New Jersey Administrative Code
Title 17 - TREASURY - GENERAL
Chapter 9 - STATE HEALTH BENEFITS PROGRAM
Subchapter 1 - ADMINISTRATION
Section 17:9-1.8 - Definitions
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Act" means the New Jersey State Health Benefits Program Act, P.L. 1961, c.49 (52:14-17.2 5 et seq.), as amended and supplemented.
"Carrier" means a voluntary association, corporation, or other organization, including, but not limited to, a health maintenance organization as defined in section 2 of the "Health Maintenance Organizations Act," P.L. 1973, c. 337 (26:2J-2 ), which is lawfully engaged in providing or paying for, or reimbursing the cost of, personal health services, including hospitalization, medical, and surgical services under insurance policies or contracts, membership, or subscription contracts, or the like, in consideration of premiums or other periodic charges payable to the carrier.
"Category of coverage" means one of the options used for determining the rates for the premium or periodic charges for different levels of coverage under the program, which include single, subscriber and spouse/partner, parent and child, and family coverage, and whether prescription drug coverage is provided in the health coverage. For retirees only, the category also reflects the Medicare entitlement of the subscriber and spouse/partner.
"Chapter 375 Dependents" means all adult children who are defined as dependents in their parent's State health benefits coverage, pursuant to P.L. 2005, c. 375, and supplemented by P.L. 2008, c. 38, which is codified at 52:14-17.29k and N.J.A.C. 17:9-13.
"Civil union partner" means a person, who is of the same sex as the employee, with whom a legally recognized union is formed. The relationship must also satisfy the definition of a civil union as set forth in 37:1-2. Civil union certificates issued to same-sex couples from other jurisdictions are accepted under the New Jersey civil union statutes. Whenever reference is made to "marriage," "husband," "wife," "spouse," "family," "immediate family," "dependent," "next of kin," "widow," "widower," "widowed" or another word, which in a specific context denotes a marital or spousal relationship, the same shall include a civil union partner; or a domestic partnership.
"COBRA" means the Federal Consolidated Omnibus Budget Reconciliation Act of 1985, 29 U.S.C. §§ 1161 -1168, which requires most employers sponsoring group health plans to offer employees and their eligible dependents the opportunity to temporarily extend their group health coverage in certain instances where coverage under the plan would otherwise end.
"Commission" means the State Health Benefits Commission created by Section 3 (52:14-17.2 7) of the Act.
"Dependent" means an employee's spouse, domestic partner, or partner in a civil union couple, and children under the age of 26 years, as well as unmarried disabled children age 26 or older who were covered by the SHBP upon reaching age 26 and who are not capable of self-support upon reaching the age 26 due to mental illness, mental incapacity, or a physical disability, and who remain substantially dependent on the subscriber for support and maintenance. "Children" shall include stepchildren, legally adopted children, and children placed by the Division of Child Protection and Permanency in the Department of Children and Families, provided they are reported for coverage and are wholly dependent upon the employee for support and maintenance. A spouse, domestic partner, partner in a civil union couple, or child enlisting or inducted into military service shall not be considered a dependent during the military service. The term "dependents" shall not include spouses, children, domestic partners, partners in a civil union couple, or children of retired persons who are otherwise eligible for the benefits under the State Health Benefits Program but who, although they meet the age or disability eligibility requirement of Medicare, are not covered by Medicare Hospital Insurance, also known as Medicare Part A, and Medicare Medical Insurance, also known as Medicare Part B.
"Director" means the Director of the Division of Pensions and Benefits.
"Division" means the Division of Pensions and Benefits.
"Domestic partner" (as defined by 26:8A-3 ) or "eligible domestic partner" means a person, who is of the same sex as the employee, who is in a committed relationship with an employee of the State of New Jersey or with an employee of a SHBP participating location that has adopted by SHBP resolution, pursuant to 52:14-17.26 , the definition of dependent that includes domestic partners. The relationship must also satisfy the definition of a domestic partnership as set forth in 26:8A-4 , and the domestic partners must execute and file an Affidavit of Domestic Partnership with the local registrar. The resulting Certificate of Domestic Partnership must be provided to the SHBP, and Certificates of Domestic Partnership issued in New Jersey must be dated prior to February 19, 2007, pursuant to the limitations on domestic partnerships established under N.J.S.A. 26:8A- 4.1. Marriage certificates issued to same-sex couples do not fall under the New Jersey Domestic Partnership statutes. Pursuant to 26:8A-11 , this definition does not include the domestic partner of a participant in the SHBP who is the opposite sex of the participant. A public employer that does not participate in the SHBP may adopt this definition of domestic partner by filing a resolution for all of their retirees enrolled in the retired SHBP.
"Education Employer" means a local school district, regional school district, county vocational school district, county special services school district, jointure commission, educational services commission, State operated school district, charter school, county college, any officer, board, or commission under the authority of the Commissioner of Education or of the State Board of Education, and any other public entity that is established pursuant to authority provided by Title 18A of the New Jersey Statutes, but excluding the State public institutions of higher education and excluding those public entities where the employer is the State of New Jersey.
"Eligible Employer" is a public agency, whose employees may join any of the retirement systems established by statute to provide retirement benefits for public employees, if they are eligible. The term "eligible employer" includes State employers, local employers, and education employers.
"Employee" means a person employed in any full-time capacity by an "eligible employer." "Full-time" shall have the same meaning as established under 52:14-17.26(c) . The term "employee" shall not include persons employed on a short-term, seasonal, intermittent, or emergency basis, persons compensated on a fee basis, persons having less than two months of continuous service, or persons whose compensation is limited to reimbursement of necessary expenses actually incurred in the discharge of their official duties; however, the term "employee" shall include persons employed on an intermittent basis to whom the State has agreed to provide coverage under 52:14-17.25 et seq. ( P.L. 1961, c. 49) in accordance with a binding collective negotiations agreement. An employee paid on a 10-month basis, pursuant to an annual contract, shall be deemed to have satisfied the two-month waiting period if the employee begins employment at the beginning of the contract year. The term "employee" shall also not include retired persons who are otherwise eligible for benefits under the State Health Benefits Program but who, although they meet the age or disability eligibility requirement of Medicare, are not covered by Medicare Hospital Insurance, also known as Medicare Part A, and Medicare Medical Insurance, also known as Medicare Part B. A determination by the Commission that a person is an eligible employee for the purposes of the State Health Benefits Program shall be final and binding on all parties.
High deductible plans are not included as "managed care plans."
"Local employer" means public employers, such as counties, municipalities and authorities, including independent State authorities not designated as "State employers" for SHBP purposes.
"Locally-administered retirement system" means an agency established under State law to provide a system of retirement benefits for public employers, which is not administered by the Division.
"Medicare" means the program established by the "Health Insurance for the Aged Act," Title XVIII of the "Social Security Act," Pub.L. 89-97( 42 U.S.C. §§ 1395 et seq.), as amended, or its successor plan or plans.
"Member" means any individual covered under the SHBP, regardless of whether the person is a subscriber or a dependent.
"NJ DIRECT10" means the coverage created by P.L. 2007, c. 103 as a successor plan to the "Traditional Plan" indemnity coverage.
"NJ DIRECT15" means the State's managed care plan created by P.L. 2007, c. 103 as a replacement to the State's former point of service plan coverage.
"NJ PLUS" is the name of the State's Point of Service plan as defined in Section 2 (52:14-17.2 6) of the Act.
"Participating HMO" means a health maintenance organization duly authorized to operate in the State which is under contract with the Commission to participate in the program.
"Participating local employers" means public employers who elect to participate in the SHBP.
"PPO" means Preferred Provider Organization duly authorized to operate in the State which is under contract with the Commission to participate in the program.
"SEHBP" means the School Employees' Health Benefits Program, which was established under P.L. 2007, c. 103, to govern the administration of health benefit plans and prescription drug coverage for eligible public local education employees and retirees and their eligible dependents.
"SHBP" means the State Health Benefits Program.
"Spouse" means a person to whom one has been joined in a properly recorded legal ceremony authorized by law (as defined by N.J.S.A. 37:1- 1). New Jersey recognizes legal marriages performed in other states or jurisdictions but does not recognize "common law" or any other form of marriage without a formal license (37:1-10 ).
"State-administered pension fund" means a retirement system administered by the Division, including such systems as the Alternate Benefit Program.
"State-administered retirement system" means an agency established under State law to provide a system of retirement benefits for public employees.
"State biweekly employer" means an agency whose employees are paid through the State's Centralized Payroll System.
"State Employer" means the State of New Jersey and those agencies so designated by statute as "State employers" for SHBP purposes.
"State managed care plan" means a health care plan under which comprehensive health care services and supplies are provided to eligible employees, retirees, and dependents:
1. Through a group of doctors and other providers employed by the plan; or
2. Through an individual practice association, preferred provider organization, or point of service plan under which services and supplies are furnished to plan participants through a network of doctors and other providers under contracts or agreements with the plan on a prepayment or reimbursement basis and which may provide for payment or reimbursement for services and supplies obtained outside the network. The plan may be provided on an insured basis through contracts with carriers or on a self-insured basis, and may be operated and administered by the State or by carriers under contracts with the State.
"State monthly employer" means an agency defined by statute as a "State employer" for SHBP purposes but independent of the State's Centralized Payroll System.
"Subscriber" means the person in whose name the coverage is listed.
"Successor plan" means a managed care plan that replaces the Traditional Plan, as defined in section 2 of P.L. 1961, c. 49 (52:14-17.26 ), and that provides an in-network level of benefits as set forth in section 36 of P.L. 2007, c. 103, as well as out-of-network benefits to participants.
"Traditional plan" means a health care plan, which provides basic benefits, extended basic benefits, and major medical expense benefits as set forth in section 5 of P.L. 1961, c. 49 (52:14-17.29 ) by indemnifying eligible employees, retirees, and dependents for expenses for covered health care services and supplies through payments to providers or reimbursements to participants. Termination of traditional plan coverage through the SHBP was effective on March 28, 2008, for State biweekly employees and March 31, 2008, for all State retirees and State monthly employees. For all local government employees and retirees, the effective date of termination was April 1, 2008.
