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New Jersey Health Insurance Coverage Eligibility

Eligibility

You are eligible to purchase an individual plan if you are:

A resident of New Jersey;
Not eligible for coverage under a group health plan, governmental plan or church plan; and
Not eligible for coverage under Medicare

1. Residency:

A New Jersey resident is defined as someone whose primary residence is in New Jersey and who is present in New Jersey for at least six months of the calendar year. However, if a person qualifies as a "federally defined eligible individual" as defined below, the person does not need to be present in New Jersey for at least six months. For non-Health Maintenance Organization (HMO) coverage, residency requirements apply only to the individual who applies for coverage -- the policyholder. The policyholder's spouse, children or other dependent(s) do not have to reside in New Jersey. However, they must reside in the United States and there are some benefit restrictions if care and treatment are received outside the United States. If you choose to purchase coverage from a Health Maintenance Organization (HMO), all covered persons must reside in that HMO's service area.

A "federally defined eligible individual" is defined as "a person who has been covered for at least 18 months without a break in coverage of 63 or more days and whose most recent coverage was under a group health plan, governmental plan, church plan, or health insurance coverage offered in connection with any such plan; who is not eligible for coverage under Medicare or Medicaid; and who does not have another health benefits plan, or hospital or medical service plan."

2. Group Coverage:

Generally, you are considered eligible for group coverage if your employer or union -- or your spouse's employer or union -- makes a group plan available and you satisfy all the conditions for participation imposed by that group plan. Even if you choose not to participate in that group plan, you are still eligible for group coverage -- and, therefore, ineligible for individual health coverage. (However, you may have an opportunity to purchase an individual plan during the Open Enrollment Period in November of each year even if you are eligible for group coverage. There are specific rules that apply to the Open Enrollment Period, so it is best to consult with an insurance producer or carrier before doing so.)

If you are already covered under an individual plan when you first become eligible for group coverage, you may elect to retain your coverage under the individual plan. The individual plan would apply a "coordination of benefits" provision, which means that the group plan would pay benefits first, and then the individual plan would pay benefits as the secondary payor. If you elect to retain your individual coverage even while you are eligible for or covered under a group plan, you will be required to pay the full premium for individual coverage.

3. Medicare:

You are not eligible to purchase an individual plan if you are already eligible for Medicare, regardless of whether or not you apply for all available benefits under Medicare. Thus, if you are age 65 and eligible for Medicare, but do not sign up for Medicare, you are still eligible for Medicare and, therefore, you are ineligible to purchase an individual plan. Most people become eligible for Medicare because of their age (65 or older), but a person may become eligible for Medicare prior to age 65 because of a disability, including end-stage renal disease. If you are age 65 or older and not eligible for Medicare you will be asked to provide evidence that you are ineligible for Medicare.

While you may not purchase an individual plan if you are already eligible for Medicare, if you are already covered under an individual plan when you first become eligible for Medicare, you may elect to retain your coverage under the individual plan, or you may elect to terminate coverage under the individual plan. If you retain the individual plan, the individual plan would apply a "coordination of benefits" provision, which means that Medicare would pay benefits first, and then the individual plan would pay benefits as the secondary payor. If you elect to retain your individual coverage even while you are eligible for or covered under Medicare, you will be required to pay the full premium for individual coverage.

Even when a Medicare-eligible person does not enroll in Medicare, the individual plan will still act as the secondary payor, applying the "coordination of benefits" rules against the benefits Medicare would have paid, if the person had enrolled. Although a Medicare eligible person may elect to continue existing coverage under an individual plan, the individual plan is not a Medicare Supplement Plan and may not be used as a substitute for Medicare.

People who are already covered under an individual plan and then become eligible for Medicare should contact the New Jersey Department of Health and Senior Services, NJ Division of Aging and Community Services at 1-800-792-8820 for information concerning Medicare Supplement Plan options. Information is also available on their website which is www.state.nj.us/health/senior/ship.shtml.

Coverage by Region:

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New Jersey Health Guide Pages:

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