N.J. Admin. Code § 10:79-3.8 - Health insurance coverage eligibility rules

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

(a) For the purposes of this chapter, the term "health insurance" does not include:
1. Student coverage which is defined as a limited coverage policy which covers injuries sustained while the student is engaged in school or school-sponsored activities;
2. Accident-only coverage, including coverage for accidental death and dismemberment only;
3. Disability income insurance;
4. Credit insurance;
5. Liability insurance, and coverage issued as a supplement to liability insurance, including automobile insurance;
6. Workers' compensation or similar insurance;
7. Personal injury protection coverage in automobile insurance;
8. Long-term care insurance;
9. Dental-only and vision-only coverage;
10. An insurance plan in which the child's lifetime total cap has been reached;
11. 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; and
12. Coverage under Medicare.
(b) With respect to a child determined eligible for NJ FamilyCare-Children's Program-Plan A, who meets the requirements listed below, other health insurance coverage shall not preclude that child from enrolling under NJ FamilyCare-Children's Program-Plan A.
1. A child who has other health insurance may be eligible for NJ FamilyCare-Children's Program-Plan A, if:
i. The child is age six or over and family income does not exceed 100 percent of the Federal poverty level;
ii. The child is age six or over and family income does not exceed the AFDC standard after disregards; or
iii. The child is under the age of six and the family income does not exceed 133 percent of the Federal Poverty Level (FPL).
(c) With respect to a child who does not meet the requirements of (b) above, a child shall be precluded from NJ FamilyCare-Children's Program-Plan A eligibility if:
1. The child is currently covered under a group health plan;
2. The child is currently covered under any other health insurance plan; or
3. The child is covered or is eligible for coverage under a group health plan or otherwise under a group health plan sponsored or self-funded by a government unit.
(d) Eligibility for coverage under a health insurance policy which is not readily accessible to the child shall not preclude the child from eligibility for NJ FamilyCare-Children's Program-Plan A.
1. In the case of coverage under an absent parent's policy, not readily accessible means a plan defined coverage network, where the network is not accessible with 45 minutes travel time of the child's residency.
2. In the case where the coverage is available under an absent parent's policy, the custodial parent shall be allowed to show good cause why the coverage is not available. Good cause may include, but shall not be limited to, concern of physical or emotional abuse.
(e) With respect to a child who does not meet the requirements of (b) above, a child shall be precluded from NJ FamilyCare-Children's Program-Plans B, C or D eligibility if:
1. The child is covered or is eligible for coverage under a non-contributory group health plan or otherwise under a group health plan resulting in no premium contribution cost to the household unit within three months prior to the date of application for NJ FamilyCare-Children's Program-Plans B, C or D;
2. The child is currently covered or was covered under any other health insurance plan within three months prior to the date of application for NJ FamilyCare-Children's Program-Plans B, C and D; or
3. The child is covered or otherwise is eligible for coverage under a group health plan sponsored or self-funded by a government unit.
(f) Exceptions to (e) above are listed below:
1. Coverage under a contract for health insurance obtained as an enrollee or family member of an enrollee, or participating in Health Access New Jersey shall not preclude a child from being eligible for NJ FamilyCare-Children's Program-Plans B, C and D.
2. Coverage under a government funded, non-employee based health insurance program which is targeted for low-income uninsured shall not preclude a child from being eligible for NJ FamilyCare-Children's Program-Plans B, C and D.
3. Coverage of a child in accordance with the Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation rights or other continuation rights available under State law shall not preclude a child from being eligible for NJ FamilyCare-Children's Program-Plans B, C and D, if the reason for the termination is expiration of the COBRA continuation rights. If the coverage was voluntarily terminated by the family prior to the expiration of continuation rights, the child is precluded only from participation in the NJ FamilyCare-Children's Program-Plan D for three months from the date of COBRA termination.
4. A child who is eligible for Medically Needy with an unmet "spend-down" liability. This unmet "spend-down" liability shall not preclude a child from being eligible for NJ FamilyCare-Children's Program-Plans B, C and D.
5. Coverage or eligibility for coverage, as applicable, under a group health benefits plan, whether sponsored through a governing entity or private employer, for the three-month period shall not be used to preclude the child's eligibility for NJ FamilyCare-Children's Program-Plans B, C, and D when:
i. The employer has ceased operations in this State, and there is no succeeding employer for that business;
ii. The employer has ceased operations in this State, and the succeeding employer has not retained the group health plan;
iii. The employer has ceased operations in this State, and the succeeding employer has altered the terms of a non-contributory group health plan to require a premium contribution for a class of employee to which the child's household member belongs; or
iv. The employee-certificate holder becomes unemployed, through no fault of their own.
6. If health insurance purchased through the individual market for a child was voluntarily terminated by a member of the family, the child is precluded only from participation in the NJ FamilyCare-Children's Program-Plan D for three months from the date of termination.

Notes

N.J. Admin. Code § 10:79-3.8
Amended by 49 N.J.R. 203(a), effective 1/17/2017

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