New Jersey Dependent Coverage Change

Transcription

1 SPECIAL NOTICE FOR OXFORD PRODUCERS New Jersey Dependent Coverage Change At Oxford Health Plans, we want to keep you informed of any changes that occur with your clients benefits plans. In accordance with recent legislation passed by the New Jersey legislature, groups 1 insurance carriers are required to provide coverage allowing certain dependents to be insured under their group plan until the age of 30, provided they meet the criteria outlined in the enclosed Frequently Asked Questions document. In order to obtain coverage, the dependent must submit a written request via the Temporary Supplemental Healthcare Information Networks & Technologies (Supplemental HINT) form. Any individual whose coverage was terminated prior to the effective date of May 12, 2006 and who meets the necessary criteria may make a written election to reinstate coverage at any time until May 11, If this request is not made during this 12-month period, the individual must wait for their group s open enrollment period. If an individual becomes eligible on or after May 12, 2006, the HINT form must be received within 30 days of the eligibility date. In the event that a person qualifies for coverage on or after May 12, 2006 and does not elect coverage within 30 days of the qualifying event, he or she cannot enroll until the next group open enrollment period. The enclosed Frequently Asked Questions document should provide a better understanding of how this legislation affects your clients coverage. For your reference, a copy of the Supplemental HINT form is available online at Please note: Employer groups will receive a similar letter in the mail within the next two weeks. We are committed to working with you on this issue. Please contact your sales representative with any questions. 1 This law only applies to fully insured groups. To unsubscribe from future communications, please send an with 'unsubscribe ' noted in the subject line to broker @oxfordhealth.com, or write to Broker Marketing - Oxford Health Plans, 55 Corporate Drive, Trumbull, CT Please include your full name and the name of your company in your request. MS May 2006

2 NJ Dependent Coverage to Age 30 Frequently Asked Questions Q) Who is eligible? A) Dependents must meet the following criteria: - Less than 30 years of age - Unmarried - Have no dependents of their own - Be a resident of the State of New Jersey. A state resident does not have to be a full-time student. However, if an individual does not live in New Jersey, they are still eligible if they are a full-time student at a private or public accredited institution of higher education - Not a subscriber or dependent under any other group or individual health benefits plan, group health plan or church health plan - Not covered under Medicare Q) What is the date of eligibility? A) There are three distinct situations that may determine the date of eligibility: 1) Any dependent whose coverage lapsed prior to May 12, 2006 is eligible to apply for coverage May 12, 2006 through May 11, Example: Jane turns 26 years old on February 20, She is eligible to apply for coverage on May 12, 2006 through May 11, ) If a dependent becomes eligible on May 12, 2006, they have 30 days from May 12 to enroll. 3) If a dependent becomes eligible after May 12, 2006, they must enroll within 30 days of the qualifying event. In situation 2 or 3 above, if the dependent does not enroll within the 30-day period, they must wait for the group s next open enrollment and follow the existing rules of enrollment. Open enrollment for Members enrolled through New Jersey small groups will take place on the anniversary of the qualifying events. Example: Sally turns 26 on December 15, She has until January 14, 2007 to enroll. If Sally does not enroll by January 14, her next opportunity to apply for coverage would be December 15, Q) How does a dependent enroll in this coverage? A) A dependent must complete and mail a Member Enrollment Form, as well as the Supplemental Temporary HINT form. The form is available online at Q) What is Oxford Health Plans requiring for eligibility? A) A completed Supplemental Temporary HINT form (#8831). The form is available online at Q) Will the dependent be retro-enrolled to the date the legislation became effective? A) No. NJ

3 Q) Does the legislation apply to any groups with New Jersey residents (i.e., Connecticut groups)? A) The coverage only applies if the policy is issued in New Jersey, regardless of the employees state of residency. For example, if a group is underwritten in New York and has a satellite office in New Jersey, the dependents of an employee working for the New Jersey office would not be eligible for coverage. Q) Can the dependent change plans during a group s open enrollment period if the group has multiple plan options? A) No. Since the dependent is tied to the employee (subscriber), only the subscriber can change plans. Q) Do the eligible dependent s covered expenses contribute to the family deductible and the family out-of-pocket maximum? A) Covered expenses do not apply to the family deductible and maximum out-of-pocket amounts. The covered expenses are applied as if the dependent had single coverage under the group contract Q) Is the dependent eligible for COBRA after age 30? A) No. Upon the termination of the over-age dependent continuation, the dependent is not eligible for COBRA or State of New Jersey Continuation. Q) If an individual is currently on COBRA, can they terminate their COBRA coverage and join as an over-age dependent? A) Yes. Please note that once they drop and elect the over-age coverage, they can not go back to COBRA or State of New Jersey Continuation. Q) Who will bill the dependent? A) Oxford Health Plans bills the dependent directly. The employer does not have any responsibility to administer the dependent s premium. Q) How is the rate for the over-age dependent being calculated? A) The rate will be calculated from a formula provided by the New Jersey Department of Banking and Insurance (DOBI), which is applied to each specific group and the subscriber s chosen plan. For small groups (2-50 lives), the rate will be calculated at.765 X the single rate For large groups (51+ lives), the rate will be calculated at.918 X the single rate Q) If an employee terminates their coverage, can the over-age dependent keep their coverage? A) No. The over-age dependent can only have coverage if the employee has coverage. Q) Will the over-age dependent appear on the group s bill? A) No. Since these individuals are being billed directly, they will not show up on the monthly group bill. Premium payment and eligibility are the responsibility of the dependent. Q) Does an employer have to contribute to the cost of an over-age dependent s coverage? A) No. NJ

4 Q) Must every employer enroll such dependents? Is this optional for the group? A) Every employer must comply. This is not optional. Oxford will issue each subscriber (including the over-aged dependent) a rider describing this provision. Q) If the over-age dependent enrolls on May 12, will their premium payment be pro-rated for the month? A) No. To align with Oxford Health Plans current billing practices, the dependent would be responsible for a full month s premium. Q) Will pre-existing condition limitations apply for eligible dependents? A) Yes, to the same extent that a pre-existing condition limitation may be applied to other dependents under the policy. Q) Can a group request that a TPA collect the premium for the over-age dependent? A) Yes Q) Will the dependent s coverage terminate on their 30 th birthday, or the end of the calendar year? A) To align with Oxford Health Plans current Age Off process, the dependent will be terminated December 31 of the year in which they turn 30. Q) Is the law applicable to self-funded groups (ASO)? A) No. Except for the coverage provided to State of New Jersey employees, this coverage applies only to fully insured groups and HMOs. * Please send completed forms to: Oxford Health Plans P.O. Box 7085 Bridgeport, CT NJ

5 Oxford Health Plans (NJ), Inc./Oxford Health Insurance, Inc. Temporary HINT Supplemental Enrollment Information Form Implementing P.L. 2005, c. 375 A. Group & Employee Information Group Name: Group Number: Employee Name: Employee ID Number: B. Type of Activity (see Important Explanatory Information below) Date of Event Change-Check all that apply / / Add dependent over the limiting age, but less than 30 / / Remove dependent over the limiting age, but less than 30 Reasons: / / Continuation of Coverage pursuant to P.L. 2005, c. 375 Coverage is being effected: During an Open Enrollment Within 30 days prior to attainment of limiting age Within 30 days after eligibility for other reasons During special 12-month enrollment C. Over-age Dependent Information Name (last, first, MI): Sex: M F Birthdate: (MM, DD, YY) / / SSN: Other Health Coverage: Yes No Other Rx Drug Coverage: Yes No Primary Office ID Number: Current Patient: Yes No Ob/Gyn Office ID Number: Current Patient: Yes No N/A OHPNJ MEF LS HINT SUPP 406 #8831

6 Previous Coverage: Yes No If yes, provide the following information AND submit a copy of the certificate of Creditable Coverage that was issued by the previous carrier, if available: Effective date of prior coverage: / / Termination date of prior coverage: / / Name of prior carrier: Prior plan number: D. Signature Employee Dependent Date Date OHPNJ MEF LS HINT SUPP 406 #8831