Section: Costs of project; inclusion of expenses furthering equal employment opportunities
7. a. No health maintenance organization authorized pursuant to section 6 of this act shall deliver or issue for delivery in this State any medicare supplement contract or evidence of coverage or any application or notification used in connection with the issuance or continuance of a medicare supplement contract or evidence of coverage unless the form of which, including a copy of the underlying plan, has been submitted to and filed by the commissioner pursuant to the provisions of this subsection.
(1) At the expiration of 60 days after submission a form shall be deemed filed unless prior thereto it has been affirmatively filed or disapproved for filing by the commissioner.
(2) No form which is disapproved for filing by the commissioner during the 60-day period, may be delivered or issued for delivery in this State unless and until the disapproval for filing is withdrawn. 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.). Any form which is filed by the commissioner or deemed filed may be delivered or issued for delivery in this State until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).
(3) The commissioner may extend the 60-day period provided in paragraph (1) of this subsection for not more than 60 additional days by giving written notice of extension before the expiration of the initial 60-day period. In the event of an extension, all of the provisions of this subsection, except this provision for an extension, relating to the initial 60-day period shall apply to the extended period instead of the initial 60-day period.
(4) The disapproval for filing or the withdrawal of the filing of any form by the commissioner shall state in writing the grounds therefor in such detail as is reasonable to inform the health maintenance organization of the reasons for withdrawal or disapproval.
(5) The provisions of this subsection shall not apply to documents which relate only to the manner of distribution of services or to the reservation of rights and services under the medicare supplement contract or evidence of coverage and which are used at the request of the enrollee.
(6) The disapproval by the commissioner of any form submitted for filing pursuant to the provisions of this subsection may be 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.
b. Every health maintenance organization providing medicare supplement health care services to a resident of 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 be certified by a qualified actuary and shall demonstrate that the actual and expected costs in relation to services provided comply with the requirements of this act and any rule or regulation promulgated hereunder.
As used in this subsection, "qualified actuary" means a person, in good standing, who is a member of the American Academy of Actuaries, a fellow of the Casualty Actuarial Society, or a person who has otherwise demonstrated actuarial competence to the satisfaction of the commissioner.
c. Services provided under a medicare supplement contract or evidence of coverage shall be expected to return to enrollees services or other benefits which are reasonable in relation to the premium or other fee charged. The commissioner shall promulgate regulations to establish minimum standards for loss ratios under medicare supplement contracts or evidences of coverage on the basis of paid medicare supplement health care expenses and written earned premiums and fees in accordance with accepted actuarial principles and practices.
We hope you find our tools helpful, please visit www.thelegalassistant.com for further information on our other free legal tools and products including LPO compliant legal case management software.