N.J. Stat. tit. 17, ch. 48D

in effect

N.J. Stat. § 17:48D-1 Title of act

This act shall be known and may be cited as the "Dental Plan Organization Act." L.1979, c. 478, s. 1.

N.J. Stat. § 17:48D-2 Definitions.

2. In this act, unless the context otherwise requires: "Capitation" means a method of compensation by a dental plan organization to its contracted dentists for dental services and supplies provided to covered persons of the dental plan organization on the basis of a fixed periodic payment per covered person or enrollee; "Commissioner" means the Commissioner of Banking and Insurance; "Consultant" means a person who holds himself out as an advisor or renders advice on the organization, financing, administration or operation of a dental plan to any employer, union, trust fund or dental plan organization; "Covered person" means any person eligible to receive covered benefits or services and supplies under the terms of a dental plan; "Dental plan" means any contractual arrangement for dental services and supplies to covered persons where contracted dentists are compensated by means of capitation, salary or a method authorized, submitted to and approved by the commissioner; "Dental plan organization" or "DPO" means any person who undertakes to provide directly or to arrange for or administer one or more dental plans providing dental services and supplies; "Dental services" means services included in the practice of dentistry as defined in R.S.45:6-19; "Enrollee" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the dental plan, or in the case of an individual contract, the person in whose name the contract is issued; "Evidence of coverage" means any certificate, agreement or contract issued to an enrollee, setting out the dental services and supplies to which the enrollee and his dependents are entitled; "Finder" means a person who brings together a dental plan organization with an employer, union or trust fund for the purpose of establishing a contractual relationship to provide dental services, or facilities or equipment related to the operation of the dental plan or dental plan organization; "National Association of Insurance Commissioners" or "NAIC" means the National Association of Insurance Commissioners, its affiliates, or subsidiaries, or any agency or committee thereof, or any successor organization. L.1979,c.478,s.2; amended 1983, c.24, s.1; 2005, c.38, s.1.

N.J. Stat. § 17:48D-3 Application for certificate of authority.

3. a. No person may establish, operate or administer a dental plan organization, or sell or offer to sell, or solicit offers to purchase, or receive advance or periodic consideration in conjunction with any dental plan organization, utilizing in the aggregate the services of more than one full-time equivalent dentist, without obtaining and maintaining a certificate of authority pursuant to this act. b. Within 90 days after the effective date of this act, every dental plan organization utilizing in the aggregate the services of more than one full-time equivalent dentist shall submit an application for a certificate of authority to the commissioner. A dental plan organization may continue to operate until the commissioner acts upon the application. If the application is denied, the dental plan organization shall be treated as if its certificate of authority has been revoked. c. An application for a certificate of authority shall be in a form prescribed by the commissioner, shall be verified by an officer or authorized representative of the dental plan organization and shall include the following: (1) All basic organizational documents of the dental plan organization, such as the articles of incorporation, articles of association, partnership agreement, trade name certificate, trust agreement, shareholder agreement or other applicable documents and all amendments to those documents; (2) The bylaws, rules and regulations or similar documents regulating the conduct or the internal affairs of the dental plan organization; (3) The names, addresses, official positions and a biographical affidavit (NAIC form) of the persons who are responsible for the conduct of the affairs of the dental plan organization, including all members of the board of directors, board of trustees, executive committee or other governing board or committee, the principal officers, in the case of a corporation, and the partners or members, in the case of a partnership or association; (4) The form of all contracts or agreements made between any dentist and the dental plan organization; (5) All contracts or agreements made between any person listed in paragraph (3) of this subsection and any dentist, consultant, finder, supplier of administrative services or business manager; (6) A description of the dental plan organization, its dental plan or plans, facilities and personnel; (7) The form of the evidence of coverage to be issued to the enrollees; (8) The form of any group contract which is issued to employers, unions, trustees or others; (9) A financial statement prepared by an independent certified public accountant, setting forth the applicant's present or anticipated assets, liabilities and sources of funds. The statement shall set forth the terms and conditions of all current liabilities and any outstanding loans made from the funds of the applicant, and shall be attested to by the applicant or an authorized officer thereof. If the commissioner requires an audit of the financial records of the applicant by an independent certified public accountant, the financial statement shall be prepared and certified by the certified public accountant having conducted the audit; (10) The proposed method of marketing the plan, a financial plan with a 3-year projection of the initial operating results and a statement of the sources of working capital and any other sources of funding. The justifications and assumptions for the marketing and financial plan shall also be disclosed; (11) A power of attorney duly executed by the dental plan organization, if not domiciled in this State, appointing the commissioner, the commissioner's successors in office and duly authorized deputies as the true and lawful attorney of the dental plan organization in and for this State, upon whom lawful process in any legal action or proceeding against the dental plan organization on a cause of action arising in this State may be served; (12) A description of the geographic area or areas to be served, by county and zip code (first 3 digits); (13) A description of the procedures and programs to be implemented to achieve an effective dental plan as required in section 5 a.(2) of this act; and (14) Such other information as the commissioner may require. d. The dental plan organization shall pay a fee of $1,000 to the commissioner, upon filing an application for a certificate of authority. e. The commissioner shall act on an application for a certificate of authority within 90 days following receipt of the application. L.1979,c.478,s.3; amended 1983, c.24, s.2; 2005, c.38, s.2.

N.J. Stat. § 17:48D-3.1 Consultants

No person shall be employed as a consultant by an employer, union, trust fund or dental plan organization or applicant, except in accordance with the provisions of this section. A consultant, entering into a contract or agreement to provide consulting services on a dental plan, shall provide a copy of the contract or agreement to the commissioner for his approval. In addition to the contract or agreement, the consultant shall provide the commissioner with a list of all sources and amounts of income received from consulting work within the preceding 5 years, and income received or anticipated to be received in the year the contract or agreement is submitted for approval, and such other information as may be required by the commissioner. No person shall be employed as a consultant who: a. Within 7 years of his employment as a consultant has been convicted of a crime listed in N.J.S. 2C:41-1; or b. At any time has been convicted of engaging in a pattern of racketeering activity, as defined in N.J.S. 2C:41-1 and 2C:41-2. In accordance with standards established by the commissioner, the commissioner may disapprove the contract or agreement within 90 days following receipt thereof. Any person employed as a consultant on the operative date of this act shall, within 30 days thereof, satisfy the requirements of this section. Unless the commissioner disapproves the contract or agreement as herein provided, the consultant shall continue to render consulting services under the terms and conditions of the contract or agreement insofar as its terms and conditions are not inconsistent with the provisions of this act. L.1983, c. 24, s. 7.

N.J. Stat. § 17:48D-3.2 Fiduciary capacity of consultants; compensation

A consultant shall be a fiduciary of the employer, union, trust fund or dental plan organization with which employed and shall not be entitled to: a. Any compensation in excess of the amount specified in the contract or agreement for consulting services; or b. Any compensation whatsoever, either as a consultant or in any other capacity, from any person associated with the dental plan, other than with whom the contract or agreement for consulting services has been entered into. L.1983, c. 24, s. 8.

N.J. Stat. § 17:48D-3.3 Report regarding finders

A dental plan organization, employer, union or trust fund shall report to the commissioner the name and address of, and the amount of any fee paid to a finder within 30 days of the use or employment of the finder or within 30 days of the operative date of this act, whichever is later. L.1983, c. 24, s. 9.

N.J. Stat. § 17:48D-4 Notice of modification of information.

4. Sixty days prior to any significant modification of information submitted with the application for a certificate of authority or a subsequent modification, a dental plan organization shall file notice of the modification with the commissioner. L.1979,c.478,s.4; amended 2005, c.38,s.3.

N.J. Stat. § 17:48D-5 Conditions for issuance; notice of disapproval.

5. a. The commissioner shall issue a certificate of authority if he is satisfied that the following conditions are met: (1) The persons responsible for conducting the affairs of the dental plan organization are competent and trustworthy and are professionally capable of providing, arranging for or administering the services offered by the plan; (2) The dental plan organization constitutes an appropriate mechanism to achieve an effective dental plan, as determined by the commissioner; (3) The dental plan organization has demonstrated the potential to provide dental services in a manner that will assure both availability and accessibility of adequate personnel and facilities; (4) The dental plan organization has arrangements for an ongoing quality of dental care assurance program; (5) The dental plan organization has a procedure to establish and maintain uniform systems of cost accounting and reports and audits that meet the requirements of the commissioner; (6) The dental plan organization is financially responsible and may reasonably be expected to meet its obligations to covered persons. In making this determination the commissioner shall consider: (a) The financial soundness of the dental plan's arrangements for services and the schedule of premiums used; (b) Any arrangement with an insurer or medical or dental service corporation for continuation of coverage in the event of discontinuance of the plan, on an indemnity basis through a group vehicle to the end of the period for which premiums were paid to the discontinued dental plan organization; and (c) The sufficiency of an agreement with dentists for the provision of dental services; (7) A general surplus is maintained as required in section 6 of this act; (8) A contingent surplus is accumulated and maintained as required in section 7 of this act; (9) The condition or methods of operation of the dental plan organization are not such as would render its operations hazardous to its enrollees or the public; and (10) The persons responsible for conducting the affairs of the dental plan organization are: (a) of good moral character, and (b) have not been convicted, within 7 years of the filing of the application for a certificate of authority, of a crime listed in N.J.S.2C:41-1 or, at any time, of engaging in a pattern of racketeering activity, as defined in N.J.S.2C:41-1 and 2C:41-2. b. When the commissioner disapproves an application for a certificate of authority, he shall notify the dental plan organization in writing of the reasons for the disapproval. c. (Deleted by amendment, P.L.2005, c.38). L.1979,c.478,s.5; amended 1983, c.24, s.3; 2005, c.38, s.4.

N.J. Stat. § 17:48D-6 General surplus of plan

The commissioner may determine, at his discretion, the amount of a general surplus, if any, that the dental plan organization shall be required to maintain. L.1979, c. 478, s. 6.

N.J. Stat. § 17:48D-7 Special contingent surplus for organizations using more than 20 full-time dentists

A dental plan organization utilizing in the aggregate the services of more than 20 full-time equivalent dentists shall accumulate and maintain a special contingent surplus in excess of its assets over liabilities at the rate of 2% annually of its net contract and certificate income until the surplus totals $100,000.00. L.1979, c. 478, s. 7.

N.J. Stat. § 17:48D-8 Fidelity bonding of officers, etc., malpractice insurance of dentists.

8. a. Any director, officer, employee or partner of a dental plan organization who receives, collects, reimburses or invests moneys in connection with the activities of the organization shall be bonded for his fidelity, or maintain crime insurance or its equivalent, in an amount which shall be determined by the commissioner. b. Each dentist employed by a dental plan organization shall be insured against professional liability or malpractice by an insurer licensed to conduct business in this State for such minimum amounts as shall be determined by the commissioner. L.1979,c.478,s.8; amended 2005, c.38, s.5.

N.J. Stat. § 17:48D-9 Evidence of coverage.

9. a. An enrollee shall be entitled to receive evidence of coverage or a certificate indicating specifically the nature and extent of coverage, and evidence of the total amount or percentage of payment, if any, which the enrollee is obligated to pay for dental services. If an individual enrollee obtains coverage through an insurance policy or through a contract issued by a medical or dental service corporation, whether by option or otherwise, the insurer or medical or dental service corporation shall issue the evidence of coverage. Otherwise, the dental plan organization shall issue the evidence of coverage. b. No evidence of coverage or amendment thereto shall be issued or delivered to any person until a copy of the form of evidence of coverage or amendment thereto has been filed with the commissioner. c. Evidence of coverage shall contain a clear and complete statement if a contract, or a reasonably complete summary if a certificate, of: (1) The dental services and the insurance or other benefits, if any, to which covered persons are entitled; (2) Any limitations on the services, kind of services, benefits, or kind of benefits to be provided, including any charge, deductible or co-payment feature; (3) Where and in what manner information is available as to how services may be obtained; and (4) A clear and understandable description of the dental plan organization's method for resolving covered persons' complaints. d. Any subsequent change in the evidence of coverage or the amount or percentage of payment which the enrollee is obligated to pay, shall be evidenced in a separate document issued to the enrollee. L.1979,c.478,s.9; amended 2005, c.38, s.6.

N.J. Stat. § 17:48D-9.1 Alternative dental coverage; original coverage restricted to limited number of providers

Each employer or other organization which employs or has 25 or more employees or members during the full preceding calendar year and which contributes to a dental plan organization contract which restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers, shall also offer its employees and their eligible dependents and members and members' eligible dependents at the time a dental benefits plan is offered or renewed the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist. L.1983, c. 143, s. 1, eff. April 20, 1983.

N.J. Stat. § 17:48D-9.2 Employer contribution

An employer or other organization shall be required to pay for or contribute towards the provision of alternative coverage an amount equal to the premium or cost which it pays or contributes to the dental plan organization contract which limits the number of providers of dental services. L.1983, c. 143, s. 2, eff. April 20, 1983.

N.J. Stat. § 17:48D-9.3 Rules and regulations

Within 120 days of the effective date of this act, the Commissioner of the Department of Insurance shall promulgate rules and regulations necessary to effectuate the purpose of this act, including procedures for notice to covered persons, employers and other organizations of the provisions of this act. L.1983, c. 143, s. 3, eff. April 20, 1983.

N.J. Stat. § 17:48D-9.4 Dental plan organization to receive, transmit transactions electronically.

9. a. Within 180 days of the adoption of a timetable for implementation pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a dental plan organization, or a subsidiary that processes health care benefits claims as a third party administrator, shall demonstrate to the satisfaction of the Commissioner of Banking and Insurance that it will adopt and implement all of the standards to receive and transmit health care transactions electronically, according to the corresponding timetable, and otherwise comply with the provisions of this section, as a condition of its continued authorization to do business in this State. The Commissioner of Banking and Insurance may grant extensions or waivers of the implementation requirement when it has been demonstrated to the commissioner's satisfaction that compliance with the timetable for implementation will result in an undue hardship to a dental plan organization, its subsidiary or its covered persons. b. Within 12 months of the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a dental plan organization or a subsidiary that processes health care benefits claims as a third party administrator shall use the standard health care enrollment and claim forms in connection with all group and individual contracts issued, delivered, executed or renewed in this State. c. Twelve months after the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a dental plan organization shall require that health care providers file all claims for payment for dental services. A covered person who receives dental services shall not be required to submit a claim for payment, but notwithstanding the provisions of this subsection to the contrary, a covered person shall be permitted to submit a claim on his own behalf, at the covered person's option. All claims shall be filed using the standard health care claim form applicable to the contract. d. (1) Effective 180 days after the effective date of P.L.1999, c.154, a dental plan organization or its agent, hereinafter the payer, shall remit payment for every insured claim submitted by a covered person or that covered person's agent or assignee if the contract provides for assignment of benefits, no later than the 30th calendar day following receipt of the claim by the payer or no later than the time limit established for the payment of claims in the Medicare program pursuant to 42 U.S.C. s.1395u(c)(2)(B), whichever is earlier, if the claim is submitted by electronic means, and no later than the 40th calendar day following receipt if the claim is submitted by other than electronic means, if: (a) the claim is an eligible claim for a health care service provided by an eligible health care provider to a covered person under the contract; (b) the claim has no material defect or impropriety, including, but not limited to, any lack of required substantiating documentation or incorrect coding; (c) there is no dispute regarding the amount claimed; (d) the payer has no reason to believe that the claim has been submitted fraudulently; and (e) the claim requires no special treatment that prevents timely payments from being made on the claim under the terms of the contract. (2) If all or a portion of the claim is denied by the payer because: (a) the claim is an ineligible claim; (b) the claim submission is incomplete because the required substantiating documentation has not been submitted to the payer; (c) the diagnosis coding, procedure coding, or any other required information to be submitted with the claim is incorrect; (d) the payer disputes the amount claimed; or (e) the claim requires special treatment that prevents timely payments from being made on the claim under the terms of the contract, the payer shall notify the covered person, or that covered person's agent or assignee if the contract provides for assignment of benefits, in writing or by electronic means, as appropriate, within 30 days, of the following: if all or a portion of the claim is denied, all the reasons for the denial; if the claim lacks the required substantiating documentation, including incorrect coding, a statement as to what substantiating documentation or other information is required to complete adjudication of the claim; if the amount of the claim is disputed, a statement that it is disputed; and if the claim requires special treatment that prevents timely payments from being made, a statement of the special treatment to which the claim is subject. (3) Any portion of a claim that meets the criteria established in paragraph (1) of this subsection shall be paid by the payer in accordance with the time limit established in paragraph (1) of this subsection. (4) A payer shall acknowledge receipt of a claim submitted by electronic means from a health care provider or covered person, no later than two working days following receipt of the transmission of the claim. (5) If a payer subject to the provisions of P.L.1983, c.320 (C.17:33A-1 et seq.) has reason to believe that a claim has been submitted fraudulently, it shall investigate the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or refer the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16). (6) Payment of an eligible claim pursuant to paragraphs (1) and (3) of this subsection shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means and on or before the 40th calendar day following receipt of a claim submitted by other than electronic means. In the event payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (b) of paragraph (2) of this subsection, the claims payment shall be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, for claims submitted by electronic means and the 40th calendar day for claims submitted by other than electronic means, following receipt by the payer of the required documentation or modification of an initial submission. (7) An overdue payment shall bear simple interest at the rate of 10% per annum. e. As used in this subsection, "insured claim" or "claim" means a claim by a covered person for payment of benefits under an insured dental plan organization contract for which the financial obligation for the payment of a claim under the contract rests upon the dental plan organization. L.1999,c.154,s.9; amended 2005, c.38, s.7.

N.J. Stat. § 17:48D-9.5 Dental plan organization to offer coverage for domestic partner.

56. Every dental plan organization contract that is delivered, issued, executed or renewed in this State pursuant to P.L.1979, c.478 (C.17:48D-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to an enrollee for an enrollee's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3). This section shall apply to all contracts in which the dental plan organization has reserved the right to change the premium. L.2003,c.246,s.56.

N.J. Stat. § 17:48D-9.6 Payment of out-of-network benefits by dental plan organization.

2. a. (1) Except as provided in subsection e. of this section, a dental plan organization that makes a dental benefit payment to an enrollee for services rendered by an out-of-network dentist shall issue the payment to the enrollee in accordance with the time frames set forth in section 9 of P.L.1999, c.154 (C.17:48D-9.4), and shall, within three days of issuing the payment, provide a notification to the out-of-network dentist of the amount and date of the payment and the services for which the payment was made. (2) In the case of a dental plan organization that supplies an administrative services only contract and makes a dental benefit payment to an enrollee for services rendered by an out-of-network dentist under that contract, paragraph (1) of this subsection shall not apply, but the dental plan organization shall, within three days of issuing the payment, provide a notification to the out-of-network dentist of the amount and date of the payment. b. An enrollee may enter into an agreement with an out-of-network dentist to sign over the dental benefit payment received from the dental plan organization to the dentist. The agreement shall: (1) be in writing; (2) be signed by the person who is entitled to receive the dental benefit payment from the dental plan organization; (3) be retained by the dentist for at least six years following the date of the most recent payment from the enrollee; and (4) give the enrollee at least 10 business days within which to sign over the dental benefit to the dentist. c. An enrollee who agrees to sign over a dental benefit payment in accordance with this section shall comply with the terms of the agreement; except that if the enrollee owes the out-of-network dentist less than the amount of the dental benefit payment, the enrollee shall pay the dentist the balance owed to the dentist. d. An enrollee who fails to sign over the dental benefit payment in accordance with subsections b. and c. of this section shall be liable to the out-of-network dentist for payment of attorney fees and costs reasonably incurred by the dentist in enforcing the agreement established pursuant to those subsections. e. (1) With respect to a dental plan organization that makes a dental benefit payment to an enrollee for services rendered by an out-of-network dentist, if the enrollee assigns, through an assignment of benefits, his right to receive reimbursement to an out-of-network dentist, the dental plan organization shall issue the payment for the reimbursement directly to the dentist, or in the alternative, to the dentist and the enrollee as joint payees, with a signature line for each of the payees. Payment shall be made in accordance with section 9 of P.L.1999, c.154 (C.17:48D-9.4). Any payment made only to the enrollee rather than the dentist while such an assignment of benefits is in effect shall be considered unpaid, and unless issued to the dentist within the time frames established by section 9 of P.L.1999, c.154 (C.17:48D-9.4), shall be considered overdue and subject to interest charges as provided in that section. (2) Nothing in this subsection shall be construed to apply to a dental plan organization that supplies a self-funded dental services plan or an administrative services only contract for a self-funded dental services plan, when making a dental benefit payment to an enrollee for services rendered by an out-of-network dentist under that plan or contract. L.2003, c.250, s.2; amended 2013, c.83, s.2.

N.J. Stat. § 17:48D-10 Schedule of premiums, approval by commissioner; establishment of premiums.

10. a. No schedule of premiums for coverage for dental services, or amendment thereto, may be used by a dental plan organization until a copy of such schedule, or amendment thereto, has been filed with the commissioner. The commissioner may disapprove the schedule of premiums at any time if he finds that the premiums are excessive, inadequate or unfairly discriminatory. If the commissioner disapproves the schedule of premiums he shall notify the dental plan organization within 5 days of the date of disapproval and specify in the notice, the reason for his disapproval. A hearing shall be granted within 20 days after a request in writing by the filer. It shall be unlawful for any dental plan organization whose schedule of premiums has been disapproved to effect any contract or issue any subscription certificate which uses the disapproved schedule of premiums until a revised schedule of premiums has been filed. b. Premiums shall be established in accordance with actuarial principles, but premiums applicable to a covered person shall not be individually determined based on the status of his health. L.1979,c.478,s.10; amended 2005, c.38, s.8.

N.J. Stat. § 17:48D-11 Books, records; examination, inspection by commissioner.

11. a. The commissioner or the commissioner's designee may, as often as the commissioner may reasonably determine, investigate the business and examine the books, accounts, records, and files of every dental plan organization. For that purpose the commissioner or the commissioner's designee shall have reasonably free access to the offices and places of business, books, accounts, papers, records, and files of all dental plan organizations. A dental plan organization shall keep and use in its business such books, accounts, and records as will enable the commissioner to determine whether the dental plan organization is complying with the provisions of this act and with the rules and regulations promulgated pursuant to it. A dental plan organization shall preserve its books, accounts, and records for at least 7 years; except that preservation by photographic reproduction or records in photographic form shall constitute compliance with this act. b. For the purpose of the examination, the commissioner may, within the limits of funds appropriated for such purpose, contract with such persons as the commissioner may deem advisable to conduct the same or assist therein. c. At the discretion of the commissioner, the Commissioner of Health and the New Jersey State Board of Dentistry may participate in the investigations and examinations described in this section to verify the existence of an effective dental plan. d. The expenses incurred in making any examination pursuant to this section shall be assessed against and paid by the dental plan organization so examined. A dental plan organization having direct premiums written in this State of less than $2,000,000 in any calendar year shall be subject to a limited scope examination with expenses for that examination not to exceed $5,000. Upon written notice by the commissioner of the total amount of an assessment, a dental plan organization shall become liable for and shall pay the assessment to the commissioner. L.1979, c.478, s.11; amended 2005, c.38, s.9; 2012, c.17, s.36.

N.J. Stat. § 17:48D-11.1 Definitions.

26. As used in sections 26 through 30 of P.L.2014, c.81 (C.17:48D-11.1 through C.17:48D-11.5): "Commissioner" means the Commissioner of Banking and Insurance. "Dental plan organization" means an entity authorized to transact business in this State pursuant to P.L.1979, c.478 (C.17:48D-1 et seq.). L.2014, c.81, s.26.

N.J. Stat. § 17:48D-11.2 Increase in amount of capital or surplus required of dental plan organization.

27. The commissioner may increase the amount of capital or surplus required of a dental plan organization, or subsequently revise or redetermine that increase, using appropriate methods and procedures established by rules and regulations adopted by the commissioner, in order to provide adequate protection against risks affecting the dental plan organization's financial condition that are not adequately or fully covered by its reserves or other assets, but under no circumstances shall a dental plan organization's capital or surplus be less than the capital or surplus required pursuant to regulation as prescribed by the commissioner; provided, however, that any increase required by a subsequent revision or redetermination pursuant to this section shall be made only after a departmental hearing, unless that hearing is waived by the affected dental plan organization. All matters pertaining to a hearing or to an increase in capital or surplus pursuant to this section shall be confidential and not subject to subpoena or public inspection, except to the extent that the commissioner finds release of that information necessary to protect the public. The hearing shall be initiated within 20 days after written notice to the dental plan organization. Any declaration regarding an increase required by a subsequent revision or redetermination shall contain findings specifying the factors deemed significant in regard to the particular dental plan organization, and shall set forth the reasons supporting the increase of capital or surplus ordered by the commissioner. In determining any increase, revision or redetermination in the amount of capital or surplus, the commissioner shall consider the risks of: a. Increases or decreases in the frequency and severity of losses under normal operating conditions, as well as increases or decreases in those values, above or below the levels contemplated by the rates that the dental plan organization charged for coverage and above or below those reasonably expected under normal conditions; b. Increases or decreases in expenses under normal operating conditions, as well as increases or decreases in those values, above or below the levels contemplated by the rates the dental plan organization charged for coverage and above or below those reasonably expected under normal conditions; c. Increases or decreases in the value of, or return on, invested assets under normal operating conditions, as well as increases or decreases in those values, above or below those levels anticipated under normal conditions; d. Changes in economic, social or market conditions that could adversely or favorably affect the financial condition of the dental plan organization, including conditions that would make liquidity more or less important than contemplated and would prevent or facilitate timely investments or force or prohibit untimely sales of assets; and e. Any other contingencies, including reinsurance and unfunded or extra contractual obligations, which may affect the dental plan organization's financial condition. L.2014, c.81, s.27.

N.J. Stat. § 17:48D-11.3 Determination of increase, revision or redetermination; factors.

28. In determining any increase, revision or redetermination in the capital or surplus of a dental plan organization pursuant to the provisions of section 27 of P.L.2014, c.81 (C.17:48D-11.2) the commissioner shall take into account the following factors: a. Methods and techniques used to measure risk exposure and variability; b. The information available relating to the magnitude of the various risks described in section 27 of P.L.2014, c.81 (C.17:48D-11.2); c. The extent to which risks described in section 27 of P.L.2014, c.81 (C.17:48D-11.2) are independent or interrelated, and whether any dependency is direct or inverse; d. The extent to which the dental plan organization has provided protection against contingencies in ways other than the establishment of surplus, including, but not limited to: redundancy of premiums; margin in reserves and liabilities; adjustability of contracts pursuant to the terms of the contracts; voluntary or mandatory investment valuation reserves; reinsurance; the use of conservative actuarial assumptions to provide a margin of security; reserve adjustments after rate increases for policies written at earlier and less adequate rates; contingency or catastrophe reserves; and diversification of assets and underwriting risk; and e. Any other relevant factors, including the National Association of Insurance Commissioners' reports and independent judgments of the soundness of the dental plan organization's financial condition, as evidenced by the rating and reports of reliable professional financial services. L.2014, c.81, s.28.

N.J. Stat. § 17:48D-11.4 Suspension, revocation of authority to do business.

29. The commissioner may suspend or revoke the authority to do business in this State of any dental plan organization that does not comply with the provisions of sections 26 through 30 of P.L.2014, c.81 (C.17:48D-11.1 through C.17:48D-11.5). L.2014, c.81, s.29.

N.J. Stat. § 17:48D-11.5 Rules, regulations.

30. The commissioner may promulgate regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to effectuate the purposes of sections 26 through 30 of P.L.2014, c.81 (C.17:48D-11.1 through C.17:48D-11.5). Such rules and regulations shall be consistent with the standards for risk based capital for health organizations adopted by the National Association of Insurance Commissioners. L.2014, c.81, s.30.

N.J. Stat. § 17:48D-12 Complaint system, records.

12. a. A dental plan organization shall establish and maintain a complaint system to provide reasonable procedures for the resolution of written complaints initiated by covered persons concerning dental plan services. The dental plan organization shall maintain records of all written complaints initiated by covered persons. b. The commissioner may examine the complaint system and if he determines that the system is not adequate he may require a revision of the complaint system. L.1979,c.478,s.12; amended 2005, c.38, s.10.

N.J. Stat. § 17:48D-13 Annual report; filing; forms.

13. a. Every dental plan organization annually on or before March 1 shall file with the commissioner a report covering its activities for the preceding calendar year. b. The reports shall be on forms prescribed by the commissioner and shall include: (1) A financial statement of the dental plan organization, prepared by an independent certified public accountant and attested to by an officer of the dental plan organization, which statement shall include full disclosure of all assets and liabilities of the dental plan organization, the terms and conditions thereof, and the sources and disposition of all funds. If the dental plan organization's records have been audited by an independent certified public accountant, the financial statement shall be certified by the certified public accountant having conducted the audit; (2) Any significant modification of information submitted with the application for a certificate of authority; (3) The number of persons who became covered persons during the year, the number of covered persons as of the end of the year and the number of enrollments terminated during the year; (4) A description of the covered persons complaint system, including the procedures of the complaint system, the total number of written complaints handled through the system, a summary of causes underlying the complaints filed, and the number, amount and disposition of malpractice claims settled during the year by the dental plan organization and any of the dentists used by it; and (5) Any other information relating to the performance of the dental plan organization as required by the commissioner. L.1979,c.478,s.13; amended 1983, c.24, s.4; 2005, c.38, s.11.

N.J. Stat. § 17:48D-14 Percentage of premiums used for payments.

14. At least 70 percent of every dental plan organization's earned premium in the first year of operation, 75 percent in the second year, and 80 percent in all subsequent years shall be used for payments to dentists for dental services and supplies provided to covered persons. L.1979,c.478,s.14; amended 2005, c.38, s.12.

N.J. Stat. § 17:48D-15 False or misleading advertising; enforcement.

15. a. No dental plan organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this act: (1) A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a dental plan; (2) A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a person who does not possess special knowledge regarding dental plan coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to a covered person of, or person considering enrollment in, a dental plan, if the benefit or advantage or absence of exclusion, limitation, or disadvantage does not in fact exist; (3) Evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography, format and language, may cause a person who does not possess special knowledge regarding dental plans and evidences of coverage therefor, to expect benefits, services, charges, or other advantages which the evidence of coverage does not provide or which the dental plan organization issuing the evidence of coverage does not regularly make available for persons covered under such evidence of coverage. b. The unfair trade practice provisions contained in chapter 30 of Title 17B of the New Jersey Statutes shall apply to dental plan organizations, dental plans and evidences of coverage, except to the extent that the commissioner determines that the nature of dental plan organizations, dental plans and evidences of coverage render these sections clearly inappropriate. c. No dental plan organization, unless licensed as an insurer, may use in its name, evidence of coverage or literature any of the words "insurance," "assurance," "casualty," "surety," "mutual" or any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurer licensed to do business in this State. The provisions of this subsection shall be enforced by the Division of Consumer Affairs in the Department of Law and Public Safety and, where applicable, the commissioner. Nothing in this act shall limit the powers of the Attorney General and the procedures with respect to consumer fraud in P.L.1960, c.39 (C.56:8-1 et seq.). L.1979,c.478,s.15; amended 2005, c.38, s.13.

N.J. Stat. § 17:48D-16 Suspension, revocation of certificate of authority.

16. a. The commissioner may suspend or revoke any certificate of authority issued to a dental plan organization pursuant to this act, if he finds that any of the following conditions exist: (1) The dental plan organization is operating in a manner significantly contrary to that described in sections 3 and 4 of this act; (2) The dental plan organization issues an evidence of coverage which does not comply with the requirements of section 9 of this act; (3) The dental plan organization does not provide or arrange for an effective dental plan, as determined by the commissioner; (4) The dental plan organization can no longer be expected to meet its obligations to covered persons; (5) The dental plan organization, or any authorized person on its behalf, has advertised or merchandised its services in an untrue or misleading manner; (6) The dental plan organization has failed to comply with this act or any rules and regulations promulgated thereunder; (7) Any person responsible for conducting the affairs of the dental plan organization is: (a) not of good moral character, or (b) has been convicted, within 7 years of the filing of the application for a certificate of authority, of a crime listed in N.J.S.2C:41-1 or, at any time, of engaging in a pattern of racketeering activity, as defined in N.J.S.2C:41-1 and 2C:41-2. b. When the commissioner has cause to believe that grounds for the suspension or revocation of a certificate of authority exist, he shall notify the dental plan organization in writing, specifically stating the grounds for suspension or revocation. A hearing on the matter shall be granted by the commissioner within 20 days after a request in writing by the dental plan organization. After the hearing, or upon failure of the dental plan organization to appear at the hearing, the commissioner shall take action on his findings. c. If the commissioner suspends the certificate of authority, the dental plan organization shall not accept any additional covered persons, except newborn children, new employees and new dependents of current employees, or engage in any advertising or solicitation during the period of the suspension. d. If the commissioner revokes the certificate of authority, the dental plan organization shall proceed to dissolve its structure immediately following the effective date of the order of revocation, and shall conduct no further business, except as may be essential to the orderly conclusion of the affairs of the dental plan organization. The commissioner by written order, however, may permit such further operation of the dental plan organization as he finds to be in the best interest of covered persons to the end that covered persons shall be afforded the greatest practical opportunity to obtain continuing dental plan coverage. e. Notwithstanding the provisions of subsections c. and d. of this section, a dental plan organization which has had its certificate of authority suspended or revoked, or has suffered an adverse decision by the commissioner, shall be entitled to a hearing pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). L.1979,c.478,s.16; amended 1983, c.24, s.5; 2005, c.38, s.14.

N.J. Stat. § 17:48D-17 Cease and desist orders

a. The commissioner may issue an order directing a dental plan organization or a representative of a dental plan organization to cease and desist from engaging in any act or practice in violation of the provisions of this act. b. Within 20 days after service of the order of cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this act have occurred. The hearings shall be conducted pursuant to the "Administrative Procedure Act," P.L.1968, c. 410 (C. 52:14B-1 et seq.) and judicial review shall be available as provided therein. L.1979, c. 478, s. 17.

N.J. Stat. § 17:48D-18 Violations; civil penalty.

18. Any dental plan organization which violates any provisions of this act, or neglects, fails or refuses to comply with any of the requirements of this act shall be liable for a civil penalty of not less than $500.00 nor more than $10,000.00 for each violation. The failure to file an annual report and the failure to reply promptly in writing to inquiries of the commissioner may result in an administrative penalty in an amount not less than $50 nor more than $500 for each day that the dental plan organization fails to file that report or response. The penalty may be sued for and recovered by the commissioner in a summary proceeding pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.). A purposeful or knowing misstatement or omission of material fact required to be supplied to the commissioner is a crime of the fourth degree. L.1979,c.478,s.18; amended 1983, c.24, s.6; 2005, c.38, s.15.

N.J. Stat. § 17:48D-20 Applications, filings and reports treated as public documents

Applications, filings and reports required under this act except contracts referred to in section 3. c. (4) and 3. c. (5) of this act, shall be treated as public documents and shall not be considered confidential. L.1979, c. 478, s. 20.

N.J. Stat. § 17:48D-21 Confidentiality of diagnostic, treatment information.

21. Data or information pertaining to the diagnosis, treatment or health of any covered person obtained by the dental plan organization from the covered person or any dentist shall be confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this act, or upon the express consent of the covered person, or pursuant to statute or court order for the production of evidence or the discovery thereof, or in the event of claim or litigation between the covered person and the dental plan organization wherein the data or information is pertinent. A dental plan organization shall be entitled to claim any statutory privileges against such disclosure which the dentist who furnished the information to the dental organization is entitled to claim. L.1979,c.478,s.21; amended 2005, c.38,s.16.

N.J. Stat. § 17:48D-23 Rules and regulations

The commissioner may promulgate such rules and regulations as he may deem necessary to effectuate the purposes of this act. L.1979, c. 478, s. 23.

N.J. Stat. § 17:48D-24 Severability

If any section, term or provision of this act shall be adjudged invalid for any reason, such judgment shall not affect, impair or invalidate any other section, term or provision of this act, and the remaining sections, terms and provisions shall be and remain in full force and effect. L.1979, c. 478, s. 24.

Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://www.njleg.state.nj.us/legislative-activity/statutesFetched: 10/17/2026