Enrollment/Change Request Form for Continuation Coverage for Eligible Dependents Until 30 Years of Age Pursuant to P.L. 2005, c. 375

State of New Jersey DEPARTMENT OF BANKING AND INSURANCE LEGISLATIVE AND REGULATORY AFFAIRS PO BOX 325 TRENTON, NJ 08625-0325 JON S. CORZINE STEVEN M. GOLDMAN Governor TEL (609) 984-3602 FAX (609) 292-0896 Commissioner Visit us on the Web at www.njdobi.org New Jersey is an Equal Opportunity Employer • Printed on Recycled Paper and Recyclable BULLETIN NO. 06-12 TO: ALL INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH MAINTENANCE ORGANIZATIONS FROM: STEVEN M. GOLDMAN, COMMISSIONER RE: ENROLLMENT/CHANGE REQUEST FORM FOR CONTINUATION COVERAGE FOR ELIGIBLE DEPENDENTS UNTIL 30 YEARS OF AGE PURSUANT TO P.L. 2005, C.375 P.L. 2005, c. 375 (Chapter 375), enacted on January 12, 2006 and effective on May 12, 2006, gives an eligible dependent child of a parent covered under a group health benefits plan the option to maintain dependent coverage after reaching the limiting age specified in the health plan. The Department is developing rules implementing Chapter 375, but these rules will not be adopted prior to the effective date of Chapter 375. Accordingly, the Department is issuing bulletins to provide guidance to carriers.1 This bulletin provides guidance regarding collection of data for the continuation election process. Commencing on May 12, 2006, carriers must be able to assure that Chapter 375 continuation elections can be completed. In accordance with P.L. 1999, c. 1542 (commonly referred to as the HINT law), carriers are required to use the standard enrollment/change request form adopted by the Department (HINT enrollment form) for their group health benefits plans. The HINT enrollment form is set forth in Appendix 1A to N.J.A.C. 11:22-3. The Department recognizes that the HINT enrollment form currently does not capture information carriers will need in order to administer coverage for eligible dependents until age 30, and that the form will need to be amended form adopted by the Department (HINT enrollment form) for their group health benefits plans. The HINT enrollment form is set forth in Appendix 1A to N.J.A.C. 11:22-3. The Department recognizes that the HINT enrollment form currently does not capture information carriers will need in order to administer coverage for eligible dependents until age 30, and that the form will need to be amended. However, such amendments will not be in place prior to May 12, 2006. Thus, until the HINT enrollment form amendments are adopted, the Department will permit carriers to use a supplemental form that captures the information contained in the attached Temporary HINT Supplemental Enrollment Information Form. Carriers will be deemed to be in 1 The Department previously issued Bulletin 06-06 on February 27, 2006 addressing rate issues. Carriers may also wish to review Bulletin 06-11, issued on April 4, 2006, primarily addressing general eligibility issues. 2 N.J.S.A. 17B:30-23, 17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17:48F-13.1, 17B:26-9.1, 17B:27-44.2, and N.J.S.A. 26:2J-8.1 2 compliance with the pertinent provisions of the HINT law when they use the Temporary HINT Supplemental Enrollment Information Form. Questions regarding this bulletin may be directed to the Office of Life and Health by phone at (609) 292-5427 x 50340, or by fax at (609) 633-0527. Please specify that the question concerns use of the Temporary HINT Supplemental Enrollment Form. The Department intends to propose rules in the near future to implement the provisions of Chapter 375. Notice of the proposed rulemaking will appear on the Department’s website at www.state.nj.us/dobi/legsregs.htm. A copy of this bulletin will also be posted to the website. 4/4/06 /s/ Steven M. Goldman Date Steven M. Goldman Commissioner BULLETIN HINT.doc s to propose rules in the near future to implement the provisions of Chapter 375. Notice of the proposed rulemaking will appear on the Department’s website at www.state.nj.us/dobi/legsregs.htm. A copy of this bulletin will also be posted to the website. 4/4/06 /s/ Steven M. Goldman Date Steven M. Goldman Commissioner BULLETIN HINT.doc NJDOBI375/March 2006 3 [Carrier Logo][Carrier Name] Temporary HINT Supplemental Enrollment Information Form Implementing P.L. 2005, c. 375 A. Group & Employee Information Group Name: ______________________________________________ Group Number: _______________ Employee Name: ___________________________________________ Employee ID Number: ___________________ B. Type of Activity (see Important Explanatory Information below) Date of Event Change – Check all that apply __/__/__ Add dependent over the limiting age, but less than 30 __/__/__ Remove dependent over the limiting age, but less than 30 Reason(s): ____________________________________________________________ ____________________________________________________________ __/__/__ Continuation of Coverage pursuant to P.L. 2005, c. 375 Coverage is being effected: During an Open Enrollment Within 30 days prior to attainment of limiting age Within 30 days after eligibility for other reasons During special 12-month enrollment Billing: Employee payroll deduction (w/ employer consent) Direct bill dependent (add billing address): __________________________________________ __________________________________________ C Open Enrollment Within 30 days prior to attainment of limiting age Within 30 days after eligibility for other reasons During special 12-month enrollment Billing: Employee payroll deduction (w/ employer consent) Direct bill dependent (add billing address): __________________________________________ __________________________________________ C. Over-age Dependent Information Name (last, first, MI): _________________________________________ Sex: M F Birthdate: (MM, DD, YY) __/__/__ SSN: _____________ Other Health Coverage: Yes No Other Rx Drug Coverage: Yes No Primary Ofc ID Number: _______________ Ob/Gyn Ofc ID Number: _______________ Current Patient: Yes No Current Patient: Yes No N/A NJDOBI375/March 2006 4 Previous Coverage: Yes No If yes, provide the following information AND submit a copy of the certificate of Creditable Coverage that was issued by the previous carrier, if available: Effective date of prior coverage: __/__/__ Termination date of prior coverage: __/__/__ Name of prior carrier: _______________________________________________ Prior plan number: _________________________ D. Signature _____________________________________ ____________________________________ Employee Dependent ___________________ ________________________ Date Date Employer Consent to Payroll Deduction: Yes No ___________________________________________________ _________________ Name & Title Date IMPORTANT EXPLANATORY INFORMATION An adult child may request to continue as a dependent on his or her parent’s coverage even after the child reaches the limiting age under the terms of the policy if the adult child: • is not yet 30 years old • is unmarried • has no children • lives in New Jersey or, if not a New Jersey resident, is a full-time student at an accredited institution of higher education • is not RY INFORMATION An adult child may request to continue as a dependent on his or her parent’s coverage even after the child reaches the limiting age under the terms of the policy if the adult child: • is not yet 30 years old • is unmarried • has no children • lives in New Jersey or, if not a New Jersey resident, is a full-time student at an accredited institution of higher education • is not eligible for Medicare and is not actually covered under another group or individual health plan. An adult child may make the request to continue as a dependent on his or her parent’s coverage either: • when he or she first reaches the limiting age • when he or she first becomes eligible for a reason other that reaching the limiting age (for example, the adult child becomes a full-time student in another state, or returns to live in New Jersey after residing elsewhere), or • during the open enrollment period for the group of which the parent is a member. In addition, adult children who reached the limiting age under the parent’s coverage prior to May 12, 2006 may make an enrollment request at any time from May 12, 2006 through May 11, 2007. The adult child or covered employee may be required to pay up to 102% of the cost of the dependent premium.