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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,” the person does not need to be present in New Jersey for at least six months. A "federally defined eligible individual" is 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.
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) must reside in the United States, but do not have to reside in New Jersey. (Note: 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), in addition to meeting the New Jersey residency requirement, all covered persons must ALSO reside in that HMO's service area.
You are eligible for group coverage (whether or not you are actually covered under the group health plan) when:
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your employer or union offers a group health plan and you meet all of the conditions to become covered, OR |
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your spouse’s employer or union offers a group health plan and you meet all of the conditions to become covered as a dependent, OR |
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your parent’s employer or union offers a group health plan and you meet all of the conditions to become covered as a dependent. |
If you are eligible for group coverage you usually are ineligible to buy an individual plan. But note:
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There is an Open Enrollment Period every November during which people eligible for group coverage have an option to buy an individual plan. There are special rules for buying during the Open Enrollment Period; check with an insurance producer or the carrier for help. |
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If you become eligible for group coverage AFTER you already have an individual plan, you can keep your individual coverage, even if you enroll in the group health plan. If you are covered by an individual and group plan, the individual plan will “coordinate benefits,” meaning that the group plan will pay first, and the individual plan will be the secondary payor. You must pay the full premium for the individual plan even if it coordinates benefits and is a secondary payor. |
You are NOT considered eligible for group coverage when:
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you no longer meet the group requirements for coverage, but may continue coverage under the group health plan through a COBRA or New Jersey Small Group Continuation election |
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you no longer meet the group requirements for coverage, but may continue coverage under the group health plan through a Dependent Under 31 election |
Under these conditions, you may purchase an individual plan without waiting for the Open Enrollment Period. You will, however, have to terminate any coverage under the group plan.
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, so 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.
If you have an individual plan when you become eligible for Medicare, you may choose to keep your individual plan. But note:
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The individual plan will “coordinate benefits” as if it were a secondary payor whether or not you enroll in Medicare. In other words, the individual plan always pays as if Medicare were paying first. |
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You will have to pay the full premium for the individual plan even though it is always the secondary payor. |
For these reasons, the individual plan is not a substitute for Medicare and it is not a Medicare Supplement Plan. People covered under an individual plan who become eligible for Medicare should consider all of their options. For help, you can:
If you are age 65 or older and state that you are not eligible for Medicare, you will be asked for proof that you are not eligible.
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