• You have to be eligible for the group health plan. For example, your employer may not give health benefits to all employees. Or, your employer may offer an HMO plan that you cannot join because you live outside of the plan’s service area.
• You cannot be turned away or charged more because of your health status. Health status means your medical condition or history, genetic information, or disability. This protection is called nondiscrimination. Employers may refuse or restrict coverage for other reasons (such as part-time employment), as long as these are unrelated to health status and applied consistently.

Discrimination due to health status is not permitted

The Acme Company has 200 employees and offers two different health plans. Full time employees are offered a high option plan that covers prescription drugs; part time employees are offered a low option plan that does not.  This is permitted under the law. By contrast, in a cost-cutting move, Acme restricts its high option plan to those employees who can pass a physical examination. This is not permitted under the law.

• When you begin a new job, your employer may require a waiting period before you can sign up for health coverage. This waiting period, however, must be applied consistently and cannot vary due to your health status.
• When you begin a new job with health coverage through an HMO, the HMO may require a waiting period before coverage begins. This waiting period is called an HMO affiliation period, and you will not have health insurance coverage during this time. An affiliation period cannot exceed 2 months (3 months for late enrollees), and you cannot be charged a premium during it. In New Jersey, affiliation periods are not permitted in the individual or small group markets.
• You must be given a special opportunity to sign up for your group health plan if certain changes happen to your family. In addition to any regular enrollment period your employer or group health plan offers, you must be offered a special, 30-day opportunity to enroll in your group health plan after certain events. You can elect coverage at this time. If your group plan offers family coverage, your dependents can elect coverage as well. Enrollment during a special enrollment period is not considered late enrollment.

Certain changes can trigger a special enrollment opportunity

•  
  •  
    • The birth, adoption, or placement for adoption of a child
    • Marriage
    • Loss of other health insurance (for example, that you or your dependents had through yourself or another family member and lost because of death, divorce, legal separation, termination, retirement, or reduction in hours worked)
• Under New Jersey law, newborns and adopted newborns are automatically covered under the parents’ fully insured group health plan for the first 31 days, if the plan covers dependents. The insurer may require that the parent enroll the baby within the 31 days in order to continue coverage beyond the 31 days.
• If a fully insured group health plan covers dependents, then it must extend coverage to domestic partners of covered enrollees. Under New Jersey law, domestic partners of covered enrollees are considered eligible dependents for the purposes of fully insured group health plan.
• Under New Jersey law, disabled adult children can remain on their parent’s fully insured group health plan after reaching the age at which dependent coverage is usually terminated, if they meet certain requirements. Your adult child must be incapable of self-sustaining employment by reason of the disability and remain dependent on you for support. Proof of incapacity must be furnished to the plan within 31 days of the child reaching the age at which dependent coverage would normally end. The plan can require you to continue furnishing proof of disability and dependency in the future.

•·           To be eligible for the tax credit, you must be receiving Trade Adjustment Assistance (TAA) benefits or retirement benefits from the PBGC.  If you are receiving PBGC benefits, you also must be at least 55 years old.

• In addition, you must meet other requirements. Specifically, you are not eligible for the HCTC if any of the following apply to you:
• o You have a health plan maintained by an employer or former employer that pays at least 50% of the cost of your coverage. Any share of your premium that is paid by you or your spouse on a pre-tax basis is considered to have been paid by your employer and must be included as such when determining the percentage of employer coverage.
• In New Jersey, fully insured group plans must extend dependent coverage to eligible children up to the age of 30.
• o You must have a qualifying event. You must have reached, or about to reach, the age, defined under the terms of the coverage, which you would otherwise lose eligibility for coverage under a fully insurance group health plan that is regulated by the State of New Jersey. This age may vary plan to plan. In addition, your sponsoring parent must still be enrolled in a fully insured group health plan that is regulated by the State of New Jersey.
• o You must meet other requirements. You must be under the age of 30 and single with no children of your own. You cannot be covered under any other health benefit plan or be eligible for Medicare. You have to be either a resident of New Jersey or, if you live out of state, a full time student.
• o You must elect this extension of coverage. If you are eligible and you want to avoid a break in coverage, you must elect in writing within 30 days prior to the qualifying event.

You can also elect later but then, for fully insured large group plans, you must wait until the plan’s open enrollment period. Fully insured small group plans must give you the right to elect annually, during the 30 days following the anniversary date that you aged off the plan.

Finally, if you cannot elect at the time of your qualifying event because you do not meet all of the eligibility requirements (e.g. you’re a resident of another state), but subsequently meet the eligibility requirements (e.g. you move back to New Jersey), you can elect within 30 days of meeting the requirements for eligibility.

• o You do not have to maintain continuous enrollment to maintain eligibility for this extension of coverage. You are permitted to re-enroll as many times as you want during the time between your qualifying event and the age of 30, however you may have to wait, unless you are re-establishing eligibility (e.g. you move back to New Jersey), until the annual opportunity to enroll. However, if you have a lapse in coverage, you may face a pre-existing condition exclusion period.
• o Employers are not required to contribute to your premium. In most cases, you will be required to pay the entire cost of the premium.
• If you have to take leave from your job due to illness, the birth or adoption of a child, or to care for a seriously ill family member, you may be able to keep your group health plan for a limited time. A federal law known as the Family and Medical Leave Act (FMLA) guarantees you up to 12 weeks of job-protected leave in these circumstances.

The FMLA applies to you if you work at a company with 50 or more employees.

If you qualify for leave under FMLA, your employer must continue your health benefits.  You will have to continue paying your share of the premium.

If you decide not to return to work at the end of the leave period, your employer may require you to pay back the employer’s share of the health insurance premium. However, if you don’t return to work because of factors outside your control (such as a need to continue caring for a sick family member, or because your spouse is transferred to a job in a distant city), you will not have to repay the premium.

For more information about your rights under the FMLA, contact the U.S. Department of Labor.