N.J. Admin. Code § 11:4-23A.6

Current through Register Vol. 56, No. 23, December 2, 2024

Section 11:4-23A.6 - Open enrollment

(a) The Under 50 Plan shall not deny or condition the issuance or renewal, nor discriminate in the pricing of coverage because of the health status, claims experience, receipt of health care or medical condition of an applicant if the application for coverage is submitted under the circumstances and within the time frames specified below:

1. When an individual is eligible for benefits under Medicare Part B, and the application is submitted during the six-month period beginning with the first month in which the individual is enrolled for benefits under Medicare Part B;

2. Where there is a retroactive determination of Medicare eligibility, and the application is submitted during the six-month period beginning with the month in which the retroactive determination is made;

3. Where an individual is no longer eligible under a plan that is considered creditable coverage or such a plan terminates or ceases to provide benefits, and the application is submitted within 63 days of the applicant losing creditable coverage;

4. Where an individual was enrolled under an employee welfare benefit plan that provided health benefits that supplement Medicare benefits and that plan terminates or ceases to provide all Medicare supplemental health benefits, or the plan is primary or secondary to Medicare and the plan terminates, ceases to provide all health benefits to the individual, or the individual leaves the plan, and the application is submitted within 63 days from the date the individual receives a notice of termination or a claim denial due to termination, or within 63 days after the health coverage ends;

5. Where an individual elects COBRA coverage and chooses to terminate his or her COBRA coverage before the maximum coverage period is reached, or the COBRA coverage period is exhausted, and the application is submitted within 63 days of the date on which the COBRA coverage terminated;

6. Where an individual who is enrolled in a Medicare + Choice plan, Medicare managed care plan, Medicare private-fee-for-service plan, Medicare risk or cost contract, a plan offered by a similar organization operating under demonstration project authority, a health care prepayment plan or a Medicare SELECT plan, and his or her enrollment ends for reasons specified in (a)6iii below, such an individual's application shall be subject to the following requirements:

i. In connection with an involuntary termination, an application shall be submitted during the period beginning on the date the individual receives a notice of termination and ending 63 days after the date their coverage is terminated;

ii. In connection with a voluntary termination, the application shall be submitted during the period beginning 60 days before the disenrollment effective date and ending 63 days after the disenrollment effective date.

iii. The reasons for termination of enrollment that will trigger the applicability of this paragraph are:

(1) The organization's or plan's certification under Part C of Medicare has been terminated or will be terminated;

(2) The plan is leaving the Medicare program;

(3) The organization has discontinued providing the plan or will be discontinuing the plan in the area where the enrollee resides;

(4) The demonstration project has ended;

(5) The enrollee moves out of the service area;

(6) The individual demonstrates that the organization substantially violated a material provision of the policy (with respect to the individual), such as failure to provide covered care on a timely basis or adhere to quality standards; or

(7) The organization, agent or other entity acting in the organization's behalf materially misrepresented the policy provisions in marketing.

7. Where an individual is enrolled under a Medicare Supplement policy and the enrollment ceases due to the bankruptcy or insolvency of the issuer, or to other involuntary termination of the coverage under the policy, and the application is submitted during the time period beginning on the earlier of the date the individual receives a notice of termination, bankruptcy or insolvency or other such similar notice, if any, and the date on which their prior coverage terminated and ending 63 days after the prior coverage is terminated.

8. Where an individual is enrolled under a Medicare Supplement policy and enrollment ends because the issuer substantially violated a material provision of the policy, or because the issuer, its agent, or another entity acting on the issuer's behalf materially misrepresented the policy provisions in marketing the policy, and the application is submitted during the period beginning on the disenrollment effective date and ending 63 days after the disenrollment effective date. However, if in such a situation the termination is voluntary, the period shall begin 60 days before the disenrollment effective date and end 63 days after the disenrollment effective date.

9. Where an individual is enrolled under a Medicare supplement policy, including the Under 50 Plan, terminates enrollment, and subsequently enrolls, for the first time, in a Medicare + Choice plan, a Medicare managed care plan, a Medicare private-fee-for-service plan, a Medicare risk or cost contract, a plan offered by a similar organization operating under demonstration project authority, a health care prepayment plan, or a Medicare SELECT plan, and thereafter terminates enrollment within the trial period, and the application is submitted during the period beginning 60 days before the disenrollment effective date and ending 63 days after the disenrollment effective date. For the purposes of this subsection, the trial period is whichever of the following that occurs first: 12 months of continuous enrollment in any one plan of the types listed above, or 24 months of continuous enrollment in any two or more plans of the types listed above.

(b) Nothing in (a) above shall be construed to prohibit the exclusion of benefits during the first three months, based on a pre-existing condition for which the insured received treatment or was otherwise diagnosed during the six months before the policy or contract became effective, except that:

1. The pre-existing condition exclusion shall not apply to individuals who submit an application under the circumstances and in the time periods referenced in (a)4, 6, 7, 8 or 9 above; and

2. The pre-existing condition exclusion shall be reduced by the amount of time the applicant had a continuous period of creditable coverage, if he or she submits an application under the circumstances and during the time periods referenced in (a)2, 3 and 5 above.

(c) The effective date of coverage by the Under 50 Plan is the first day of the month following the date an applicant enrolls in the Under 50 Plan and makes a premium payment.

N.J. Admin. Code § 11:4-23A.6

Amended by R.2004 d.86, effective 3/1/2004.
See: 35 New Jersey Register 2565(a), 36 New Jersey Register 1194(a).
Rewrote the section.