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IHC Program Forms

Standard Plans, Riders and Enrollment Forms
Plans A/50, B, C, and D Exhibit A (MS Word)
HMO Plan Exhibit B (MS Word)
Explanation of Brackets: Plans A/50, B, C, and D Exhibit C (MS Word)
Compliance and Variabilty Rider (Standard Amendment Shell) Exhibit D (MS Word)
Individual Basic and Essential Health Services Plan Exhibit F (MS Word)
Plan Update Rider Exhibit G (MS Word)
Enrollment Form (HINT Form) Exhibit 1B (N.J.A.C. 11:22-1)
 
Reporting Forms
Certification of Compliance with Individual Health Coverage Plans Exhibit E (formerly Exhibit Q) (MS Word) > Worksheet (MS Excel)
Identification of Plans Exhibit H (MS Word)
Loss Ratio report Exhibit J (MS Word)
Market Share and Net Paid Loss Report Exhibit K (MS Word)
Enrollment Report - Quarterly Exhibit L – Part 1 (MS Excel)
Enrollment Report - Annual Exhibit L – Part 2 (MS Excel)
 
Filing Deadlines
*

NLT**

 Exhibit Report Description N.J.A.C. Reference
A Feb. 14 Ex. L
Part 1 & Part 2
(MS Excel) 		Quarterly and Annual Enrollment Report 11:20-17.3
A Mar 1† Ex. E (MS Word) > Worksheet (MS Excel) Certification of Compliance 11:20-3.2
A Mar 1 *** B&E Plans with riders selection report 11:20-22.5
B Apr 1 Ex. K (MS Word) Assessment report (premium data, enrollment data, adjusted net earned premium) 11:20-8.2 through 8.4
B Apr 1 *** Certification of Non-group Lives (by carriers seeking an exemption) 11:20-9.5
A May 1 *** Good-faith marketing of B&E Plans (for carriers offering B&E plans) 11:20-22.6
B May 1 *** Good-faith Performance Report (for carriers seeking reimbursement of losses) 11:20-10.3
A May 15 Ex. L
Part 1 (MS Excel)		 Quarterly Enrollment Report 11:20-17.3
A May 31 *** B&E Plans with riders selection report 11:20-22.5
B 30 days after notice of min. target lives *** Request for exemption from loss assessments (Note:  the Board issues a notice of minimum enrollment targets about 60 days after all completed Exhibit K’s are submitted) 11:20-9.2
A Aug 14 Ex. L
Part 1 (MS Excel)		 Quarterly Enrollment Report 11:20-17.3
A Aug 15 Ex. J (MS Word) Loss Ratio Report (and refund plan, if required) 11:20-7.4
A Aug 30 *** B&E Plans with riders selection report 11:20-22.5
A Nov 14 Ex. L
Part 1 (MS Excel)		 Quarterly Enrollment Report 11:20-17.3
A Nov 30 *** B&E Plans with riders selection report 11:20-22.5
†† --------- *** Informational rate filings 11:20-6.3
*This column indicates the frequency for filing the report.  A= annually.  B= biannually, in odd-numbered years. 
**NLT= no later than the date specified, unless the Board issues a bulletin extending a deadline.  The Board issues bulletins to carriers on the Board’s mailing list and posts bulletins to the Board’s website.
***There is no form; the rules specify the information that must be submitted.
†Exhibit E also must be filed before marketing, issuing or renewing any standard policy form.
††These reports must be filed prior to using the rates; rates cannot be stated for a period exceeding 12 months.
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New Jersey Department of Banking and Insurance