Affiliation Period. The time an HMO may require you to wait after you enroll and before your coverage begins.  HMOs that require an affiliation period cannot exclude coverage of pre-existing conditions.  Premiums cannot be charged during HMO affiliation periods.  See also HMO.

Alternative Trade Adjustment Assistance (ATAA). ATAA is a benefit for workers at least 50 years old who have obtained different, full-time employment within 26 weeks of the termination of adversely-affected employment. These workers may receive 50% of the wage differential (up to $10,000) during their 2 year eligibility period. To be eligible for the ATAA program, workers may not earn more than $50,000 per year in their new employment. Also, the firm where the workers worked must meet certain eligibility criteria.

Certificate of Creditable Coverage.  A document provided by your health plan that lets you prove you had coverage under that plan.  Certificates of creditable coverage will usually be provided automatically when you leave a health plan.  You can obtain certificates at other times as well.  See also Creditable Coverage.

COBRA.  Stands for the Consolidated Omnibus Budget Reconciliation Act, a federal law in effect since 1986.  COBRA permits you and your dependents to continue in your employer’s group health plan after your job ends.  If your employer has 20 or more employees, you may be eligible for COBRA continuation coverage when you retire, quit, are fired, or work reduced hours.  Continuation coverage also extends to surviving, divorced or separated spouses; dependent children; and children who lose their dependent status under their parent’s plan rules. You may choose to continue in the group health plan for a limited time and pay the full premium (including the share your employer used to pay on your behalf).  COBRA continuation coverage generally lasts 18 months, or 36 months for dependents in certain circumstances.  See also State Continuation Coverage.

Community Rating.  A rule that prohibits health plan premiums in New Jersey from varying based on your age, gender, health status, or occupation.  Individual health policy premiums, except in regards to the Basic and Essential Plan, are subject to community rating.

Continuous Coverage.  If you are joining a self-funded group health plan or if you want to be HIPAA eligible, health insurance coverage is continuous if it is not interrupted by a break of 63 or more consecutive days.  Employer waiting periods and HMO affiliation periods do not count as gaps in health insurance coverage for the purpose of determining if coverage is continuous.  See also Creditable Coverage, HIPAA eligible, Fully Insured Group Health Plan, Individual health insurance, Self-funded Group Health Plan.

Conversion Policy.  Your right, when losing coverage under fully insured group health plans due to divorce in New Jersey, to convert your policy into an individual health insurance policy. You will not face a new pre-existing condition exclusion period.  Your conversion policy will be similar to individual health insurance policies offered to individuals.

Creditable Coverage.  Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance in Colorado; Medicare; Medicaid; CHAMPUS and TRICARE (health coverage for military personnel, retirees, and dependents); the Federal Employees Health Benefits Program; Indian Health Service; the Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, a foreign country); State Children’s Health Insurance Program; or a state health insurance high risk pool.  See also Continuous Coverage, Group Health Plan, Individual Health Insurance.

Enrollment Period.  The period during which all employees and their dependents can sign up for coverage under an employer group health plan.  Besides permitting workers to elect health benefits when first hired, many employers and group health insurers hold an annual enrollment period, during which all employees can enroll in or change their health coverage.  See also Group Health Plan, Special Enrollment Period.

Elimination Rider (or waiver).  An amendment permitted in individual health insurance policies in some states that permanently excludes your coverage for a health condition, body part, or body system.  Elimination riders are not permitted in New Jersey.

Family and Medical Leave Act (FMLA). A federal law that guarantees up to 12 weeks of job-protected leave for certain employees when they need to take time off due to serious illness, to have or adopt a child, or to care for another family member.  When you qualify for leave under FMLA, you can continue coverage under your group health plan.

Fully Insured Group Health Plan. A health plan purchased by an employer from an insurance company.  Fully insured health plans are regulated by New Jersey.  See also Self-funded Group Health Plans.

Genetic Information.  Includes information about family history or genetic test results indicating your risk of developing a health condition.  A health plan cannot consider pre-existing (and therefore exclude coverage for) a condition about which you have genetic information, unless that health condition has been diagnosed by a health professional.

Group Health Plan.  A health plan (usually sponsored by an employer, union or professional association) that covers at least 2 employees.  See also Fully Insured Group Health Plan, Self-funded Group Health Plan.

Guaranteed Issue.  A requirement that health plans must permit you to enroll regardless of your health status, age, gender, or other factors that might predict your use of health services.  All health plans sold to individuals and small employers with 2 to 50 employees in New Jersey are guaranteed issue.  Plans that are guaranteed issue can only turn you away for other reasons permitted under by law.

Guaranteed Renewability.  A feature in health plans that means your coverage cannot be canceled because you get sick.  HIPAA requires all health plans to be guaranteed renewable.  The precise definition of guaranteed renewable may vary based on what type of insurance you have.   Your coverage can be canceled for other reasons unrelated to your health status.

Health Coverage Tax Credit (HCTC). The Health Coverage Tax Credit (HCTC) is a program that can help pay for nearly two-thirds of eligible individuals’ health plan premiums. In general, in order to be eligible for the health coverage tax credit, you must be 1) receiving Trade Readjustment Allowance benefits (TRA), or 2) will receive TRA benefits once your unemployment benefits are exhausted, or 3) receiving benefits under the Alternative Trade Adjustment Assistance (ATAA) program, or 4) aged 55 or older and receiving benefits from the Pension Benefit Guaranty Corporation (PBGC).

Health Insurance or Health Plan.  In this guide, the term means benefits consisting of medical care (provided directly or through insurance or reimbursement) under any hospital or medical service policy, plan contract, or HMO contract offered by a health insurance company or a group health plan.  It does not mean coverage that is limited to accident or disability insurance, workers’ compensation insurance, liability insurance (including automobile insurance) for medical expenses, or coverage for on-site medical clinics.  Health insurance also does not mean coverage for limited dental or vision benefits to the extent these are provided under a separate policy.

Health Plan Year.  That calendar period during which your health plan coverage is in effect.  Many group health plan years begin on January 1, while others begin in a different month.

Health Status.  When used in this guide, refers to your medical condition (both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), and disability.  See also Genetic Information.

HIPAA.  The Health Insurance Portability and Accountability Act, sometimes known as Kassebaum-Kennedy, after the two senators who spearheaded the bill.  Passed in 1996 to help people buy and keep health insurance, even when they have serious health conditions, the law sets a national floor for health insurance reforms.  Since states can and have modified and expanded upon these provisions, consumers’ protections vary from state to state.

HIPAA Eligible.  Status you attain once you have had 18 months of continuous creditable health coverage.  To be HIPAA eligible, you also must have used up any COBRA or state continuation coverage; you must not be eligible for Medicare or Medicaid; you must not have other health insurance; and you must apply for individual health insurance within 63 days of losing your prior creditable coverage. No matter where you live in the U.S., if you are HIPAA eligible you must be offered at least some type of individual health insurance with no pre-existing condition periods.  In New Jersey, you do not need to meet all the requirements of HIPAA eligibility to have this protection.  See also COBRA, Continuous Coverage, Creditable Coverage, State Continuation Coverage.

HMO.  Health maintenance organization.  A kind of health plan.  HMOs usually limit coverage to care from doctors who work for or contract with the HMO.  They generally do not require deductibles, but often do charge a fee, called a copayment, for services like doctor visits or prescriptions. If you are covered under an HMO, the HMO might require an affiliation period before coverage begins.  See also Affiliation Period, Point-of-Service (POS).

Indemnity Health Plan.  A kind of health plan that reimburses you or your health care provider on the basis of services rendered. Indemnity plans generally do not restrict you to a limited network of providers for covered care.  However, indemnity plans often impose other restrictions on covered services. For example, plans can require prior authorization of hospital care or other expensive services.

Individual Health Insurance.  Policies for people not connected to an employer group.  Individual health insurance is regulated by New Jersey.  All residents without access to employer-sponsored or government-sponsored health insurance can buy coverage for themselves and their families from a variety of private insurance companies.  All individual policies offer standardized benefits and are community rated.  See also Community Rating.

Large Group Health Plan.  One with more than 50 employees.

Late Enrollment.  Enrollment in a health plan at a time other than the regular or a special enrollment period.  If you are a late enrollee, you may be subject to a longer pre-existing condition exclusion period.  See also Special Enrollment Period.

Look Back.  The maximum length of time, immediately prior to enrolling in a health plan, that can be examined for evidence of pre-existing conditions.  See also Pre-existing Condition.

Medicaid.  A program providing comprehensive health insurance coverage and other assistance to certain low-income people living in New Jersey.  All other states have Medicaid programs, too, though eligibility levels and covered benefits will vary.

Modified Community Rating. A rule that prohibits insurers from varying premiums based on health status, while allowing premiums to vary based on other factors, such as age, gender and geographic location. 

New Jersey Cancer Education and Early Detection Screening Program (NJCEED). A program provding qualified men and women with comprehensive screening services for breast, cervical, prostate, and colorectal cancer.  In addition, a woman screened through NJCEED and diagnosed with breast or cervical cancer may be eligible for treatment through Medicaid.

NJ Family Care.   A program that provides insurance for children under the age of 19 who are uninsured and are not eligible for Medicaid.

Nondiscrimination.  A requirement that group health plans not discriminate against you based on your health status.  Your coverage under a group health plan cannot be denied or restricted, nor can you be charged a higher premium, because of your health status.  Group health plans can restrict your coverage based on other factors (such as part time employment) that are unrelated to health status.  See also Group Health Plan, Health Status.

Pension Benefit Guaranty Corporation (PBGC). PBGC is a federal government corporation established by Title IV of the Employee Retirement Income Security Act of 1974 (ERISA) to encourage the continuation and maintenance of defined benefit pension plans, provide timely and uninterrupted payment of pension benefits to participants and beneficiaries in plans covered by PBGC. It currently guarantees payment of basic pension benefits earned by American workers and retirees participating in private-sector defined benefit pension plans. The agency receives no funds from general tax revenues. Operations are financed largely by insurance premiums paid by companies that sponsor pension plans and by PBGC’s investment returns.

Point-of-Service (POS).  A type of managed care plan that lets you decide whether to get care from providers in or out of the HMO network.  When you get care in-network, your out-of-pocket costs will be less than if you get care outside of the network.  See also HMO. 

Pre-existing Condition.  Any condition (either physical or mental) for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period immediately preceding enrollment in a health plan.  For group coverage, pregnancy cannot be counted as a pre-existing condition.  Genetic information about your likelihood of developing a disease or condition, without a diagnosis of that disease or condition, cannot be considered a pre-existing condition.  Newborns, newly adopted children, and children placed for adoption covered within 30 days cannot be subject to pre-existing condition exclusions.

Pre-existing Condition Exclusion Period.  The time during which a health plan will not pay for covered care relating to a pre-existing condition.  See also Pre-existing Condition.

Prudent Person Rule.  In individual health insurance only, a rule that permits insurers to exclude as pre-existing any condition for which - in the insurer’s judgment - most people would have sought care or treatment prior to enrolling in an individual health insurance.

Self-funded Group Health Plans.  Plans set up by employers who set aside funds to pay their employees’ health claims.  Because employers often hire insurance companies to run these plans, they may look to you just like fully insured plans.  Employers must disclose in your benefits information whether an insurer is responsible for funding, or for only administering the plan.  If the insurer is only administering the plan, it is self-funded.  Self-funded plans are regulated by the U.S. Department of Labor, not by New Jersey.

Small Group Health Plans.  Plans with at least 2 but not more than 50 employees.

Special Enrollment Period.  A time, triggered by certain specific events, during which you and your dependents must be permitted to sign up for coverage under a group health plan. Employers and group health insurers must make such a period available to employees and their dependents when their family status changes or when their health insurance status changes.  Special enrollment periods must last at least 30 days.  Enrollment in a health plan during a special enrollment period is not considered late enrollment.  See also Late Enrollment.

State Continuation Coverage.  A program similar to COBRA.  In New Jersey, if you are in a fully insured group health plan sponsored by an employer with 2 to 19 employees and meet other requirements, you and your dependents also have rights to continue your health coverage for up to 18 or 36 months (depending on your circumstance) when you are no longer eligible for your employer’s health plan.  See also COBRA.

Supplemental Security Income (SSI).  A program providing cash benefits to certain very low-income disabled and elderly individuals.  When you qualify for SSI, you generally also qualify for Medicaid.  In addition, Medicaid coverage often continues for a limited time if your income increases so that you no longer qualify for SSI. See also Medicaid.

Temporary Assistance for Needy Families (TANF). A program (also known as Work First New Jersey or WFNJ) that provides cash benefits to low-income families with children.  When you qualify for TANF, you generally also qualify for Medicaid.  In addition, Medicaid coverage often continues for a limited time or longer if you no longer qualify for TANF.  See also Medicaid.

Trade Adjustment Assistance (TAA) Program. A program authorized by the Trade Adjustment Assistance Reform Act of 2002.  This program provides aid to workers who lose their job or whose hours of work and wages are reduced as a result of increased imports.  The TAA Program offers six benefits and reemployment services to assist unemployed workers prepare for and obtain new suitable employment.  In addition, TAA offers a significant tax credit that covers 65% of health insurance premiums for certain plans

U.S. Department of Labor.  A department of the federal government that regulates employer provided health benefit plans.  You may need to contact the Department of Labor if you are in a self-funded group health plan, or if you have questions about COBRA or the Family and Medical Leave Act.  See also COBRA, Family and Medical Leave Act.

Waiting Period.  The time you may be required to work for an employer before you are eligible for health benefits.  Not all employers require waiting periods.  Waiting periods do not count as gaps in health insurance for purposes of determining whether coverage is continuous.  If your employer requires a waiting period, your pre-existing condition exclusion period begins on the first day of the waiting period.  See also Pre-existing Condition Exclusion Period.