New Jersey Administrative Code › Title 17 - TREASURY - GENERAL › Chapter 9 - STATE HEALTH BENEFITS PROGRAM › Subchapter 1 - ADMINISTRATION › Section 17:9-1.8 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
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.