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Other Important Features
NJ Small Employer Health Benefits Program Buyer's Guide
 
Domestic Partners and Civil Union Partners

New Jersey law currently recognizes domestic partnerships and civil unions in addition to marriages between individuals of opposite gender.  Civil unions may be created only among individuals of the same gender.  Domestic partnerships include individuals of the same gender or of opposite genders, but for purposes of health coverage, only same-gender domestic partnerships are considered.  Note that same-gender domestic partnerships are no longer formed as a matter of law in New Jersey as of February 19, 2007. 

In general, the rights of spouses and partners of civil unions are the same for purposes of health coverage under New Jersey law.  If an employer offers dependent coverage to employees, the employer must permit an employee to cover a civil union partner.  Employers do not have to offer coverage to domestic partners when offering coverage to spouses or partners of civil unions.  However, when an employer opts to offer coverage to domestic partners, the employer must treat all domestic partners consistently.

Neither an employer nor a carrier may discriminate in the coverage of a child the employee claims as a dependent based on whether the child becomes a dependent of the employee pursuant to birth, adoption, marriage, civil union or domestic partnership.
 
“Dependent Under 31” Continuation Election

New Jersey law permits an employee’s child who no longer qualifies as a child dependent under the terms of an employer’s health benefits plan to elect to remain covered as an “over-age” dependent until the child’s 31st birthday, so long as s/he meets the other eligibility requirements associated with the “Dependent Under 31” continuation election.  In the case of a child who is aging-out of a parent’s coverage at age 26, the Dependent Under 31 continuation election right is in addition to the aging-out child’s right to make either a COBRA or NJSGC election. Thus, upon aging-out on his or her 26th birthday (or such later date as may be stated in the health benefits plan), a child covered under a small employer health benefits plan may make a continuation election pursuant to COBRA or NJSGC with the expectation of continuing coverage for up to 36 months, or may make a Dependent Under 31 (DU31) election with the expectation of continuing coverage until age 31, so long as he continues to be DU31-eligible.

An over-age child may make a DU31 election upon loss of the group coverage as a result of turning age 26 as well as during the employee enrollment period or any special enrollment period that may occur prior to the attainment of age 31. 

The cost of continuing coverage pursuant to a DU31 election will be determined by the age of the dependent.   
 

Appealing Unfavorable Medical Necessity Decisions

The SEH Program health benefits plans permit carriers to consider whether many of the services covered under the contract or policy are medically necessary and appropriate for purposes of treatment of the covered person’s condition.  If a carrier determines that a service is not medically necessary and appropriate (including determinations that the service is experimental or investigational, cosmetic, or dental instead of medical), the covered employee or dependent has the right to appeal the unfavorable determination.

In New Jersey, carriers are required to have a two-stage internal appeal process.  In addition, if the outcome continues to be unfavorable and the employee or dependent continues to disagree, the appeal may be taken to an external independent utilization review organization through the Independent Health Care Appeals Program, which is under the auspices of the New Jersey Department of Banking and Insurance.

The covered employee or dependent may authorize a health care provider to make the appeals on behalf of the covered employee or dependent by providing written consent.  The small employer does not have to become involved with either the internal or external appeal process.

The New Jersey Department of Banking and Insurance has a more detailed discussion of the right to appeal medical necessity determinations both internally and through the Independent Health Care Appeals Program on the Department’s web site. 

   
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