Key Takeaways
- New Jersey requires a 10-day free look period for individual health insurance policies
- New Jersey Individual Health Coverage Program (IHC) provides guaranteed issue for individual coverage
- New Jersey Small Employer Health Benefits Program (SEH) covers groups of 2-50 employees
- Pre-existing condition exclusions are prohibited in New Jersey individual and small group markets
- New Jersey operates through the federal health insurance marketplace (Healthcare.gov)
New Jersey Health Insurance Policy Requirements
New Jersey has comprehensive health insurance regulations that protect consumers. Understanding these state-specific rules is essential for the licensing exam.
Regulatory Structure
New Jersey health coverage is primarily regulated by DOBI:
| Program | Coverage |
|---|---|
| Individual Health Coverage (IHC) | Individual market plans |
| Small Employer Health Benefits (SEH) | Groups of 2-50 employees |
| Large Group Market | Groups of 51+ employees |
Key Programs
Individual Health Coverage Program (IHC):
- Established in 1992
- Provides guaranteed issue for individuals
- Standardized plan types
- Community-rated premiums
Small Employer Health Benefits Program (SEH):
- Covers employers with 2-50 employees
- Guaranteed issue for small groups
- Standardized plans available
- Cannot deny coverage based on health
Free Look Period
New Jersey provides a 10-day free look period for individual health insurance:
- Policyholder can return for full premium refund
- Begins when policy is delivered
- Applies to individual health policies
- No penalty for exercising the free look
Required Coverage
New Jersey mandates coverage for numerous benefits under Essential Health Benefits:
Essential Health Benefits
All individual and small group plans must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Mental Health Parity
New Jersey requires mental health parity:
- Mental health benefits equal to medical benefits
- Same copays, deductibles, and limits
- Covers severe mental illness and substance use
- Applies to group and individual plans
Covered Conditions
- Schizophrenia
- Bipolar disorder
- Major depression
- Autism spectrum disorders
- Substance use disorders
- Other mental health conditions
Pre-Existing Condition Protections
New Jersey prohibits pre-existing condition exclusions:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual (IHC) | Prohibited |
| Small Group (SEH) | Prohibited |
| Large Group | Limited restrictions apply |
New Jersey Marketplace
New Jersey uses Healthcare.gov (federal marketplace):
- Individuals purchase coverage through federal marketplace
- Premium tax credits available based on income
- Open enrollment and special enrollment periods
- Navigators and certified application counselors available
Key Features
- Plans categorized by metal tiers (Bronze, Silver, Gold, Platinum)
- Premium subsidies based on income
- Cost-sharing reductions for Silver plans
- Special enrollment for qualifying life events
Guaranteed Issue and Renewal
New Jersey requires:
Guaranteed Issue
- Insurers must accept all applicants in IHC and SEH programs
- Cannot deny coverage based on health status
- Applies to individual and small group markets
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with notice)
What is the size range for employers covered under the New Jersey Small Employer Health Benefits (SEH) Program?
How long is the free look period for individual health insurance policies in New Jersey?