New Jersey Small Group Health (2-50 Employees)
What is the NJ Small Employer Health Benefits Program Act?
Can I purchase small group coverage if I am a self-employed husband and wife with no other employees?
Does the employer have to contribute a certain amount of premium?
Am I required by law to provide health benefits for my employees?
How does a carrier determine the rates for my group?
Will my rates change if I deal directly with the insurance carrier instead of using a broker?
What is an employee?
Do I include employees from other companies that I own?
When is an employer subject to the Medicare Secondary Provision (TEFRA/DEFRA)?
When is an employer subject to COBRA?
Am I required to cover a certain percentage of eligible employees?
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?
How do I know if I qualify as a small employer?<br />
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;
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?
Can I offer different plans by class of employee?
Is there a limit to the number of employees that can work outside of NJ?
What is an Open Access POS plan?
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?
New Jersey Individual Health
May I purchase an individual plan if I live in another state during part of the year?
May I keep my New Jersey individual plan if I become Medicare eligible?
If I waive coverage under Medicare, may I purchase an individual plan?
To what age can my children be covered as a dependent on my individual plan?
Can I purchase an individual plan if I am eligible for coverage under COBRA or NJ Continuation?
If I have group coverage may I purchase an individual plan?
Can I be eligible for individual coverage if I don't have a social security number?
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?
Can I change to another individual plan whenever I want during the year?
What is Medicare?
-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?
-Skilled nursing facility (SNF) care
-Home health care usually, you dont 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 arent eligible for premium-free Part A, you may be able to buy Part A, and pay a premium.
What is Medicare Part B?
-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?
-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?
-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
-$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?
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.