N.J. Admin. Code § 11:24-13.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:24-13.1 - General applicability of producer licensing requirements

(a) Except as (e) below or N.J.A.C. 11:24-13.2 may apply, no HMO shall employ, directly or indirectly, any person to solicit, negotiate or bind contracts for the delivery to subscribers or members of health care services through an HMO, or to communicate with subscribers or members concerning the terms and conditions of such a contract, or to establish or administer office management practices affecting subscribers or members, or to process claims, or to transmit funds between subscribers or members, producers, premium finance companies, insurance companies or the HMO unless such person is licensed as an insurance producer in New Jersey in accordance with N.J.A.C. 11:17, Producer Licensing, and the HMO has complied with the specific requirements of N.J.A.C. 11:17-2.9.

1. An HMO shall contract only with an insurance producer who has completed the educational requirements prescribed at N.J.A.C. 11:17-3 and is licensed as an insurance producer with a health authority.

2. Those persons whose duties are clerical in nature shall not be required to be a licensed producer. Clerical duties are those administrative tasks accomplished in the office and under the supervision of the HMO or a licensed producer that are necessary to produce the contract for health services in accordance with the HMO's or producer's normal procedures and systems, including but not limited to, those functions incorporated under the definition of clerical duties at N.J.A.C. 11:17A-1.2.

3. Those persons who are in the employ of the HMO whose income from his or her employ with the HMO is not dependent, in whole or in part, upon commission shall not be required to be licensed as a producer unless such person's duties with the HMO include soliciting, negotiating or binding contracts with subscribers or members.

(b) Every person under contract with or employed by an HMO who is required to be licensed as an insurance producer shall comply with the provisions of N.J.S.A. 17:22A-1 et seq., and rules promulgated thereunder, including but not limited to the continuing education requirements of N.J.A.C. 11:17, 11:17A, Market Conduct, 11:17B, Commissions and Fees, and 11:17C, Management of Funds, as appropriate for any producer licensed with a health authority.

(c) Every person under contract with or employed by an HMO who is required to be licensed as an insurance producer shall be subject to action by the Commissioner in accordance with N.J.S.A. 17:22A-17 and N.J.A.C. 11:17D, Administrative Procedures and Penalties.

(d) An HMO and its employees or other representatives who perform functions set forth at (a) above who are not licensed as an insurance producer on July 1, 1997 shall be permitted to come into compliance with the requirements of this subchapter by July 1, 1998, and shall not be subject to penalty or fine for the performance of those functions set forth at (a) above within that one year period, if the HMO and the person are making a good faith effort to comply with this subchapter. Good faith shall be demonstrated upon the written request of the Department and may include, but is not necessarily limited to, demonstrations of the following:

1. Proof of registration in one or more prelicensing courses by January 1, 1998, or application for a waiver of the prelicensing requirements, as specified at N.J.A.C. 11:17-3.2, with respect to persons who are not licensed as producers.

2. Proof of registration by September 29, 1997 for continuing education courses with respect to those persons who may be licensed as producers, but who had not intended to retain their license while in the employ of or working under contract with the HMO, and who are otherwise lacking in the required continuing education credits necessary to maintain their license on the effective date of this subchapter.

N.J. Admin. Code § 11:24-13.1