Health Insurance in New Jersey
Health insurance in New Jersey requires an insurer to pay all or some of the insured's medical bills in exchange for premiums paid by the insured. It is an insurance product that covers medical costs incurred due to illnesses, accidents, or injuries. People without health insurance often lack access to good health care services. They are more likely to be in poor or fair health conditions since they cannot meet their medical needs, including access to physicians or other health care professionals.
Out of the over 7.2 million under-65 New Jersey residents in the 2019 U.S. Census Bureau Small Area Health Insurance Estimates (SAHIE) survey, over 675 thousand did not have health insurance coverage. Passaic County had the highest percentage of uninsured (under-65) in the state in that year, at 14.2%. In 2021, the state had over 9.2 million residents, and 9.2% of the under-65 demographics did not have proper health coverage. When not obtaining coverage from the employer, New Jersey residents typically purchase private insurance from the NJ health insurance marketplace.
Generally, access to quality health care services is essential for maintaining a healthy life, managing or preventing diseases, and reducing disability and avoidable premature deaths in New Jersey. That is the essence of health insurance; it helps you gain entry into the healthcare system and provide the required health care without burdening you with outrageous medical bills. New Jersey residents can get health insurance in various ways. They include employer-provided plans, individual or family plans, and government-assisted plans. These plans can be purchased under either of the following health insurance systems:
Public Health Insurance System - Health insurance plans under the public health system are provided and sponsored by the government, especially for seniors, low-income persons or families, and others eligible for special subsidies. The common health insurance plans under the public health insurance system are Medicaid, CHIP, and Medicare
Private Health Insurance System - Under this system, private health insurance companies provide health insurance plans to individual consumers and groups, especially employers (employer-sponsored plans)
How Does Health Insurance Work in New Jersey?
Generally, the premiums you pay for health insurance to a New Jersey health insurance provider allow you to share risks with other persons who make similar payments. Health insurance companies use the premium dollars paid by many insureds to cover the medical expenses of the relatively small number requiring medical treatment.
When choosing a suitable health insurance plan in New Jersey, you must do so carefully by considering your unique needs and the health insurance company's offering. Certain factors determine health coverage costs, and you need to consider them when choosing a health plan. In New Jersey, a health insurance company will consider factors like age, income, and any pre-existing medical conditions to determine your annual health coverage costs. They will also set the maximum coverage amount, otherwise known as the sum assured.
If you incur some medical expenses in New Jersey and need to file a claim, you can do so using any of the following two methods:
Use the refund procedure, a process in which you pay your medical bills while your health insurance provider reimburses you. However, you must provide your insurer with invoices and receipts
Use the cashless option, especially if you get medical treatment from a hospital on your insurer's network list. Your health insurer will check with the health care provider and settle all your medical costs
According to the New Jersey Department of Banking and Insurance (DOBI), state residents can get health insurance in various ways. The common ones are:
Through an employer - Small Employer Health Benefits (SEH) Program
Through individual or family plan - Individual Health Coverage Program (IHC)
Through government-sponsored programs - For instance, Medicare and Medicaid
To better understand how New Jersey health insurance works, it is vital to understand the following terms:
Deductible: The amount paid for covered health care services before your insurance plan kicks in and starts paying. If you have a plan with low premiums, you will pay a high deductible, and vice-versa
Coinsurance - The percentage of covered health care service costs paid after paying your deductible. The lower your health insurance premiums, the higher your coinsurance, and vice-versa
Copayment: This is a fixed amount paid for a covered health care service after paying your deductible. Health insurance plans with lower premiums come with higher copayments and vice-versa
Out-of-Pocket Expenses - Medical care expenses that are not refunded by insurance. These include copayments, coinsurance, and deductibles for covered health care services and costs for other uncovered services
Open Enrollment: The only time a person can enroll in health insurance during the year. New Jersey open enrollment is between November 1 and January 31. However, you can qualify for a special enrollment period (a time outside open enrollment) if you experience any major life event
The Division of Insurance of the DOBI regulates all insurance businesses and products, including health insurance in New Jersey. You can shop for health insurance during open enrollment or if you qualify for a special enrollment period through the state's official health insurance marketplace, Get Covered New Jersey (Get Covered NJ). The New Jersey health insurance marketplace can offer financial help to lower your insurance premiums and out-of-pocket expenses if you qualify. You can also purchase a health insurance plan directly from a health insurance provider through a New Jersey-licensed health insurance agent. The categories of plans available in the New Jersey health insurance marketplace, which are also called metal levels, are:
Bronze Level - Comes with the lowest monthly premium but highest costs whenever you need health care services
Silver Level - Comes with a moderate monthly premium and medical costs when you need health care services
Gold Level - You pay a high monthly premium but low medical costs for health care services
Platinum Level - Of the four levels, this comes with the highest monthly premium but the lowest costs when you receive health care services
How Does Group Insurance Work in New Jersey?
Group health insurance is a type of insurance that provides medical coverage to members of a group. It is only meant for groups; no individual can purchase a group health insurance plan in New Jersey. However, you can add your dependents to your group health plan (if enrolled in one) at an additional cost. In group health insurance, a group may be an organization or company. Group health insurance usually comes at a lower cost because the risk is spread across a wider number of group members. Participating in or declining health coverage from a group health insurance plan is a choice. However, at least 70% participation of group members is usually required.
Most group health insurance plans are employer-sponsored. Per the Affordable Care Act (ACA), employers with at least 50 full-time employees must provide such employees with group medical insurance; it is not mandatory for those with less than 50 full-time employees. The Small Employer Health Benefits Program (SEH) is an example of a group health insurance plan in New Jersey. It gives small employers access to group health plans regardless of the health status or occupation of the group members. The Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO) plans are other common examples of group health insurance plans. PPO plans are more flexible than HMO plans and are more expensive. They offer more options for seeing physicians. In contrast, HMO plans are less costly because they contract with health providers within a specific network. However, they provide less flexibility and options regarding how group members can access medical care.
Your employer likely offers multiple levels of flexible group insurance plans, so make sure to carefully compare plans for features and their associated costs.
How Does Individual Health Insurance Work in New Jersey?
Individual health insurance in New Jersey is a type of health coverage purchased on an individual or family basis. It is for individuals who cannot access or do not have access to health care plans under state sponsored programs, federal government, or employer-sponsored coverage. Such people include individuals who retire early and do not qualify for Medicare, and need to get personal health coverage before they turn 65. Individual health insurance is also a perfect option for self-employed persons.
In New Jersey, individual health insurance is available through the state's health insurance marketplace, known as Get Covered NJ, during the annual open enrollment period. If you have a qualifying event outside the yearly open enrollment period, you will become eligible to purchase individual health coverage during the special enrollment period. With an individual health plan, you can choose your preferred health insurance company, the options suitable for your needs, and a plan that includes hospitals and physicians you can trust. Additionally, you may qualify for a federal government subsidy to assist you in paying for insurance. Since it is not tied to your job, you will not lose coverage even when you change jobs.
New Jersey runs an Individual Health Coverage (IHC) Program to ensure that residents who cannot access government or employer-sponsored health coverage can get one from private health insurance companies. This program offers individual benefits plans and renewable coverage for individuals and families regardless of their health status or age. The DOBI provides New Jersey residents with a guide on selecting a plan under the IHC program.
Individual Health Plans Vs. Employer Group Health Plans in New Jersey
| Employer-sponsored health plans | Individual Plans | |
| Coverage for pre-existing medical conditions | Yes | Yes |
| Ability to choose a plan with your preferred health care provider and physician | Limited | Yes |
| Insurance premiums shared/subsidized | Employers typically pay a percentage of the premiums | Insureds pay premiums and may qualify for government subsidies |
| Coverage retained with job change | Limited | Yes |
| Premium payments on a pre-tax basis | Yes | No |
What are Alternative Health Plans in New Jersey?
Alternative health plans in New Jersey are health insurance plans that may not necessarily comply with the Affordable Care Act (ACA) rules. Generally, these plans are more affordable, allowing you to save on health insurance costs. The 9.2% of the under-65 New Jersey residents without health insurance can take advantage of alternative health plans to have some form of health coverage. Additionally, alternative health insurance is frequently purchased as supplementary, to compliment the major health coverage.
Although alternative health plans in New Jersey offer affordable health coverage, unlike ACA-compliant plans, they are not eligible for federal aid, such as cost-sharing reductions, which can lower your premiums. Also, alternative health plans may not cover all illnesses or injuries, including chronic or pre-existing medical conditions.
The common alternatives to Affordable Care Act-compliant plans in New Jersey include:
Limited benefits health plan
Subscription health plans
Discount health plans
Association health plans
Direct primary care
Telehealth and Telemedicine
To get complete details about coverages, discuss your health insurance needs with a New Jersey-licensed health insurance agent or a broker who has access to multiple insurers and their health care plans for comparison.
SHORT-TERM LIMITED-DURATION HEALTH INSURANCE
Although an alternative offer low cost coverage option in many states, New Jersey has since 1993 banned the sale of short-term limited-duration health plans, otherwise known as short-term plans. The New Jersey Statute 17B:27A-3 prohibits short-term plans and requires all health insurance plans sold in the state to provide quality care through full-year coverage. NJ health coverage must be guaranteed issue and renewable and offer comprehensive benefits that surpass ACA requirements. Generally, short-term limited-duration health plans provide coverage for less than 12 months, although renewable for up to three years. They are primarily meant to plug coverage gaps when a person is changing health plans.
LIMITED BENEFIT HEALTH PLANS
Limited benefit health plans in New Jersey provide fixed benefit amounts for covered health care services. Sometimes called fixed indemnity or no deductible plans, limited benefit health plans only pay some of a person's medical costs. For instance, if you have a limited benefit plan and are involved in an accident, it will only reimburse part of your medical bills for certain injuries. Sometimes, they will only pay part of a person's health care costs for a specific illness. Typically, your plan provider will pay you a fixed benefit amount per hospital visit, incident, day, week, or month, up to a set limit when you receive health care services covered by this plan. You can use the benefit amount received to pay out-of-pocket medical costs.
Limited benefit health plans in New Jersey can be used to supplement other health insurance coverage options for additional protection. Essentially, it is suitable for anyone receiving preventive health treatment regularly. Since you can pair a limited benefit health plan with any other health coverage option, you may choose to use your benefits to pay for the deductible, copay, and coinsurance amounts for your ACA policy. Limited benefit health plans are usually available all year round.
SUBSCRIPTION HEALTH PLANS
Subscription health plans in New Jersey are healthcare plans that allow enrolled members to pay a monthly or annual fee to enjoy services included in the plans or see a physician. They are sometimes called concierge care plans and may include unlimited access to laboratory services, prescription, immunization, and healthcare professionals. Subscription fees vary widely depending on providers. Some providers specialize in one aspect of healthcare services, for instance, reproductive health.
Subscription health plans are affordable, making access to healthcare easier and quicker for New Jersey residents. They are flexible, allowing patients to choose from a network of healthcare providers and only pay a minimal fee for the medical services they need. If you become dissatisfied with a provider, you can easily opt-out and switch to another provider anytime. Also, subscription health plans help patients to manage their health proactively. Rather than wait until you discover a sudden health concern before visiting the hospital, you can leverage the services of a subscription health plan provider to monitor your health before it deteriorates. This can help you to lessen the financial impact of treating a sudden medical condition.
Generally, subscription health plans in New Jersey can bridge the gap between expensive deductibles, copays, and conventional medical care pitfalls and quality, affordable healthcare services. Types include:
Medical plan - Covers virtual care and direct medical care arrangement
Mental health plan - Covers therapy, addiction, behavioral health, and counseling
Dental plans - Provide coverage for dental health
Vision plans - Cover vision health
Complementary medicine plan - Covers pain management, chiropractic, physical therapy, and wellness program
DISCOUNT HEALTH PLANS
Discount health plans in New Jersey are a form of health plan where enrolled members pay certain fees to enjoy reduced rates on specific medical services and procedures. Depending on the healthcare plan provider, membership fee payment may be either monthly or annually. Although they are less expensive than health insurance, discount health plans are typically not suitable as someone's only medical coverage because they cannot provide any of the protections of a conventional health insurance policy. However, discount health plans may help your well being, by enabling you to save costs on products and services that may be excluded under your health insurance policy.
In New Jersey, a discount health plan may be a plus to your health insurance plan, particularly if your insurance type needs additional policies to get dental, hearing, or vision coverage. You will pay more premiums if you opt for additional policies to cover these services. Instead, you can leverage a discount health plan targeted toward medical services that include hearing, dental and vision dental plans. It is best to understand your current health insurance coverage and identify what is and is not covered to determine whether a discount health plan is suitable for you. Be careful not to enroll in any discount health plan that can interfere with or replace your health insurance coverage. If unsure how to go about it, consult with a New-Jersey licensed insurance agent for professional advice.
ASSOCIATION HEALTH PLANS
Association health plans (AHPs) in New Jersey are a type of group health insurance that allows small businesses and self-employed individuals with common interests to band together and access health coverage. Common interests may include shared industry, trade organization, profession, geographical region, or line of business. Anyone who joins an AHP will receive a membership card. Typically, most AHPs have a large health insurer's network of healthcare professionals and provide low rates by paying for members' medical care in bulk. They cannot exclude coverage for a pre-existing medical condition or bill a person more for being sick.
Depending on who holds the financial risks associated with healthcare claims and how AHPs are funded, an AHP can either be self-insured or fully insured. A self-insured AHP is responsible for paying claims using premiums charged to employees (members) and its other financial resources. It does not transfer medical claims risks to any third-party insurance company. On the other hand, a fully insured AHP transfers its risks of medical claims to a third-party health insurance provider in exchange for premiums. Self-insured AHPs are not subject to health insurance taxes, and no third-party health insurer is making a profit off them unless they use the services of a stop loss insurer. Hence, it usually costs less than fully insured AHPs. In New Jersey, an AHP can come in any conventional healthcare delivery type, including Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), and Exclusive Provider Organization (EPO).
According to Bulletin No. 18-13, released by the New Jersey Department of Banking and Insurance (BOI) in 2018, an AHP must comply with all applicable state laws and regulations. New Jersey law requires all employer associations with small employee members, including AHPs, to provide coverage to such employees in compliance with the standard health benefits approved by the state's SEH Program Board.
DIRECT PRIMARY CARE
Direct primary care (DPC) in New Jersey is a healthcare model where patients pay physicians periodic fees directly for services rendered without a third-party insurance provider as “middlemen”. Under this model, physicians charge their patients a flat annual or monthly fee in exchange for an extensive range of primary care services as agreed in a contract. Such services include care coordination, exams, consultations, and certain lab services; the exact coverages differ by physicians and practices. NJ DPC plans are especially suitable for patients with high deductible insurance plans as they can help them save money. Instead of striving to meet high deductibles and paying in full, they can receive routine quality care treatment from DPC doctors with their membership.
Generally, the DPC medical business model in New Jersey offers patients improved healthcare services at lower medical expenses. Patients do not need to worry about separate copays or deductibles for each medical procedure. Their one-off monthly or annual fee covers all their primary care needs. With the DPC model, it is easier for physicians to comprehensively address patients' primary care needs since they usually spend more time with each patient. As a result of a better doctor-patient relationship, physicians can potentially prevent health issues from escalating into crises requiring inpatient or emergency care.
Membership in the DPC doctor's office is included in the New Jersey SHBP/SEHBP benefits at no extra cost to employees, pre-65-year-old retirees who are not qualified for Medicare, and their dependents. However, regardless of how comprehensive any covered primary care services are, getting major health (ACA-compliant) insurance coverage in the state is recommended. Generally, inpatient care, surgery, emergency care, and specialty care are beyond DPC plans' scope and can be unaffordable for the average state resident, hence the need for health insurance coverage.
TELEHEALTH and TELEMEDICINE
Although people often use telehealth and telemedicine interchangeably, there is a difference between both. Based on the advances in ICT, medical professionals and other healthcare providers in the United States, including New Jersey, can provide remote services robustly to patients and consumers. With these virtual visits, which are often interactive (two-way), you do not have to leave your home to meet your physician at a medical facility before accessing certain routine healthcare services.
Telehealth is all-encompassing and offers a wider scope of remote medical services than telemedicine. Its scope is beyond clinical services. Besides the ability to remotely detect fluctuations in the medical condition of a home-bound patient, telehealth facilitates patients' remote diagnoses and evaluation in New Jersey. After diagnosis evaluation or fluctuation detection, physicians can recommend medications or alter patients' therapy if applicable. Beyond remote clinical services, telehealth may include virtual visits for:
Administrative meetings
TrainingSocial support and medication compliance
Continuing medical education via ICT
Telemedicine has a smaller scope than telehealth and involves using ICT to support remote clinical services, including diagnostic, medical, and treatment-related, primarily by doctors, services delivery. For instance, in New Jersey, telemedicine can be used to diagnose a patient, monitor their progress after therapy or treatment, and enable access to specialists not in the same area as the patient. Besides audio consultations, access to specialists may include video consultations. Telemedicine is often a choice for patients needing medication management, follow-up visits, and chronic medical conditions management.
Commercial Health Insurance
Commercial health insurance in New Jersey comprises comprehensive coverage issued by private carriers subject to the state's DOBI regulations. Such carriers include regulated insurance companies, healthcare providers, and HMOs. New Jersey commercial insurance does not include self-funded health coverage by labor unions, larger establishments, or government. Also, government-sponsored programs like Medicaid, Medicare, or health coverage for civilian federal employees or military employees are excluded from the state's commercial health insurance.
Generally, commercial health insurance is administered by non-governmental agencies. In New Jersey, most commercial insurance is employer-sponsored. An employer is responsible for selecting the plan for employer-sponsored health insurance and the required coverage. In most cases, they share the health insurance premiums costs with their employees.
Group Employer Sponsored Health Insurance
According to an SBA report, in 2021, New Jersey had over 937 thousand small businesses, representing 99.6% of all registered businesses in the state. These small businesses accounted for at least 1.9 million employees that same year, which formed 49.5% of the total employees in the state. Per the Affordable Care Act (ACA), employers with at least 50 full-time employees (or the equivalent of part-time employees) must provide 95% of them with minimum essential health coverage. Failure to do so attracts a penalty as determined by the Internal Revenue Service (IRS). In 2020, this penalty was a $3,860 fine per uninsured employee. Besides complying with the ACA, an employer may be required to provide group health insurance coverage to an employee when the employment contract requires it.
Other common commercial health insurance products in New Jersey include temporary disability insurance and workers’ compensation insurance.
New Jersey Disability Income Insurance
Disability income insurance is an insurance plan designed to partially replace income for persons who cannot work because of an illness or disability. New Jersey disability income insurance is commonly called temporary disability insurance. An employer may choose a temporary disability insurance plan offered by the state or a private insurance provider. Disability income insurance protects against wage loss by employees if they become incapable of working and earning income due to an accident or illness. New Jersey temporary disability insurance is available to most workers, excluding:
Out-of-state employees
Workers who are technically not employees, like independent contractors
Federal government employees
Faith-based organizations
Local government employees, including those in the school district (optional for them)
New Jersey state plans of temporary disability insurance provide cash benefits to workers who need to stop working due to mental or physical health conditions or other disabilities unrelated to work. The healthcare provider certifies how long it takes for an employee to recover from their medical condition, usually up to 26 weeks, max. Employees covered by state plans can apply for their temporary disability insurance benefits online via the Department of Labor and Workforce Development (LWD) secure system.
Employers' provision of temporary disability insurance coverage through an approved private plan is permitted by the Temporary Disability Benefits Law. While private plans differ between employers, they must be endorsed by the Division of Temporary Disability Insurance, Private Plan Operations. Employers are responsible for processing and paying benefits on a disability claim for any employee covered under a private plan. If you are covered by a private plan, your employer will educate you on how to file a disability claim. Employers and workers contribute to the New Jersey temporary disability program cost. Usually, workers' contributions are made through deductions from their paychecks. In 2022, workers' contribution was set at 0.14% on the first $151,900 wage cap in covered earnings made during the calendar year. This applies to both state and private New Jersey temporary disability insurance plans.
New Jersey Workers’ Compensation Insurance
Although New Jersey law does not require employers to provide health insurance for their employees, carrying worker's compensation insurance is mandatory for most businesses in the state. The only exemptions are:
Casual employment
Sole proprietorships (with no employee)
Single-member LLCs without employees
New Jersey workers' compensation benefits include hospital or medical services and cash payments provided to workers of their families (if workers die) who sustain work-related illnesses or injuries. The New Jersey Division of Workers' Compensation administers the workers' compensation program.
New Jersey employers may purchase workers' compensation insurance coverage from any state-authorized private workers' compensation insurance company. Under workers' compensation insurance, employees are not required to make contributions in any form, including salary deductions. Governmental agencies in New Jersey must provide workers' compensation benefits to their employees. They may do so by either maintaining a separate allocation for workers' compensation, participating in an insurance pool, or purchasing an insurance policy.
The willful failure of an employer to provide workers' compensation coverage, even without a job-related injury in New Jersey, is a fourth-degree crime. For such a failure, penalties can amount to $5,000 for the first 10 days and up to $5,000 for each additional 10-day period of an employer's refusal to insure. Besides the cash fine, New Jersey law provides for civil penalties against employers that deliberately refuse to provide workers' compensation. If your employer is uninsured in the state, you can complete a Report of Non-Compliance Form or contact the Office of Special Compensation Funds via email. The New Jersey Department of Labor and Workforce Development provides employers operating in the state with an employer's guide to workers' compensation.
How Does Health Insurance for Seniors Work in New Jersey?
Health insurance for seniors in New Jersey provides a good blend of comprehensive medical coverage options and low costs for all their health care needs. In 2021, 16.9% of the New Jersey population was adults over 65 years old who were qualified for health insurance for seniors. According to the Blueprint for Healthy Aging in New Jersey, the average per capita personal health care expenditure is $4,418, which is higher than the nation's average of $4,026. The leading causes of death for senior New Jersey residents are influenza, diabetes, unintentional injuries, and pneumonia, all of which can be managed well with the right health insurance.
According to New Jersey State Health Assessment Data, life expectancy for state residents aged 65 and over fell from 85.6 years old in 2016 to 83.5 in 2020. Life expectancy usually indicates the overall health status of any population. Deaths per 1,000 persons in New Jersey between 2016 and 2019 of adults aged 85 years and over also increased from 13,086 to 13,335. Hence, the declining life expectancy of senior residents and the increasing number of deaths in the age group may be due to a lack of necessary health coverage. The New Jersey Department of Health and Senior Services (DHS) administers a free State Health Insurance Assistance Program (SHIP). This program assists New Jersey Medicare beneficiaries with financial assistance through a United States Administration for Community Living grant.
As you grow older, you should consider getting some types of health insurance. The common ones in New Jersey include:
MEDICARE
Medicare is a health insurance program funded by the federal government for adults 65 years or older (seniors), individuals with ESRD (end-stage renal disease), and certain people with qualifying disabilities. Like in every other state in the United States, in New Jersey, employees and their employers are assessed for a mandatory 2.9% payroll tax, which is paid into Medicare. The best time to benefit from such an investment is during your senior years. Between 2011 and 2020, the number of persons enrolled in New Jersey Medicare increased by over 200,000. In 2011, the state had 1.42 million enrollees; as of 2020, almost 1.7 million people have enrolled. If you have been a permanent legal resident in the U.S. for over five years or are a U.S. citizen, you may qualify for Medicare in New Jersey. However, you must meet at least one of the following criteria:
You have been on SSDI (Social Security Disability Insurance) for two years
You are at least 65 years old
You have ESRD
Generally, Medicare plans have four parts. These are:
Part A - This covers hospitalization and care in hospice care or any skilled nursing facility. It also known as hospital insurance, and it is free for most persons
Part B - Also known as medical insurance, this covers outpatient services like preventive care, clinical trials, doctor's visits, mental health care, and laboratory tests. It also covers medical equipment and supplies
Part C - This part permits interested persons to enroll in Medicare health plans issued by private insurance providers. However, such insurance companies must be in a contract with Medicare. Part C is sometimes called Medicare Advantage.
Part D - This part covers the costs of prescription drugs for Original Medicare enrollees.
Medicare beneficiaries in New Jersey can access Medicare coverage and benefits primarily in two ways: Original Medicare and Medicare Advantage. Under Original Medicare, the federal government directly bears the costs of coverage. In contrast, with Medicare Advantage, an individual will enroll in a plan with a private health insurer under an agreement with the federal government to provide Medicare coverage. In 2022, 63% of Medicare eligible residents in New Jersey chose Original Medicare, while 37% used Medicare Advantage.
If you are aging, you become eligible for Medicare in New Jersey three months before you turn 65 (including your birthday month). Your eligibility continues until three months after the month of your birthday. To get Medicare in the state, contact the Social Security Administration (SSA) at 1 (800) 325-0778 or apply online. If you need free help with Medicare in New Jersey, contact the State Health Health Insurance Assistance Program (SHIP) at 1 (800) 792-8820.
MEDICAID
Medicaid is a type of health insurance program that the federal and state governments jointly fund to enable low-income earners, including seniors, to access low-cost health coverage. It is the most affordable health care plan for seniors with low incomes. In New Jersey, Medicaid coverage runs in a special way and provides health insurance to the following categories of persons in the state:
As of 2022, over 2.1 million residents of New Jersey have enrolled in the state's Medicaid program. Depending on the health care program for which a person qualifies, New Jersey Medicaid pays for prescriptions, hospital services, home care, doctor visits, and other medical needs. Eligibility criteria for New Jersey Medicaid include:
Being a New Jersey resident
Earning up to 138% of the FLP (Federal Poverty Level)
Being a citizen of the United States or a qualified alien
The Division of Medical Assistance and Health Services (DMAHS) of the New Jersey Department of Human Services provides a list of services covered by NJ Medicaid. While some services are mandatory, the optional ones include dental care, hearing aid, and optometry services. The New Jersey Department of Human Services provides residents with the NJHelps to help determine their eligibility and subsequent enrollment in the state's Medicaid program.
MEDIGAP
Medigap, otherwise known as Medicare supplement insurance, is sold by private health insurance companies to help fill gaps in Original Medicare. Over 50% of New Jersey Medicare beneficiaries choose to use Medigap to supplement Original Medicare. It primarily pays some of the health care costs not covered by the original Medicare. In New Jersey, Medigap can cover some or all of your out-of-pocket health care costs, including deductibles, coinsurance, and copayments, that you would otherwise bear if you only had Original Medicare. Typically, Medigap policies do not cover the following health services:
Eyeglasses
Long-term care (for instance, non-skilled care received in a nursing home)
Private-duty nursing
Hearing aids
Dental and vision services
Generally, federal rules regulate Medigap plans, and such laws do not guarantee access to Medigap plans for persons under 65 and qualified for Medicare due to disabilities. Medigap coverage is guaranteed issue when you are at least 65 and enrolled in Medicare Parts A and B. However, New Jersey adopted some rules to ensure some access to Medigap plans by residents under 65, even at lower costs. The monthly premiums paid for under-50 Medigap plans in New Jersey in 2022 range from $143 to $155. Such enrollees are individuals who qualify for Medicare for reasons other than age, usually due to disability. As of December 2021, New Jersey had 26 Medigap insurance companies offering policies in the state.
LONG-TERM CARE (LTC) INSURANCE
Long-term care (LTC) insurance in New Jersey is a type of insurance designed for people with long-term care needs. Generally, long-term care is the assistance needed by people with cognitive disorders, disabilities, and prolonged illnesses, which are common health issues among seniors. LTC services include the following:
Adult Daycare, Homemaker care, Respite care, and Hospice care
Help with ADLs (activities of daily living) like dressing, continence, eating, transferring, toileting, and bathing
Personal care for instrumental ADLs
Non-stop skilled nursing care for people with disability, cognitive disorders, or prolonged physical illnesses
The cost of long-term care in New Jersey may be over $65,000 annually, which necessitates the use of insurance. LTC insurance provides coverage for medical expenses for long-term care and assists qualified persons in affording their required ongoing care costs. Many of the health services covered by long-term care insurance plans are not covered by Medicare, Medicaid, and private health insurance. In New Jersey, LTC insurance plans are available through some private insurance carriers.
Discuss your long term care insurance needs with a New Jersey life and health insurance agent. A knowledgeable insurance professional can assess your LTC needs and suggest the multiple coverages and tips that can fit those needs, based on your budget.
What are Additional or Stand-Alone Health Insurance Options in New Jersey?
Alternative health insurance options in New Jersey include the following:
Vision Insurance - Covers eyeglasses, contacts, or both. It offers flexible plans with no age restrictions
Dental Insurance - Dental insurance covers basic services, major services, and preventive care without age limits
NJ FamilyCare - This is a state publicly sponsored health insurance program for qualified New Jerseyans of any age. It offers free or low-cost coverage and includes Medicaid, CHIP, and Medicaid expansion populations. NJ FamilyCare provides comprehensive and quality healthcare services, including hospitalization, eyeglasses, dental, mental health, and prescription services. The State Department of Human Services provides a guide on NJ FamilyCare
Catastrophic Illness in Children Relief Fund - This health care option is designed to provide financial assistance for families with potential medical expenses based on a child's catastrophic illness
What Health Insurance Rights Do I Have in New Jersey?
New Jersey laws give individuals and employers in the state guaranteed access to health coverage, regardless of age, health status, claims history, or other risk factors. If you are denied health coverage or have other health insurance-related complaints, you have a right to file your complaints. The state's Division of Insurance - Consumer Protection Services investigates health insurance-related complaints and inquiries, except for Managed Care medical complaints.
You can file any health insurance-related complaints in New Jersey using any of the following methods:
Online using the Consumer Complaint Form - The most convenient method
Completing the Insurance Complaint Form and submitting it by mail or fax at:
New Jersey Department of Banking and Insurance
Consumer Inquiry and Response Center
P.O. Box 471
Trenton, NJ 08625-0471
Phone: (609) 292-7272
Fax: (609) 777-0508 or (609) 292-2431
If you have further questions about health insurance in New Jersey, speak with a state-licensed health insurance agent who has access to multiple insurers. Always get several quotes and run a comparison of features and services provided.
