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. The residency requirement does not apply to dependents. However, 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 coverage 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, because you will no longer meet the residency requirement. 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 is covered under the group plan I have from my employer but he will turn 26 soon. 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, your son still has options:
- He (or you) may purchase an individual plan for him and decide to keep it only until he becomes covered under a group plan.
- He could continue his coverage under your group health plan through a federal COBRA election or a New Jersey small group continuation election. Check with your employer. Both of these continuation laws allow your son to continue coverage under your group plan for up to 36 months.
Question 8: If I cover my children under my individual plan, up to what age will they be covered?
Typically, you may cover your child up to the child's 26th birthday. Dependent children 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.
Or you may want to explore whether your children are eligible for NJFamilyCare, which covers children in families with income up to 350% of the federal poverty level. For more information about NJFamilyCare, call 1-800-701-0710 or go online to www.njfamilycare.org.
In addition, for children in families with incomes above 350% of the federal poverty level, there is NJFamilyCare Advantage. In many instances, it will be more cost effective for a parent to purchase a NJFamilyCare Advantage plan. For more information about NJFamilyCare Advantage, call 1-800-637-2997 or go online to www.horizonnjhealth.com/ourplans/njfamilycareadvantage/about-plan-affordable-health-care-your-children.
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:
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 Small Group continuation elections result in continuation of coverage under a group plan, you are still eligible to purchase an individual plan. You may choose to continue your coverage under your employer's group plan through a COBRA or New Jersey Small Group continuation election for some, all, or none of the permissible continuation period. Once you purchase an individual plan, you will have to terminate your group health coverage elected under COBRA or New Jersey Small Group continuation, except that you may keep your group 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 when you make a Dependent Under 31 election, you are continuing coverage under a group plan, 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?
Generally, you are not allowed to purchase an individual plan if you are covered by or eligible for a group health plan. There are exceptions:
- You always can purchase an individual plan if you are no longer part of an employer's group, but are continuing coverage through a COBRA election, a New Jersey Small Group continuation election, or a Dependent Under 31 continuation election. You must terminate the group continuation coverage.
- You can purchase an individual plan during the annual Open Enrollment Period each November even if you are eligible for or covered under an employer's group plan, but
- You cannot buy an individual plan that is the same as or similar to the group plan, and
- You must terminate your coverage under the group plan no later than December 31 of the year you make the purchase of the individual plan
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.