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Home > Insurance Division > Individual Health Coverage Program >  Buyer's Guide
Eligibility
NJ Individual Health Coverage Program Buyer's Guide
You are eligible to purchase an individual plan if you are:

1. A resident of New Jersey; and
2. Not eligible for coverage under Medicare
 
Residency:


A New Jersey resident is defined as someone whose primary residence is in New Jersey. 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.

You must provide proof that you are a resident of New Jersey. The proof often takes the form of a utility bill, a bank account, a NJ driver's license or student ID. A letter addressed to you at a NJ address is not proof of residence.

 
Medicare:


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.

  1. 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.

  2. 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 you have an individual plan when you become eligible for Medicare, you may choose to keep your individual plan. But note:

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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.

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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:

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contact your County Office on Aging

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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/

Check mark 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.

 
Who is a Dependent Eligible to be Covered Under an Individual Plan?

Individual health coverage may also cover your eligible dependents. Dependent is defined to mean your:

1. Spouse; and
2. Dependent child who is under age 26.

Defining "Spouse"

In the individual plans, the term "spouse" includes:

1. An individual legally married to you under the laws of the State of New Jersey or under the laws of another jurisdiction,
2. Your Domestic Partner pursuant to New Jersey law at P.L. 2003, c. 246,
3. Your Civil Union Partner pursuant to New Jersey law at P.L. 2006, c. 103; and
4. A person legally joined to you in a same sex relationship in another jurisdiction if such relationship provides substantially all of the rights and benefits of marriage.

Defining "Dependent Child"

In the individual plans, the term "dependent child" includes:

1. Your biological child,
2. Your legally adopted child (including children placed in the home for the purposes of adoption),
3. Your step-child,
4. Your foster child,
5. The child of Your Domestic Partner or Civil Union Partner,
6. Children under a court appointed guardianship,
7. Any other child over whom You have legal custody or legal guardianship or with whom You have a legal relationship or a blood relationship, provided the child depends on You for most of the child’s support and maintenance and resides in Your household; (If you buy an individual policy through the Marketplace the children listed in this item 7 are not eligible.) and
8. A child age 26 or older who has a mental, developmental or physical disability who is unmarried and incapable of earning a living, but only if: (a) the child's condition started prior to age 26 and while the child was covered under your plan; (b) the child remains continuously covered under your plan; and (c) the child depends on you for most of his or her support and maintenance.

Please note
that the law allowing certain children to remain covered under the same group plan as a parent up to age 31 does not apply to individual plans. If you have a child who is not eligible under your policy as a dependent, he or she may be eligible to purchase his or her own individual plan.


Frequently Asked Questions About Eligibility and Dependent Eligibility
 
Question 1: May I purchase an individual plan if I live in another state during part of the year?
  Yes, provided New Jersey is your primary residence. The policyholder is required to be a New Jersey resident. The residency requirement does not apply to dependents.  However, for coverage under an HMO, everyone intended to be covered must live in the HMO’s service area. 
   
Question 2: My parents are coming to visit me from abroad. They will be staying with me for about 4 months. May I buy a plan to cover them while they are in New Jersey?
  No, visitors do not generally satisfy the residency requirement and should investigate coverage available where they reside.
   
Question 3: I just moved to New Jersey, may I purchase an individual plan?
  Yes, if you relocate to New Jersey with the intention of making New Jersey your primary residence, and meet all other eligibility requirements, you may purchase individual coverage.
   
Question 4: May I keep my New Jersey individual plan if I move out of state?
  No, because you will no longer meet the residency requirement. However, your carrier or another carrier may offer a plan with similar benefits in other states. You should check with your insurance company or HMO regarding a plan termination date before you move.
   
Question 5: May I keep my New Jersey individual plan if I become eligible for Medicare?
  Yes. However, the individual plan will not act like a Medicare Supplement Plan and it will not replace Medicare coverage. The benefits for which you are eligible under Medicare will be coordinated with the benefits of the individual plan whether or not you actually enroll in Medicare. Medicare would pay benefits first, and then the individual plan would pay benefits as the secondary payor. In addition, the only individual plan you may be covered under once you become eligible for Medicare is the plan you are covered under at the time you become eligible for Medicare. You may not elect another individual plan or plan option or switch to another carrier.
   
Question 6:  I need family coverage, not just individual coverage.  How do I get coverage for my family? 
  It is called individual coverage because you are buying it on your own rather than getting the coverage through an employer group plan.  If the members of your family qualify as dependents, they can also be covered under your individual plan.
   
Question 7: My son is covered under the group plan I have from my employer but he will turn 26 soon. May I purchase a short-term policy to cover him until he finds a job that offers group health coverage?
 

No, there are no "short-term" plans available in New Jersey.  However, your son still has options:

  • He (or you) may purchase an individual plan for him and decide to keep it only until he becomes covered under a group plan. 
  • He could continue his coverage under your group health plan through a federal COBRA election or a New Jersey small group continuation election. Check with your employer. Both of these continuation laws allow your son to continue coverage under your group plan for up to 36 months. 
  • He 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).  For more information see www.state.nj.us/dobi/division_consumers/du31.htm
   
Question 8: If I cover my children under my individual plan, up to what age will they be covered?
  Typically, you may cover your child until the end of month following 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. 
   
Question 9: Can I purchase coverage for a child or 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. To compare the child rates of all of the plans, see the rate comparison chart.

Or you may want to explore whether your children are eligible for NJFamilyCare, which covers children in families with income up to 350% of the federal poverty level. For more information about NJFamilyCare, call 1-800-701-0710 or go online to www.njfamilycare.org.
   
Question 10: My grandchildren live with me and I am responsible for their care and support, but I am not their legal guardian. I am covered under an individual plan. May I add them for coverage under my individual plan?
  Yes, if your individual plan was not purchased through the Marketplace. A dependent child, for the purpose of an individual plan, includes a child related to you by blood, if the child depends on you for most of the child’s support and maintenance and resides in your household.

If you bought your individual plan through the Marketplace your grandchildren are not eligible dependents unless you have legal guardianship.
   
Question 11: If I waive coverage under Medicare, may I purchase an individual plan?
 

Yes. 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.

  1. 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.

  2. 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 you are concerned that Medicare may not provide adequate coverage, you may purchase another type of health plan specifically designed to supplement Medicare coverage. You may obtain free information on plans that supplement Medicare by:

   
Question 12: May I purchase an individual plan if I am eligible for coverage under COBRA or New Jersey State continuation? 
  Yes. Although COBRA and New Jersey Small Group continuation elections result in continuation of coverage under a group plan, you are still eligible to purchase an individual plan. See the section on Enrollment for information concerning when you may purchase an individual plan. Once you purchase an individual plan, you will have to terminate your group health coverage elected under COBRA or New Jersey Small Group continuation.
   
Question 13:  May I purchase an individual plan if I am eligible for coverage as a dependent under age 31 under P.L. 2005, c. 375?
  Yes.  Although when you make a Dependent Under 31 election, you are continuing coverage under a group plan, such coverage does not preclude you from purchasing an individual plan. If you continue through a Dependent Under 31 election you can later purchase an individual plan during the Annual Open Enrollment Period or during a Special Enrollment Period, if any applies.
   
Question 14: May I purchase an individual plan if I actually have group coverage?
  Yes.  Just remember, you cannot be covered under both an individual and group plan.  You must terminate your coverage under the group plan no later than the day before the individual plan will take effect. See the section on Enrollment for information concerning when you may purchase an individual plan.
   
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