Frequently Asked Questions

New Jersey Small Group Health (2-50 Employees)
New Jersey Individual Health
Medicare
What is the NJ Small Employer Health Benefits Program Act?
Enacted in 1992, the New Jersey Small Employer Health Benefits Program Act (SEH Act) (N.J.S.A. 17B:27A-17 et seq) has provided significant protections to New Jersey small employers since 1994.� Through the years, the SEH Act has been amended by State laws as well as Federal laws.� Since 1996, standards regarding privacy and security of health information have been governed by the federal Health Insurance Portability and Accountability Act (HIPAA).� Various mandated requirements of the federal Patient Protection and Affordable Care Act (PPACA) became effective starting in 2010 with the most recent requirements becoming effective beginning in January 2014.�
Can I purchase small group coverage if I am a self-employed husband and wife with no other employees?
No, a business with only husband and wife does not qualify under the new federal law requirements.�
Does the employer have to contribute a certain amount of premium?
The employer must contribute at least 10% of the total group�s premium.
Am I required by law to provide health benefits for my employees?
You are not required by law to provide coverage to your employees if you are a small employer. However, if you provide small group health coverage, you are then subject to comply with the requirements of state and federal laws. Only ALEs (Applicable Large Employers) are subject to the Employer Shared Responsibility provision under section 4980H of the Internal Revenue Code (added to the Code by the Affordable Care Act). An ALE, defined in the text of the ACA, is an employer who averaged at least 50 full-time employees (including full-time equivalent employees (FTEs)) on business days during the preceding calendar year.
How does a carrier determine the rates for my group?
Rates are first based on the plan of benefits selected. Age, geography and family status are the only factors used in determining the premium for each group. Gender is no longer a factor under ACA. Carriers use modified community rates for small employer plans. Rates are not based upon the actual or expected claims history of any particular person or persons in the small employer group. In addition, carriers do not rate based on gender and there is no special rate for smokers versus non-smokers. Prior to 2014 carriers rated policies based on the average of all their employees and dependents. This is known as a composite rate. Starting in 2014, carriers were required to use separate rates for each employee and their dependents. This is known as age rating. Carriers now use a child rate for ages 0 through 20. This is incrementally increasing every year from age 21 through 64. Age 64 and over remains the same. Medicare carve out rates have been eliminated. Each carrier must set its rates so that its highest rate is not more than 2 times its lowest adult rate for a specific individual plan. (This is referred to as a 2:1 rate band.)
Will my rates change if I deal directly with the insurance carrier instead of using a broker?
The initial and renewal rates will remain the same whether you go directly to the insurance carrier or use a broker.
What is an employee?
Under the Federal definition, an �Employee" means an individual who is an employee under the common law standard as described in 26 CFR 31.3401(c)-1. For purposes of determining whether an employer is a small employer, employee excludes an individual and his or her spouse when the business is owned by the individual or by the individual and his or her spouse, a sole proprietor, a partner in a partnership, and more than a two percent shareholder in a Subchapter S corporation as well as immediate family members of such individuals. Employee also excludes a leased employee.
Do I include employees from other companies that I own?
All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. In the case of an employer that was not in existence during the preceding Calendar Year, the determination of whether the employer is a small or large employer shall be based on the average number of Employees that it is expected that the employer will employ on business days in the current Calendar Year.
When is an employer subject to the Medicare Secondary Provision (TEFRA/DEFRA)?
The working aged Medicare Secondary Provision applies only to group health plans of employers with 20 or more employees and to multi-employer and multiple employer group health plans in which at least one employer employs 20 or more employees. This requirement is met if an employer has 20 or more full-time and/or part-time employees for each working day in each of 20 or more calendar weeks in the current or preceding year.
When is an employer subject to COBRA?
All employers who had 20 or more employees on 50% of its typical business days during the preceding calendar year are subject to COBRA. The only exceptions are: (a.) The federal government has its own rules regarding continuation coverage and (b.) Church plans (within the meaning of Section 414(e) of the Internal Revenue Code. Full-time and part-time employees count regardless of their eligibility for the group health plan. Under the 2001 Final Regulations, part-time employees are counted as a fraction of a full-time employee.
Am I required to cover a certain percentage of eligible employees?
Yes, this is known as the 75% participation requirement. Credits are available to go towards this requirement. If an employer pays 100% of the cost of coverage, a carrier cannot require greater than 75% participation.
Which employees can waive coverage and be credited towards the group participation requirement?
The law does not allow a carrier to impose a participation requirement of more than 75% of all eligible employees. There is no participation requirement for dependents. A carrier shall count as covered under the small employer's health benefits plan, for the purpose of satisfying employee participation requirements, a full time employee who:

-Is covered as an employee or dependent under any fully insured health benefits plan offered by the small employer
-Is covered under Medicare
-Is covered under Medicaid or NJ FamilyCare
-Is covered under another group health benefits plan
-Is covered under a spouse's group health benefits plan
-Is covered under Tricare; or with respect to Small Business Health Options Program coverage only, is covered under an individual plan.


The term employee means an individual who is an employee under the common-law standard. See � 31.3401(c)-1(b). For purposes of this paragraph (a)(15), a leased employee (as defined in section 414(n)(2) [26 USCS � 414(n)(2)]), a sole proprietor, a partner in a partnership, a 2-percent S corporation shareholder, or a worker described in section 3508 [26 USCS � 3508] is not an employee.
Can a small employer cover part-time employees who work less than 25 hours per week?
No, they are not eligible employees.
How do I know if I qualify as a small employer?
An employer that satisfies the requirements of either part one or part two of the definition below is a small employer in New Jersey. "Small employer" means: Any person, firm, corporation, partnership, or political subdivision that is actively engaged in business that employed an average of at least one but not more than 50 eligible employees on business days during the preceding calendar year and who employs at least one eligible employee on the first day of the plan year;

or

An employer with a business location in the state of New Jersey who employed an average of at least one but not more than 50 employees on business days during the preceding calendar year; and who employs at least one employee on the first day of the plan year. With respect to parts one and two of the definition above, any person treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 (26 U.S.C. � 414) shall be treated as one employer.

Note the emphasis to eligible employees in part one of the definition and to employees in part two of the definition.
Can I have different waiting periods for certain employees?
Waiting periods cannot exceed 6 months. Different classes can be established on bona fide conditions of employment, such as hours worked, salary, title, etc.
Can I offer different plans by class of employee?
Different classes can be established on bona fide conditions of employment, such as hours worked, salary, title, etc. By offering a specific plan or plans for a particular class of employees that class of employee will not be eligible to enroll for other plans offered to other classes employees.
Is there a limit to the number of employees that can work outside of NJ?
The majority of its eligible employees must work in a physical location in New Jersey in order for the employer to be eligible to purchase Small Employer Health Program health benefits plans for the group. An employee that works from his or her home located outside of New Jersey is not considered to be working in New Jersey, even if the employer�s offices are located in New Jersey.
What is an Open Access POS plan?
Open access point of service adds an additional option to the classic POS plan's referral policies. As in an HMO, you can decide to have your primary care physician refer you to in-network specialists and facilities. This option provides the lowest co-pay level. As an added benefit, open access POS plans also let you 'self-refer' to in-network specialists and facilities at what the insurance companies call 'discounted rates.' When you 'self-refer,' you see a doctor, specialist or use a health care facility without having a written referral from your physician.
What is MOOP (Maximum Out-of-Pocket)?
"Maximum out of pocket" means the annual maximum dollar amount that a covered person must pay as copayment, deductible, and coinsurance for all covered services and supplies in a calendar year. All amounts paid as copayment, deductible, and coinsurance shall count toward the maximum out of pocket. Once the maximum out of pocket has been reached, the covered person has no further obligation to pay any amounts as copayment, deductible, and coinsurance for covered services and supplies for the remainder of the calendar year. Under ACA, prescription copays and deductibles must be applied to MOOP.

ACA MOOP limits:

2016 - $6,550/Individual $13,100/Family
2017 - $7,150/Individual $14,300/Family
Must I offer continuation coverage to an employee and their dependents?
You must offer continuation coverage to an employee and their qualified beneficiaries upon the occurrence of certain qualifying events (Such as termination of employment, divorce or legal separation, dependent ceasing to be a dependent, reduction of hours, etc.)
Can a carrier cancel my coverage if someone covered has large claims?
A carrier cannot terminate a small group�s coverage based upon the claims experience of the group or a covered individual.
What is the range of deductibles that I can have?
A carrier may offer a range of deductibles for the standard health plans from $250 to $5,000 per covered person. A carrier can offer a HMO plan with a deductible range of $250 to $2,500.
What is the range of coinsurances that I can have?
A carrier may offer a range of coinsurances for the standard health plans from 60% to 90%. A carrier can offer a HMO plan with coinsurance ranges of 50% to 90%.
What is in-network vs. out-of-network benefits?
The amount of benefits paid to a covered person is based on whether a provider of services participates in a network or not. Health care providers in a carrier�s network have agreed with the carrier to a negotiated rate of payment. Any charges in excess of the negotiated rate of payment cannot be billed to the insured person. When a covered person chooses to receive covered services out-of-network, the person is responsible for any charges that the health care provider may bill that exceed what the carrier considers to be reasonable and customary. This is known as �balance billing�. These excess charges do not count toward satisfying any deductible or MOOP requirements in the standard health benefits plan.
What is Dependent Under 31?
The law permits children who no longer qualify to be eligible under a group health plan the option of continuing or enrolling in a parent's group health benefits plan until the child reaches his or her 31st birthday, marries, has a child, moves out-of-state (and does not become a full-time student), enrolls in other group or individual health coverage, or becomes entitled to Medicare.
What is a preexisting condition limitation?
Under the Affordable Care Act, health insurance companies can't refuse to cover you or charge you more just because you have a �pre-existing condition� � that is, a health problem you had before the date that new health coverage starts. They also can�t charge women more than men.

Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer. They cannot limit benefits for that condition either. Once you have insurance, they can't refuse to cover treatment for your pre-existing condition.
How are preexisting conditions limited for groups of 5 or fewer eligible employees?
A health benefits plan issued to a small employer with five or fewer eligible employees, as determined on the effective date of the plan and on each subsequent policy anniversary, may contain preexisting condition exclusion. However, a preexisting condition exclusion shall not exclude coverage for a period of more than 180 days following the enrollment date, and shall relate to conditions, whether physical or mental, manifesting themselves during the six months immediately preceding the enrollment date of the enrollee and for which medical advice, diagnosis, care or treatment was recommended or received during the six months immediately preceding the enrollment date.
What are late enrollees?
A late enrollee is someone who declined coverage when he or she was first eligible to enroll, and decides to enroll at a later date. Late enrollees are subject to a 6-month preexisting condition limitation period. However, if you were covered under another group health plan or a government program at the time of eligibility and enroll within 30 days of your coverage terminating (involuntarily), you will not be subject to any preexisting condition limitation period. This limitation will not apply to anyone who enrolls within 30 days following his or her marriage/civil union/domestic partnership, or the birth, adoption or placement for adoption of his or her child.
What is the annual NJ certification form?
At the time of application, the determination of whether an employer is a small employer shall be based upon the small employer's completed New Jersey Small Employer Certification form. Small employer carriers shall require each small employer covered by a small employer health benefits plan issued by the small employer carrier to that small employer to complete each year the New Jersey Small Employer Certification form. This form shall be sent to the small employer for completion no earlier than 150 days prior to the renewal of the small employer's health benefits plan.
Must I notify a carrier if I am terminating my policy?
A carrier is only required to honor prospective termination requests, not retroactive termination requests. If you make a prospective request to terminate the policy, the carrier will terminate the policy as of the date you specify. You are liable for payment of premiums for the period of time during which the contract remains in force, but the carrier will refund any premiums you have already paid for time period exceeding the date of termination. With respect to requests for retroactive termination, the carrier will terminate your policy on the date the carrier receives the notice, and the refund premium for any remaining days.
What are Domestic Partners and Civil Unions?
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. Two individuals of the same gender may form domestic partnerships 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.
May I purchase an individual plan if I live in another state during part of the year?
A New Jersey resident is defined as someone whose primary residence is in New Jersey (at least 6 months out of the year). 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. 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.
May I keep my New Jersey individual plan if I become Medicare eligible?
You are not eligible to purchase an individual plan if you are already covered under Medicare, regardless of whether you have Parts A and B or only have Part A of Medicare. Thus, if you are age 65 and eligible for Medicare, but do not sign up for Medicare, you are not covered for Medicare, so you are eligible to purchase an individual plan. If you are eligible for Medicare and thinking of buying an individual policy instead of enrolling for Medicare, there are two important facts you should consider. The individual plan will �coordinate benefits� with Medicare. The individual plan will be the secondary payor even though you do not have coverage under Medicare. For example, for a physician bill of $1000, assuming Medicare allows the full, $1,000 charge; Medicare Part B would pay $800. The individual policy will consider the $800 benefit Medicare would have paid and only pay benefits based on the $200 difference. In other words, you will be out of pocket whatever Medicare would have paid for your services. If you are eligible for Medicare but do not enroll when you are first eligible, when you later enroll for Medicare your monthly cost will be increased because you enrolled after you were first eligible.
If I waive coverage under Medicare, may I purchase an individual plan?
 If you have an individual plan when you become eligible for Medicare, you may choose to keep your individual plan. But note: The individual plan will �coordinate benefits� as the secondary payor whether or not you enroll in Medicare. In other words, the individual plan always pays assuming Medicare pays first. 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: Contact your County Office on Aging Contact New Jersey�s Division of Aging and Community Services at 1-800-792-8820 or go to www.state.nj.us/humanservices/doas/services/ship/ Go to www.Medicare.gov 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.
To what age can my children be covered as a dependent on my individual plan?
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. They may be eligible to continue coverage under your group plan as a dependent under 31 years old based on New Jersey law (P.L. 2005, c. 375, as amended).
Can I purchase an individual plan if I am eligible for coverage under COBRA or NJ Continuation?
Yes. Eligibility for coverage under COBRA or New Jersey State continuation does not prevent you from purchasing an individual plan. Once an individual plan is purchased you may not maintain health coverage under COBRA or New Jersey State continuation and as a result will have to cancel your health coverage under COBRA or New Jersey State continuation. If you are eligible for COBRA you may elect to maintain your dental or vision coverage, if available, since dental and vision coverage is not available with individual plans.
If I have group coverage may I purchase an individual plan?
The law normally prohibits you from purchasing an individual plan if you are covered or The law normally prohibits you from purchasing an individual plan if you are covered or eligible for a group health plan. However, you may be eligible to purchase an individual plan during the open enrollment period in November of each year, subject to certain restrictions. You would be required to terminate your group coverage no later than December 31st since the individual policy would become effective on January 1st. Even though you are eligible for an individual plan, you may not purchase an individual plan that provides the same or similar level of coverage as your group plan for which you are eligible.
Can I be eligible for individual coverage if I don't have a social security number?
Yes. Most carriers will usually require a copy of the VISA or passport along with proof of residency such a copy of your utility bill or driver�s license.
How many months of prior credible coverage is required so I will not be subject to pre-existing conditions?
A new participant must have at least 12 months of continuous coverage that was terminated within 31 days prior to the new individual plan's effective date in order to have the pre-existing condition waiting period waived.

A "federally defined eligible individual" will be allowed a 63-day break between plans. The following criteria must be met: the person must have had at least 18 months of prior credible coverage, the most recent being a group plan. In addition, if COBRA or NJ continuation was offered the individual must have elected and exhausted that coverage
What is a "federally defined eligible individual"?
1. A resident of New Jersey; and
2. Not eligible for coverage under Medicare
Are rates locked-in for any length of time?
All individual plan premium rates are based on a calendar year, and will not change until January 1 of the following calendar year. If you buy a plan on February 1, the rate will be �locked-in� until the following January 1. .
Can I change to another individual plan whenever I want during the year?
No, if you do not purchase or renew coverage during the Annual Open Enrollment Period, you will not be able to buy coverage in the individual market until the next Annual Open Enrollment Period, unless you have a triggering event that creates a Special Enrollment Period for you.
If I elect an HMO plan will I have coverage outside of New Jersey?
Coverage for services provided outside the service area of the HMO or EPO is generally limited to medical emergencies and urgent care. Sometimes carriers allow members covered under an HMO or EPO plan to use doctors or hospitals located in another state if the doctor or hospital belongs to that carrier�s network in that other state. In addition, if there are no doctors or hospitals in the carrier�s network that can provide the care you need, you can request an �in-plan exception.� Contact your carrier for details.
What if I am not satisfied with the level of benefits provided under the plan I selected?
You have a 30-day period during which you may examine the policy or contract and the benefits included. If you are dissatisfied, you may return your policy or contract for a full premium refund, less any claims paid or services provided.
What is the pre-existing condition limitation?
A "pre-existing condition" is an illness or injury that you had before you applied for coverage. For plans issued before January 1, 2014, carriers were permitted to exclude the costs for treating pre-existing conditions for up to 12 months after the effective date of coverage (for people 20 years old and older). There were rules that required carriers to shorten the pre-existing condition limitation period if someone had certain types of prior coverage. However, for plans issued on or after January 1, 2014, no carrier may limit coverage for anyone because of any pre-existing condition.
What is considered to be "credible coverage"?
-A Group Health Plan (including a self-insured plan)
-A Group or Individual Health Benefits Plan
-Part A or Part B of Medicare
-Medicaid
-A State Health Benefits risk pool
-A public health plan as defined by federal regulations
-A health benefits plan under section 5(e) of the Peace Corps Act
-Coverage under any other type of plan set forth by the Commissioner of Banking and Insurance by regulation
What is "MOOP" maximum out of pocket?
Maximum out of pocket refers to the limit on how much you will have to pay in the form of deductible, coinsurance and copayment requirements during any calendar year. After the maximum out of pocket has been reached, all covered charges you incur during the rest of that calendar year will be paid at 100% of allowed charges by the carrier.
What does Pre-Approval mean?
Many services and supplies require carrier pre-approval. Pre-approval gives the carrier the opportunity to evaluate the medical need before you incur charges and to advise you, up front, what will be covered. If you do not secure pre-approval, as required, the carrier has no obligation to provide benefits. Examples of services for which pre-approval is required include but are not limited to: home health care, hospice care, durable medical equipment, the exchange of unused inpatient days for additional outpatient visits for treatment of non-biological based mental illness. Carriers also may require pre-approval for certain prescription drugs for certain therapies.
Do any individual plans have coverage for infertility?
None of the individual plans will cover treatment for infertility.
Can a plan be purchased for children only?
Yes. The plans available to cover an individual adult or family can also be purchased to cover a child or children without any adults covered under the policy. All plans have a child rate applicable to children under the age of 21.
I am pregnant but currently have no coverage. Can I get an individual plan?
Yes, but unlike group coverage, pregnancy which exists on the date coverage begins will be subject to the pre-existing limitation. However, certain complications of pregnancy will not be excluded for coverage as pre-existing conditions.

Pursuant to N.J.A.C. 11:1-4.3 complications of pregnancy are defined as:

1. Conditions (when the pregnancy is not terminated) whose diagnosis are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as, acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity.

2. Nonelective caesarean section, ectopic pregnancy, which is terminated, and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

Complications of pregnancy shall not include false labor, occasional spotting, physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy.
What is the Annual Open Enrollment Period?
During the Annual Open Enrollment Period, people can buy individual insurance. It does not matter whether you are buying your very first individual plan, or replacing individual coverage that you already have. For 2016, the Annual Open Enrollment Period starts November 1, 2015 and continues through January 31, 2016. Coverage applied for during the Annual Open Enrollment Period by December 31 will begin January 1 of the next year. When the Annual Open Enrollment Period extends beyond December 31 � as it will for 2016 � coverage applied for after December 31 will be effective on the first day of the month following the month the application is received (so, an application received January 10 will have a coverage effective date of February 1). Some carriers allow effective dates on the 15th of the month (in which case, an application received January 10 could have an effective date of January 15.) Applications must be received during the Annual Open Enrollment Period to be considered.
What I need to know about Replacing Coverage?
You cannot be covered under two individual plans. If you are replacing an individual plan, be sure to notify the carrier of the plan being replaced that the individual policy should be terminated as of the day before the new policy takes effect. Give notice no later than 30 days after the new policy takes effect. So, if you are replacing coverage during an Annual Open Enrollment Period, this means you should give notice no later than 30 days after January 1, that the old policy needs to be terminated as of December 31.

If you are buying an individual policy to replace group coverage, be sure to notify the group plan that you are waiving the group coverage. You must waive group coverage as of the day before the new individual policy takes effect. So, if you are buying an individual policy to replace group coverage during the individual Annual Open Enrollment Period, you must waive the group coverage as of December 31.
What is a Special Enrollment Period?
When certain events happen in your life, you have the right to buy an individual policy or change your current coverage without waiting for the Annual Open Enrollment Period. These triggering events create 60-day Special Enrollment Periods. The 60-day period starts on the date of the triggering event.

Triggering Events

Generally, a triggering event is one that results in a change in your family, a change in your location, or one that results in a loss of minimum essential coverage for a family member. It can also include a change in your eligibility for coverage. It does NOT include a loss of coverage because you failed to pay premiums, or misrepresented material facts, or committed fraud. If you lose coverage contact the carrier that issued the coverage you lost to ask if the loss of coverage is considered to be a triggering event. When there is a change in your family, such as birth or marriage, or if you move your primary residence, contact your current carrier and ask if the event entitles you to a special enrollment period During the Annual Open Enrollment Period, people can buy individual insurance. It does not matter whether you are buying your very first individual plan, or replacing individual coverage that you already have. For 2016, the Annual Open Enrollment Period starts November 1, 2015 and continues through January 31, 2016. Coverage applied for during the Annual Open Enrollment Period by December 31 will begin January 1 of the next year. When the Annual Open Enrollment Period extends beyond December 31, as it will for 2016, coverage applied for after December 31 will be effective on the first day of the month following the month the application is received (so, an application received January 10 will have a coverage effective date of February 1). Some carriers allow effective dates on the 15th of the month (in which case, an application received January 10 could have an effective date of January 15.) Applications must be received during the Annual Open Enrollment Period to be considered.
What is The Health Insurance Marketplace?
Healthcare.gov is a health insurance exchange website operated under the United States federal government under the provisions of the Patient Protection and Affordable Care Act (ACA, often known as ObamaCare), designed to serve the residents of the thirty-six U.S. states that opted not to create their own state exchanges. The exchange facilitates the sale of private health insurance plans to residents of the United States and offers subsidies to those who earn less than four times the federal poverty line. If you would like help enrolling in the Marketplace or would like to know if you qualify for a subsidy, please contact our office at (973) 808-2888.
What is Medicare?
-People 65 or older
-People under 65 with certain disabilities
-People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)
What is Medicare Part A?
-Inpatient care in hospitals
-Skilled nursing facility (SNF) care
-Hospice care
-Home health care usually, you don�t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working. This is sometimes called premium-free Part A. If you aren�t eligible for premium-free Part A, you may be able to buy Part A, and pay a premium.
What is Medicare Part B?
-Services from doctors and other health care providers
-Outpatient care
-Home health care
-Durable medical equipment (DME)
-Some preventive services Most people pay the standard monthly Part B premium. Note: You may want to get coverage that fills gaps in Original Medicare coverage. You can choose to buy a Medicare Supplement Insurance (Medigap) policy from a private company.
What is Medicare Part C?
-Includes all benefits and services covered under Parts A and B
-Usually includes Medicare prescription drug coverage (Part D) as part of the plan
-Run by Medicare-approved private insurance companies
-May include extra benefits and services for an extra cost
What is Medicare Part D?
-Helps cover the cost of prescription drugs
-Run by Medicare-approved private insurance companies
-May help lower your prescription drug costs and help protect against higher costs in the future
How much does Medicare pay?
Part A premium
-Most people don't pay a monthly premium for Part A (sometimes called "premium-free Part A"). If you buy Part A, you'll pay up to $411 each month.

Part A hospital inpatient deductible and coinsurance
You pay:
-$1,288 deductible for each benefit period
-Days 1-60: $0 coinsurance for each benefit period
-Days 61-90: $322 coinsurance per day of each benefit period
-Days 91 and beyond: $644 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
-Beyond lifetime reserve days: all costs

Part B premium
-Most people pay $104.90 each month.

Part B deductible and coinsurance
-$166 per year. After your deductible is met, you typically pay 20% of the amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy, and durable medical equipment.

Part C premium
-The Part C monthly premium varies by plan.

Part D premium
-The Part D monthly premium varies by plan (higher-income consumers may pay more
Who can get Medicare Part D?
Everyone with Medicare is eligible for this coverage, regardless of income and resources, health status, or current prescription expenses.Everyone with Medicare is eligible for this coverage, regardless of income and resources, health status, or current prescription expenses.
How does Medicare Part D coverage work?
Your decision about Medicare prescription drug coverage depends on the kind of health care coverage you have now. There are two ways to get Medicare prescription drug coverage. You can join a Medicare prescription drug plan or you can join a Medicare Advantage Plan or other Medicare Health Plan that offers drug coverage.

Whatever plan you choose, Medicare drug coverage will help you by covering brand-name and generic drugs at pharmacies that are convenient for you.

Like other insurance, if you join, generally you will pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay a part of the cost of your prescriptions, including a copayment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible.
Why should I get Medicare Part D coverage?
Medicare prescription drug coverage provides greater peace of mind by protecting you from unexpected drug expenses. Even if you don't use a lot of prescription drugs now, you should still consider joining. As we age, most people need prescription drugs to stay healthy. For most people, joining now means protection from unexpected prescription drug bills in the future.
What if I have a limited income and resources?
There is extra help for people with limited income and resources. If you qualify for extra help, Medicare will pay for almost all of your prescription drug costs. You can apply or get more information about the extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778)
chevron-down