Medicare (Parts A, B, C and D), the standardized Medigap plans, Medicaid and the basics of long-term care insurance are covered in the national Senior and Special Needs guide. This guide covers the New Jersey rules that sit on top: the Medicare supplement statute (N.J.S.A. 17B:26A) and the long-term care insurance statute (N.J.S.A. 17B:27E). Both are administered by the Department of Banking and Insurance.

Medicare supplement (Medigap) rules

New Jersey's Medicare supplement law has the Commissioner set standards by regulation for renewability, eligibility, nonduplication, probationary periods and replacement (N.J.S.A. 17B:26A-2). The statute itself sets these rules:

• No duplication: a Medicare supplement policy may not contain benefits that duplicate Medicare (N.J.S.A. 17B:26A-3a).
• Pre-existing conditions: a policy may not define a pre-existing condition more restrictively than one for which medical advice or treatment was recommended or received within 6 months before the effective date. A claim for a loss incurred more than 6 months after the effective date can't be denied as pre-existing (N.J.S.A. 17B:26A-4).
• Loss ratios: the Commissioner sets a uniform loss ratio method and requires refunds or credits when policies fall short (N.J.S.A. 17B:26A-5b).
• Outline of coverage: must be delivered when the application is made. It describes the principal benefits and the renewal provisions, including any right to change premiums and any automatic age-based increases, and says it is only a summary (N.J.S.A. 17B:26A-7).
• 30-day free look: the policy must prominently state that the applicant may return it within 30 days of delivery for a premium refund if not satisfied for any reason (N.J.S.A. 17B:26A-8).

Long-term care insurance

Definition. In New Jersey, long-term care insurance covers at least 12 consecutive months of necessary care services provided somewhere other than an acute care unit of a hospital (N.J.S.A. 17B:27E-4).

What a policy can't do (N.J.S.A. 17B:27E-6):

• Cancel, nonrenew or terminate coverage because of the insured's age or deteriorating mental or physical health.
• Cover only skilled nursing care, or give much more coverage for skilled care in a facility than for lower levels of care.
• Start a new waiting period when coverage is converted or replaced within the same or an affiliated company, except for benefit increases the insured chose.
• Require a prior hospital stay before benefits are payable.

Pre-existing conditions. A pre-existing condition is one for which advice or treatment was received within 6 months before coverage began, and the exclusion can apply only to losses that begin within 6 months after the effective date (N.J.S.A. 17B:27E-6b(2)).

Contesting the policy (N.J.S.A. 17B:27E-7):

Benefits already paid can't be recovered if the policy is rescinded (N.J.S.A. 17B:27E-7d).

Nonforfeiture offer. No long-term care policy may be delivered unless the policyholder was offered a nonforfeiture benefit, which may be a rider. For a group policy, the offer goes to the group policyholder (N.J.S.A. 17B:27E-8a).

Medicaid in New Jersey

New Jersey's Medicaid and children's health program is called NJ FamilyCare. It is needs-based, so eligibility depends on income and other program rules. The general Medicaid rules are in the national guide.

Common exam traps

• Medigap free look is 30 days in New Jersey. The individual health policy free look is 10 days (N.J.S.A. 17B:26-3.1).
• Six months both ways: for both Medigap and long-term care, the pre-existing look-back is 6 months and the exclusion can't last past 6 months.
• The outline of coverage comes at application, not at delivery.
• Long-term care can't require a prior hospital stay or be skilled-care-only.
• After 2 years, a long-term care policy can be contested only for a knowing, intentional misrepresentation of health facts.