2017 New Jersey Revised Statutes
TITLE 17B - INSURANCE
Section 17B:32B-3 - Definitions relative to certain insolvent health maintenance organizations.

17B:32B-3 Definitions relative to certain insolvent health maintenance organizations.

3. As used in this act:

"Association" means the New Jersey Insolvent Health Maintenance Organization Assistance Association created by section 5 of this act.

"Commissioner" means the Commissioner of Banking and Insurance.

"Contractual obligation" means an obligation, arising from an agreement, policy, certificate or 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 policy, certificate, evidence of coverage or contract for health care services issued in New Jersey by HIP Health Plan of New Jersey, Inc. or American Preferred Provider Plan, Inc., 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.

"Department" means the Department of Banking and Insurance.

"Eligible claim" means a claim for a covered service or benefit under a contract or policy issued by an insolvent health maintenance organization 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 section 6 of this act.

"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 P.L.1973, c.337 (C.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 section 9 of P.L.1973, c.337 (C.26:2J-9).

"Provider" means a physician, hospital or other person which is licensed or otherwise authorized by this State, or licensed or otherwise authorized under similar laws of another state, to provide health care services, and which provided health care services to covered individuals. As used in this act, provider also includes persons who incurred a contractual obligation as defined by this act by providing home health care services, durable medical equipment, physical therapy services, medical transportation, ambulance services or laboratory services to covered individuals.

L.2000,c.12,s.3.

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