26:2J-10.3 Coverage for certain dependents until age 31 by health maintenance organization.

6. a. As used in this section, "dependent" means an enrollee's child by blood or by law who:

(1) is 30 years of age or younger;

(2) is unmarried;

(3) has no dependent of his own;

(4) is a resident of this State or is enrolled as a full-time student at an accredited public or private institution of higher education; and

(5) (a) is not actually provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan or health benefits plan, or entitled to benefits under Title XVIII of the Social Security Act, Pub.L.74-271 (42 U.S.C. s.1395 et seq.) at the time dependent coverage pursuant to this section begins or will begin; and

(b) there is evidence of prior, creditable coverage or receipt of benefits under a benefits plan or by law as set forth in subparagraph (a) of this paragraph.

b. (1) A health maintenance organization contract that provides coverage for an enrollee's dependent under which coverage of the dependent terminates at a specific age before the dependent's 30th birthday, and is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) on or after the effective date of this section of P.L.2008, c.38, shall, upon the application of the dependent as set forth in subsection c. of this section, provide coverage to the dependent after that specific age, until the dependent's 31st birthday.

(2) Nothing herein shall be construed to require:

(a) coverage for services provided to a dependent before the effective date of this section of P.L.2008, c.38; or

(b) that an employer or other group contract holder pay all or part of the cost of coverage for a dependent as provided pursuant to this section.

c. (1) A dependent covered by an enrollee's contract, which coverage under the contract terminates at a specific age on or before the dependent's 30th birthday, may make a written election for coverage as a dependent pursuant to this section, until the dependent's 30th birthday:

(a) within 30 days prior to the termination of coverage at the specific age provided in the contract;

(b) within 30 days after meeting the requirements for dependent status as set forth in subsection a. of this section, when coverage for the dependent under the contract previously terminated; or

(c) during an open enrollment period, as provided pursuant to the contract, if the dependent meets the requirements for dependent status as set forth in subsection a. of this section during the open enrollment period.

(2) (Deleted by amendment, P.L.2008, c.38)

d. (1) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall consist of coverage which is identical to the coverage provided to that dependent prior to the termination of coverage at the specific age provided in the contract. If coverage is modified under the contract for any similarly situated dependents for coverage prior to the termination of coverage at the specific age provided in the contract, the coverage shall also be modified in the same manner for the dependent.

(2) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall not be conditioned upon, or discriminate on the basis of, lack of evidence of insurability.

e. (1) The enrollee's contract may require payment under the schedule of charges by the enrollee or dependent, as appropriate, subject to the approval of the Commissioner of Banking and Insurance, for any period of coverage relating to a dependent's written election for coverage pursuant to subsection c. of this section. The payment shall not exceed 102% of the applicable portion of the schedule of charges previously paid for that dependent's coverage under the contract prior to the termination of coverage at the specific age provided in the contract.

(2) The applicable portion of the schedule of charges previously paid for the dependent's coverage under the contract shall be determined pursuant to regulations promulgated by the Commissioner of Banking and Insurance, based upon the difference between the contract's rating tiers for adult and dependent coverage or family coverage, as appropriate, and single coverage, or based upon any other formula or dependent rating tier deemed appropriate by the commissioner which provides a substantially similar result.

(3) Payments under the schedule of charges may, at the election of the payor, be made in monthly installments.

f. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following:

(1) the date upon which the dependent is disqualified for dependent status as set forth in subsection a. of this section;

(2) the date upon which coverage ceases under the contract by reason of a failure to make a timely payment under any schedule of charges required under the contract by the enrollee or dependent for coverage provided pursuant to this section. The payment under any schedule of charges shall be considered to be timely if made within 30 days after the due date or within a longer period as may be provided for by the contract; or

(3) the date upon which the contract, under which coverage is provided to a dependent, ceases to provide coverage to the enrollee.

Nothing herein shall be construed to permit a health maintenance organization to refuse a written election for coverage by a dependent pursuant to subsection c. of this section, based upon the dependent's prior disqualification pursuant to paragraph (1) of this subsection, other than a disqualification based on age or lack of evidence of prior, creditable coverage or receipt of benefits.

g. Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to an enrollee by the health maintenance organization:

(1) in the certificate of coverage or other equivalent document prepared for enrollees and delivered on or about the date of commencement of the enrollees' coverage; and

(2) (Deleted by amendment, P.L.2008, c.38)

(3) in a notice delivered to enrollees on a quarterly basis.

h. This section shall apply to those contracts in which the health maintenance organization has reserved the right to change the schedule of charges.

L.2005, c.375, s.6; amended 2008, c.38, s.34.