N.J. Admin. Code § 10:78-3.6 - Third party liability and other health insurance

Current through Register Vol. 54, No. 7, April 4, 2022

(a) Program applicants and beneficiaries are required to identify to the eligibility determination agency any third party (individual, entity, or program) that is or may be liable to pay all or part of the medical cost of injury, disease, or disability of an applicant or beneficiary.
(b) For the purposes of this section, the terms "health insurance" or "group health plan" do not include:
1. Student coverage which is defined as a limited coverage policy covering injuries sustained during school or school-sponsored activities;
2. Accident-only coverage (including death and dismemberment);
3. Disability income insurance;
4. Credit insurance;
5. Liability insurance, and coverage issued as a supplement to liability insurance, including automobile insurance;
6. Worker's compensation or similar insurance;
7. Personal injury protection coverage in automobile insurance;
8. Long-term care insurance;
9. Dental-only and vision-only coverage; and
10. Hospital indemnity or other fixed dollar indemnity insurance if the benefits of such insurance are provided under a separate policy, contract or certificate, and, there is no coordination or integration of the benefits with a group health plan or other health insurance.
(c) An applicant is not eligible for NJ FamilyCare if he or she:
1. Is currently covered under a non-governmental group health plan, is currently covered, or eligible for coverage, under Medicare, Medicaid or NJ FamilyCare Children's Program, or under a group health plan sponsored or self-funded by a government unit; or
2. Has been covered under a group health plan or Medicare at any time during the three-month period preceding the date of application for NJ FamilyCare; except that coverage which has lapsed within the three-month period due to the expiration of an applicant's continuation rights under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or other continuation rights available under State law shall not preclude an applicant from being eligible for NJ FamilyCare. An applicant who has lost coverage under an employer's plan will also not be subject to the three-month period if the applicant becomes unemployed through no fault of his or her own. In addition, an applicant may voluntarily terminate coverage under COBRA, or any other health insurance purchased through the individual market, in order to be considered for NJ FamilyCare eligibility.
i. The exceptions noted in (c)2 above with respect to COBRA and purchases in the individual market shall not apply to children in families with income greater than 200 percent of the Federal poverty level.
(d) The provisions of (c)1 and 2 above shall not apply to those parents, caretakers and children who would qualify for AFDC-related Medicaid or NJ FamilyCare Plan A but for Federal immigration residency restrictions.

Notes

N.J. Admin. Code § 10:78-3.6
Amended by R.2006 d.347, effective 10/2/2006.
See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a).
Rewrote (c)1; in (c)2, substituted "three-month" for "six month" throughout; in (c)2i, substituted "(c)2" for "(b)2"; and in (d), substituted "(c)1" for "(b)1", "AFDC-related" for "AFDC related" and "FamilyCare" for "KidCare".

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