescribed in Exhibit D or D1 of the Appendix of this chapter,
incorporated herein by reference, in no less than 12 point type. The outline of
coverage shall consist of a cover page, premium information, disclosure pages,
and charts displaying the features of each benefit plan offered by the carrier.
All plans shall be shown on the cover page, and the plan(s) offered by the
carrier shall be prominently identified. Premium information for the plan(s)
offered by the carrier shall be provided on the cover page, or immediately
following the coverage page, clearly and prominently, specifying both the
premium and the mode. All possible premiums for the applicant on all plans
offered to the applicant by the carrier shall be illustrated. Appendix Exhibit
D shall be used for the outline of coverage for all policies with an effective
date for coverage prior to June 1, 2010 and shall not be used with any policy
with an effective date for coverage on or after June 1, 2010. Appendix Exhibit
D1 shall be used for the outline of coverage for any policy with an effective
date for coverage on or after June 1, 2010 and shall not be used for any policy
with an effective date for coverage prior to June 1, 2010.
(c) All health and disability income policies, except as specified in this subsection, issued for delivery in this State to persons eligible for Medicare shall notify insureds under the policy. Such notice is not required for: Medicare supplement policies; policies of one or more employers or labor organizations, of 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 members or former members, or combination thereof, of the labor organization; or policies issued pursuant to a contract under Section 1876 of the Federal Social Security Act ( 42 U.S.C. §§ 1395 et seq.). The notice shall either be printed or attached to the first page of the outline of coverage delivered to the insureds under the policy, or, if no outline of coverage is delivered, to the first page of the certificate or policy delivered to insureds. The notice shall be in no less than 12 point type and shall contain the following language:
"THIS IS NOT A MEDICARE SUPPLEMENT (POLICY OR CERTIFICATE). If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."
1. Applications provided to persons eligible
for Medicare for the health insurance policies described above shall disclose,
using the applicable statement in Exhibit H in the Appendix the extent to which
the policy duplicates Medicare. The disclosure statement shall be provided as
part of, or together with the application for the policy or
certificate.
(d) At least 30 days prior to the effective dates of any Medicare benefit changes, notice shall be provided by carriers to New Jersey insureds describing the revisions of the Medicare program and the resulting modifications made by the carrier to an insured's Medicare supplement policy or certificate to eliminate duplication of Medicare benefits.
1. The
notices shall be in the format set forth in the Appendix to subchapters 16 and
23 of this chapter, Exhibit C (Notice of Changes in Medicare and Your Medicare
Supplement Coverage), which is incorporated herein as part of this
rule.
2. No modification shall be
made to an existing Medicare supplement policy or certificate when notices are
sent except those modifications necessary to eliminate duplication of Medicare
benefits.
3. Notices shall include
a description of revisions to the Medicare program and a description of each
modification made to the coverage provided under the Medicare supplement policy
or certificate.
4. Notices shall
provide information as to when any premium adjustment is to be made due to
changes in Medicare.
5. Information
on benefit modifications and premium adjustments shall be in outline form and
in clear and simple terms to facilitate comprehension.
6. Notices shall not contain or be
accompanied by any solicitation.
7.
No notice shall contain benefits and premium information for more than one
policy or certificate form.
(e) Carriers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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