New Jersey Health Study Guide

New Jersey went its own way on health coverage twice over: it built a state exchange after using the federal one, and it kept an individual mandate after the federal penalty went to zero. Both facts are tested, and both are the sort of thing a national outline written a few years ago gets wrong. The other reliable source of marks is continuation coverage, where New Jersey’s numbers are shorter than the COBRA figures you have already memorised.

The marketplace, the mandate, and NJ FamilyCare

New Jersey runs a state-based exchange — Get Covered New Jersey, operated by DOBI. It left HealthCare.gov and ran its own platform beginning with the 2021 plan year.

It also enacted the New Jersey Health Insurance Market Preservation Act, which requires most residents to maintain coverage and collects a Shared Responsibility Payment through the state income tax return from those who do not. The federal penalty went to zero in 2019; New Jersey’s did not follow. Residents not required to file a New Jersey return fall outside it.

Medicaid expanded to 138% of the federal poverty level effective 1 January 2014, delivered through NJ FamilyCare — New Jersey’s combined Medicaid and CHIP programme, administered by the Department of Human Services rather than by DOBI.

Prompt pay — two clocks, and the paper one is 40

New Jersey splits its clean-claim deadline by how the claim arrived (N.J.A.C. 11:22-1.5, the Health Claims Authorization, Processing and Payment Act):

• 30 calendar days for a clean claim submitted electronically
• 40 calendar days for a clean claim submitted on paper

Miss either and interest runs at 12% a year, simple — 10% for dental plan organizations.

External appeal — IHCAP, and it binds

New Jersey’s Independent Health Care Appeals Program (IHCAP) is run by DOBI and decided by an Independent Utilization Review Organization, and its decision is binding on the carrier. A member files within four months of the final internal denial; the IURO decides within 45 days, or 48 hours on an expedited review.

Continuation — a gap-filler, with one number that trips people

Federal COBRA applies at 20 or more employees. New Jersey’s small-employer continuation exists to cover the employers COBRA does not reach, so the two fit together rather than competing. The duration matches — up to 18 months — and only the election window really differs:

• Who: small-employer group plans, roughly 2 to 50 employees
• How long: up to 18 months from the qualifying event — extended to 36 months for a spouse or dependent child on the covered employee’s death or a divorce
• Election: within 30 days of the termination or reduction in hours
• Cost: up to 102% of the group rate

Long-term care — the training New Jersey does require

Long-term care sits inside the Accident & Health line; New Jersey issues no separate LTC credential. What it does require is training, and the figures are specific: eight hours initially, then four hours every 24 months (N.J.A.C. 11:4-34.29). The producer must already hold life or accident-and- health authority, and the training may not be insurer- or product-specific — a carrier’s own product course does not discharge it.

The LTC free look is 30 days from delivery, with the premium refunded (N.J.S.A. 17B:27E-6(d)).