N.J. Admin. Code § 11:21-7.5

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:21-7.5 - Participation requirements

(a) A small employer carrier shall require a minimum participation under the small employer's health benefits plan of 75 percent of full-time employees (where full-time means 25 or more hours per week for purposes of eligibility for coverage and participation requirements) who are not serving under a waiting period as permitted under 11:21-7.8(d), except as set forth in (b) below. This participation requirement shall be applied by the small employer carrier uniformly among all health benefits plans and all small employers. 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:

1. Is covered as an employee or dependent under any fully insured health benefits plan offered by the small employer;

2. Is covered under Medicare;

3. Is covered under Medicaid or NJ FamilyCare;

4. Is covered under another group health benefits plan;

5. Is covered under a spouse's group health benefits plan;

6. Is covered under Tricare; or

7. With respect to Small Business Health Options Program coverage only, is covered under an individual plan.

(b) A small employer carrier may, upon approval by the Board, require a minimum participation of less than 75 percent provided that the small employer carrier:

1. Notifies the Board in writing of its minimum requirement;

2. Explains why the lesser requirement is reasonable; and

3. Applies the requirement uniformly to all small employer health benefits plans and to all small employers.

(c) The Board shall notify the small employer carrier in writing within 60 days of the small employer carrier's filing with the Board whether such request is approved.

(d) A small employer carrier shall not require a minimum participation under the small employer's health benefits plan of 75 percent of full-time employees with respect to employer applications received during the employer annual open enrollment period.

N.J. Admin. Code § 11:21-7.5

Amended by 48 N.J.R. 2360(a), effective 11/7/2016