Frequently Asked Questions About Eligibility and Dependent Eligibility
Question 1: May I purchase an individual plan if I live in another state during part of the year?
Yes, provided New Jersey is your primary residence and you are present in New Jersey for at least six months of the year. The policyholder is required to be a New Jersey resident. These residency requirements do not apply to dependents. Although, for coverage under an HMO, everyone intended to be covered must live in the HMO’s service area. Also, as explained in the section on residency, the requirement to be present in New Jersey for at least six months of the year does not apply to a federally defined eligible individual.
Question 2: My parents are coming to visit me from abroad. They will be staying with me for about 4 months. May I buy a plan to cover them while they are in New Jersey?
No, visitors do not generally satisfy the residency requirement and should investigate coverages available where they reside.
Question 3: I just moved to New Jersey, may I purchase an individual plan?
Yes, if you relocate to New Jersey with the intention of being present in New Jersey for at least 6 months of the year, and meet all other eligibility requirements, you may purchase individual coverage.
Question 4: May I keep my New Jersey individual plan if I move out of state?
No. However, your carrier may offer a plan with similar benefits in other states. You should check with your insurance company or HMO regarding a plan termination date before you move.
Question 5: May I keep my New Jersey individual plan if I become eligible for Medicare?
Yes. However, the individual plan will not act like a Medicare Supplement Plan and it will not replace Medicare coverage. The benefits for which you are eligible under Medicare will be coordinated with the benefits of the individual plan whether or not you actually enroll in Medicare. Medicare would pay benefits first, and then the individual plan would pay benefits as the secondary payor. In addition, the only individual plan you may be covered under once you become eligible for Medicare is the plan you are covered under at the time you become eligible for Medicare. You may not elect another individual plan or plan option or switch to another carrier.
Question 6: I need family coverage, not just individual coverage. How do I get coverage for my family?
It is called individual coverage because you are buying it on your own rather than getting the coverage through an employer group plan. If the members of your family qualify as dependents, they can also be covered under your individual plan.
Question 7: My son will be graduating from college in May. He is covered under the group plan I have from my employer until he graduates. May I purchase a short-term policy to cover him until he finds a job that offers group health coverage?
No. There are no "short-term" plans available in New Jersey. However, you may purchase an individual plan for him and decide to keep it only until he becomes covered under a group plan. Another option to cover him would be COBRA or New Jersey group continuation. You should check with your employer to find out whether the employer is subject to the requirements of COBRA or New Jersey group continuation. Under both of these continuation laws, your son could elect to continue coverage under your group plan for up to 36 months. Another option is coverage for certain dependents who are under 31 years old under P.L. 2005, c. 375. You can find lots of information about coverage under this law on the Department of Banking and Insurance website: www.state.nj.us/dobi/division_consumers/du31.html
Question 8: If I cover my children under my individual plan, up to what age will they be covered?
A policyholder’s children -- including those for whom you have legal custody or guardianship, as well as those with whom you have a blood or legal relationship, and who depend on you for most of their support and maintenance and live in your household -- are eligible for coverage under your plan until their 19th birthday. Children who are and remain full-time students may be covered until their 23rd birthday. Coverage will end earlier, if the child graduates or is otherwise no longer a full-time student. Dependents who are incapacitated may be covered indefinitely, provided documentation is supplied to the carrier as requested, and your plan remains in effect. Please note that the option to continue coverage for dependents to age 31 under P.L. 2005, c. 375 does not apply to individual coverage.
Question 9: Can I purchase coverage for a child or children only?
Yes. If you wish to purchase coverage for one child, you will be charged the single rate. If you wish to purchase coverage for more than one child, you will be charged the adult and child(ren) rate. Since all plans may be age-rated, resulting in more favorable rates for younger people, you may want to explore coverage options under age-rated plans as described later in this Guide and identified on the rate comparison chart.
Question 10: My grandchildren live with me and I am responsible for their care and support, but I am not their legal guardian. I am covered under an individual plan. May I add them for coverage under my individual plan?
Yes. A dependent child, for the purpose of an individual plan, includes a child related to you by blood, if the child depends on you for most of the child’s support and maintenance and resides in your household.
Question 11: If I waive coverage under Medicare, may I purchase an individual plan?
No. Even if you waive or postpone coverage under Medicare, you are considered eligible for Medicare and thus not eligible for IHC coverage. If you are concerned that Medicare may not provide adequate coverage, you may purchase another type of health plan specifically designed to supplement Medicare coverage. You may obtain free information on plans that supplement Medicare by contacting the New Jersey Department of Health and Senior Services, NJ Division of Aging and Community Services at 1-800-792-8820 or visit their website at www.state.nj.us/health/senior/ship.shtml.
Question 12: May I purchase an individual plan if I am eligible for coverage under COBRA or New Jersey State continuation?
Yes. Although COBRA and New Jersey State continuation are a continuation of a group plan, eligibility for coverage under COBRA or New Jersey State continuation does not preclude the purchase of an individual plan. You may choose to continue your coverage under COBRA or New Jersey State continuation for some, all, or none of the permissible continuation period. Once you purchase an individual plan, you may not maintain health coverage under COBRA or New Jersey State continuation, and therefore, you will have to cancel your health coverage under COBRA or New Jersey State continuation. If you are eligible for COBRA you may elect to maintain your dental or vision coverage, if available, since dental and vision coverage is not available with individual plans.
Question 13: May I purchase an individual plan if I am eligible for coverage as a dependent under age 31 under P.L. 2005, c. 375?
Yes. Although over-age dependent coverage is coverage under a group plan, eligibility for such coverage does not preclude you from purchasing an individual plan. For some over-age dependents, a plan using rates that vary by age may be an option worth exploring. You can read about age-rated plans later in this Guide.
Question 14: May I purchase an individual plan if I actually have group coverage?
The law generally prohibits you from purchasing an individual plan if you are covered by or eligible for a group health plan. However, you may be eligible to purchase an individual plan during the Open Enrollment period in November of each year, subject to certain restrictions. You would be required to terminate your coverage under the group plan no later than December 31 since the individual coverage would take effect on January 1.
Please note that, even if you are eligible for an individual plan, you may not purchase an individual plan that provides the same or similar level of coverage as the group plan for which you are eligible.
An insurance producer or carrier representative can help you evaluate your particular circumstances and the options that may be available to you during the Open Enrollment Period which occurs each year during the month of November. The individual plan would not take effect until January 1 following the Open Enrollment Period.
Exception: If you are covered under your parent’s group plan as an over-age dependent you may elect to drop that over-age dependent coverage at any time and purchase your own individual plan.
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