N.J. Admin. Code § 11:21-7.7A

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:21-7.7A - Special enrollment period

(a) The special enrollment period means a period of time that is no less than 30 days following the date of a triggering event listed in (b)1 through 5 below and no less than 60 days following a triggering event listed in (b)6 below during which:

1. Full-time employees and dependents who are late enrollees are permitted to enroll under the small employer's plan; and

2. Full-time employees and dependents who already have coverage are allowed to replace current coverage with a different plan, if any, offered by the small employer.

(b) Triggering events are:

1. The date a full-time employee or dependent loses eligibility for minimum essential coverage, including a loss of coverage resulting from the decertification of a qualified health plan by the marketplace. A loss of coverage resulting from nonpayment of premium, fraud or misrepresentation of material fact shall not be a triggering event;

2. The date a full-time employee acquires a dependent or becomes a dependent due to marriage, birth, adoption, placement for adoption, or placement in foster care;

3. The date a full-time employee's enrollment or non-enrollment in a qualified health plan is the result of error, misrepresentation, or inaction by the Federal government or carrier;

4. The date a full-time employee or eligible dependent demonstrates to the marketplace or State regulatory agency that the qualified health plan in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee;

5. The date the full-time employee or dependent gains access to new qualified health plans as a result of a permanent move provided the employee and/or dependent demonstrates having minimum essential coverage for one or more days during the 60 days preceding the permanent move;

6. The date NJFamilyCare determines an employee or dependent who submitted an application during the open enrollment period or during a special enrollment period is ineligible if that determination is made after the open enrollment period or special enrollment period ends;

7. The date an employee and/or his or her dependent who are victims of domestic abuse or spousal abandonment need to enroll for coverage apart from the perpetrator of the abuse or abandonment;

8. The date the full-time employee or dependent loses or gains eligibility under Medicaid or NJFamilyCare; and

9. The date of a court order that requires coverage for a dependent.

(c) The effective date of the employee's coverage or dependent's coverage shall be:

1. The day after the loss of minimum essential coverage as described in (b)1 above;

2. The date of marriage, birth, adoption, placement for adoption, or placement in foster care as described in (b)2 above;

3. The first of the month following receipt of the enrollment form with respect to the events described in (b)3, 4, 5, and 6 above; or

4. The date specified in the court order with respect to item (b)7 above.

(d) If a full-time employee initially waived coverage and stated at that time that such waiver was because he or she was covered under another group plan, and the employee subsequently elects to enroll under the small employer's plan, the employee and his or her dependents will not be late enrollees.

1. The employee may enroll under the small employer's plan within 90 days of the date any of the events described in (d)2 below occurs. The small employer carrier will assign an effective date as of the day after the event described in (d)2 below occurs.

2. The employee is not considered to be a late enrollee if the coverage under the other plan ends due to one of the following events:

i. Termination of employment or eligibility;

ii. Reduction in the number of hours of employment;

iii. Involuntary termination;

iv. Divorce or legal separation or dissolution of the civil union or termination of the domestic partnership;

v. Death of the full-time employee's spouse;

vi. Termination of the policyholder's contribution toward coverage; or

vii. Termination of the other plan's coverage.

(e) The full-time employee must enroll within 90 days of the date that any of the events described in (d) above occur. Coverage will take effect as of the date the applicable event occurs.

N.J. Admin. Code § 11:21-7.7A

Amended by 48 N.J.R. 2360(a), effective 11/7/2016

Amended by 49 N.J.R. 3757(a), effective 12/4/2017