New Jersey Health Insurance Law, Plan and Regulation | EINSURANCE (2023)

New Jersey Health Insurance Information, Resources and Access to Online Health Insurance Quotes

As a New Jersey resident you can choose from health insurance plans offered to individuals and groups by private insurance companies. You may also purchase individual and family coverage from participating private insurers through, the federal exchange. If you are self-employed with no employees, you can also use the federal exchange to purchase coverage. You may also be entitled to certain state and federal programs such as Medicaid and COBRA.

(Video) Laws And Ruls Pertinent To Insurance

New Jersey and the Patient Protection and Affordable Care Act of 2010

The Patient Protection and Affordable Care Act (also known as ObamaCare and the Affordable Care Act and referred to in this guide as ACA) became law in 2010. Provisions of the law have continued to be phased in following passage. As of January 1, 2014, most U.S. citizens and legal residents are required by law to have qualifying health care coverage or pay an annual tax penalty for every month they go without insurance. This is called the “individual mandate.” There is a grace period through March 31, 2014. Beginning in 2014, the penalty for not having qualifying coverage is $95 per adult and $47.50 per child or 1% of your taxable income; whichever is higher (up to $285 per family). The penalty increases annually through 2017 and beyond.

Individual Mandate Exemptions

You may be exempt from the individual mandate and tax penalties if:

  • You have religious objections
  • Are in the U.S. illegally
  • Are in jail
  • The cost of coverage exceeds 8% of your household income
  • Your income is below 100% of the poverty level
  • You have hardship waivers
  • You are not covered for fewer than three months during the calendar year

New Jersey Small Business Coverage

If you own a small business in New Jersey (50 or fewer full-time-equivalent employees – FTEs), you can purchase qualifying coverage for your employees through SHOP, the Small Business Health Option Program or through a private broker or insurance agent. However, you may qualify for tax credits worth up to 50% of your premium costs if you use SHOP. Beginning in 2016, SHOP will be open to employers with up to 100 FTEs. Under the Employer Shared Responsibility provision of ACA, beginning in 2015, all employers with 50 or more FTEs must offer employees at least one plan that is ACA-compliant or face fines of $2,000 per employee.

ACA Standardized Benefits

Plans offered by private insurers may offer additional benefits and individual states may require additional benefits, but all qualifying plans must offer these 10 standardized essential benefits:

  • Ambulatory patient service
  • Emergency services*
  • Hospitalization
  • Maternity and newborn care*
  • Mental health and substance use disorder services including behavioral health treatment*
  • Prescription drugs*
  • Rehabilitative and habilitative services and devices
  • Preventive and wellness and chronic disease management for adults and children, including 100% coverage for some services*
  • Pediatric service, including oral and vision care*

*Lifetime dollar limits on these essential health benefits have been eliminated.

(Video) Health Insurance In New Jersey: What You Need to Know

New Jersey Additional Mandated Benefits

New Jersey currently mandates that the following benefits, which exceed ACA requirements, must be provided or offered by private providers authorized to sell health insurance within the state:

  • Home health care services – up to 60 visits per year – for individual and group plans, does not apply to HMOs
  • Durable medical equipment – orthotic and prosthetic appliances – for individuals, small and large group plans
  • Hearing aids – for children 15 and under – for individual, small and large group plans
  • Reconstructive surgery – breast reconstruction following mastectomy – for individual and group plans
  • Cancer treatments – for individual and group plans
  • Diabetes care management –for individual, small and large group plans
  • Infant formulas – for individual and group plans
  • Off label prescriptions drugs – for individual, small and large group plans
  • Prescription drugs other – oral anticancer treatment – for individual, small and large group plans
  • Second and third surgical opinion – for individual, small and large group plans
  • Sickle cell anemia – for individual, small and large group plans
  • Hemophilia treatment – blood products and infusion equipment – for individual and group plans
  • Wilm’s tumor treatment – for individual and group plans

New Jersey Available Standardized Plans

To help you more easily compare costs and benefits, ACA designates that all qualifying plans be one of four metals: Bronze, Silver, Gold and Platinum. Each is based on the average amount of healthcare costs the plan will cover shown as a percentage of what is covered by your insurance company and what is paid for by you. All insurers participating in the federal or a state healthcare exchange must offer , at minimum, Silver and Gold plans. All metal plans have a shared maximum out-of-pocket amount that you can be charged in any calendar year.

Metal PlanInsurer PaysYou Pay

In addition, if you are under 30 or meet the criteria for a hardship exemption, you can purchase a catastrophic plan that is compliant with ACA requirements.


Premiums charged for any of the qualifying metal plans may be based on:

  • Your age
  • Tobacco use
  • Where you live – determined by rating area
  • The number of family members enrolling with you

Guaranteed Issue

Under ACA, no one can be denied coverage or charged significantly higher premiums because of past health history (pre-existing conditions) or gender. There can be no look-back or waiting periods imposed. Policies are effective on issue. All coverage is renewable, if you choose to renew it. Plans can only be canceled for non-payment of premiums or fraud. The guaranteed issue provision applies to all non-grandfathered plans.

(Video) Everything you Need to Know about COBRA Insurance

ACA Financial Assistance

You may qualify for financial assistance in the form of tax credits to help with monthly premiums and subsidies to help with out-of-pocket costs.

  • Tax credits can be applied to any of the four metal plans to lower your monthly premiums. They are paid directly to your insurance provider by the federal government. Your tax credit is based on your estimated income for the calendar year, in advance of filing your federal return.Note that if your actual income exceeds the eligibility limit, you will have to reimburse the government for the difference. Tax credits are only available to New Jersey residents who purchase coverage from
  • Subsidies to help New Jersey residents with out-of-pocket expenses such as copayments are only available for Silver plans purchased through and are only offered to those who earn up to 250% of the federal poverty level.

Provider Options

The following types of health insurance plans are available in New Jersey for individuals and families. They may be purchased through private providers or providers participating in New Jersey through the federal exchange,

  • Preferred Provider Organizations (PPOs)
    You have access to a network of healthcare providers participating in your selected PPO. You do not have to select a Primary Care Physician or obtain a referral to see any in-network provider. Some PPOs may require that you meet a deductible before their portion of the coverage begins.
  • Health Maintenance Organizations (HMOs)
    Most HMOs require you to select a Primary Care Physician to coordinate your healthcare and provide referrals to specialists. HMOs typically charge a fixed copayment for each doctor visit and other care provided. Depending on the HMO, there may be a low deductible or no deductible in addition to the copayments. All services must be obtained through the HMO’s network, unless otherwise stated in your plan.
  • High-Deductible Health Plans with Health Savings Accounts (HDHP w/HSAs)
    These plans give you more control over your out-of-pocket expenses by offering lower monthly premiums with higher deductibles. They are typically combined with HSAs that allow you to set aside interest-earning pretax funds (through your employer’s payroll deduction) or tax-deductible funds you deposit in a private account. These funds can be drawn on to cover your healthcare costs. Any interest accrued is tax-deferred and any unused funds can roll over from year to year. See your tax advisor for information specific to your situation.
  • Flexible Spending Accounts (FSAs)
    ACA provisions allow you to continue to make tax-free contributions up to $2,500 per year to an FSA. These can be used for out-of-pocket healthcare expenses not covered by your insurance plan. This includes many over-the-counter (OTC) preparations, devices and equipment as allowed by law. However, you will need to obtain a prescription for OTC items and submit an itemized receipt to qualify for the tax deduction.

New Jersey Regulating Agencies and Insurance Information Resources

New Jersey Department of Banking and Insurance
20 West State Street, P.O. Box 325, Trenton, NJ 08625

Insurance Information Institute
110 William Street, New York, NY 10038

Federal Healthcare Exchange
Find local in person enrollment assistance

(Video) EAS Pension and Annuity Webinar

SHOP New Jersey – Healthcare Insurance for Small Businesses

Fast Facts About ObamaCare

New Jersey Health Insurance GuidebyE-Insure Services, licensed under aCreative Commons Attribution-No Derivative Works 3.0 United States License. Based on a work Permissions beyond the scope of this license may be available at

New Jersey Health Insurance Law, Plan and Regulation | EINSURANCE (1)

(Video) Life Insurance study class TYPES OF INSURANCE


How can I avoid health insurance fines in NJ? ›

If you have Medicaid or Medicare, or have health insurance through your job, or purchase health insurance through the Health Insurance Marketplace created by the ACA, or purchase comprehensive insurance directly from an insurance company, you meet the MEC requirement and will not have to pay the penalty.

Is there a penalty for not having health insurance in NJ 2022? ›

Bottom Line. There are no federal mandates for health insurance in 2022 or tax penalties in most states. Few states have enacted penalties for the uninsured, including Massachusetts, New Jersey, Rhode Island, California, and Washington DC.

Is NJ 2022 insurance mandatory? ›

The New Jersey Health Insurance Market Preservation Act requires most state residents to maintain health coverage. You and your tax household must have minimum essential health coverage, qualify for an exemption, or remit a Shared Responsibility Payment when you file your New Jersey Income Tax return.

What is the maximum income to qualify for free health care NJ? ›

View coronavirus (COVID-19) resources on Visit for live updates.
Who is eligible for New Jersey Medicaid Program?
Household Size*Maximum Income Level (Per Year)
4 more rows

Do I have to pay penalty for not having health insurance in NJ? ›

Failure to have health coverage or qualify for an exemption may result in the assessment of a Shared Responsibility Payment (SRP) on your New Jersey Income Tax return. Individuals who are not required to file a New Jersey Income Tax return are automatically exempt from the SRP.

Is it mandatory to have medical insurance in NJ? ›

The New Jersey Health Insurance Market Preservation Act requires every New Jersey resident to obtain health insurance, have a valid exemption, or make a Shared Responsibility Payment (SRP).

Do I have to pay IRS for not having health insurance? ›

If you had no health coverage

Unlike in past tax years, if you didn't have coverage during 2021, the fee no longer applies. This means you don't need an exemption in order to avoid the penalty.

What type of insurance is mandatory in New Jersey? ›

Auto insurance is mandatory in New Jersey, but the type and cost of that coverage can vary significantly. Every day, consumers are finding that there are options available to make it easier to comply with the law. The Automobile Insurance Cost Reduction Act mandated that a Basic Policy be available to all drivers.

Can you get fined for not having health insurance? ›

There is no federal penalty for not having health insurance since 2019, however, certain states and jurisdictions have enacted their own health insurance mandates. The federal tax penalty for not being enrolled in health insurance was eliminated in 2019 because of changes made by the Trump Administration.

What is the income limit for NJ Medicaid 2022? ›

The New Jersey Care… Special Medicaid Programs are for individuals with gross monthly income that is equal to or less than 100% of the Federal Poverty Level which is $1,133 per month for a single person and a resource maximum of $4,000; $1,526 per month for a couple and a resource maximum of $6,000 in 2022.

What is the highest income to qualify for Medicaid 2022? ›

Income Limit in Most States

Most states — 38 and Washington, D.C. — have the same income limit of $2,523 per month for a single person for most types of Medicaid services. For a married couple, the limit increases to $5,046 in most cases.

How much money can you have in the bank to qualify for Medicaid in NJ? ›

The medically needy asset limit is $4,000 for an individual and $6,000 for a couple. 2) Qualified Income Trusts (QIT) – Also called Miller Trusts, QITs offer a way for persons over the Medicaid income limit to still qualify for nursing home Medicaid or Home and Community Based Services.

What happens if you don't make enough money to qualify for Obamacare? ›

Enroll on-exchange if your income is uncertain

Enroll in Medicaid if you're eligible. For people who aren't eligible for Medicaid but who have uncertain incomes, it's generally a good idea to enroll through the exchange during open enrollment.

What happens if you have a gap in health insurance coverage? ›

Known gap: Known out-of-pocket costs

Usually, if the doctor charges up to $500 more than the no gap amount, you pay the difference between the no gap amount and the doctor's fee. The health fund and Medicare pay the rest. This usually limits your out-of-pocket costs to a maximum of $500.

Is the Affordable Care Act still in effect for 2022? ›

You can get health coverage for the rest of 2022 if you qualify for: A Special Enrollment Period due to a recent life event, like losing other coverage, moving, getting married, or having a baby.

Does New Jersey have an individual mandate? ›

New Jersey's State Individual Mandate requires New Jersey taxpayers to have minimum essential coverage throughout the year (or qualify for coverage exemption). Exemptions can be obtained if there is a short gap in coverage, if coverage is deemed unaffordable, or other reasons.

Who qualifies for health coverage exemption? ›

Health coverage exemptions, forms & how to apply

You need an exemption if you're 30 or older and want to enroll in a "Catastrophic" health plan. A Catastrophic health plan offers lower-priced coverage that mainly protects you from high medical costs if you get seriously hurt or injured.

Do I have to file Form 3853? ›

Giving evidence of health care coverage, federal Form 8962, does not remove the requirement to file California Form 3849. The two California Forms 3849 and 3853 need to be completed as needed in addition to the federal forms.

Is the individual mandate gone? ›

The individual mandate itself still exists (and qualifying for an exemption from the mandate still allows a person to buy a catastrophic health plan even if they're 30 or older). But there is no longer a federal penalty for non-compliance. What Is the Individual Mandate?

Is health insurance tax deductible in NJ? ›

If you are considered self-employed for federal tax purposes, or you received wages in 2021 from an S corporation in which you were a more-than-2% shareholder, you can deduct the amount you paid during the year for health insurance for yourself, your spouse/civil union partner or domestic partner, and your dependents.

What is considered minimum essential coverage under ACA? ›

Minimum essential coverage, also called qualifying health coverage, is any health plan that meets Affordable Care Act (ACA) requirements for having health coverage. Qualifying plans include marketplace insurance, job-based health plans, Medicare, Medicaid and the Children's Health Insurance Program (CHIP).

Does the IRS know if you have health insurance? ›

Form 1095-C

Companies report to the IRS whether or not employees participate in their health plans. They also send employees Form 1095-C to keep as a tax record.

Do insurance companies report claims to IRS? ›

Generally, insurance companies will only be required to file Form 8300, Report of Cash Payments Over $10,000 Received in a Trade or Business, to report cash received as payment for insurance products if the cash received is in the form of currency (U.S. and foreign coin and paper money) in excess of $10,000.

What is proof of minimum essential coverage? ›

Acceptable Documents for Proof of Minimum Essential Coverage

Notice of Action of discontinuance from Medicaid. Notice of Action of discontinuance from Medi-Cal. Confirmation of disenrollment from your health insurance plan. Confirmation of disenrollment from your employer-sponsored health insurance plan.

What is the minimum insurance requirement in New Jersey? ›

The minimum amount of New Jersey auto insurance coverage is $15,000/$30,000/$5,000. In the event of a covered accident, your limits for bodily injury are $15,000 per person, with a total maximum of $30,000 per incident. It also covers up to $5,000 for damage to another person's property.

What is full coverage in New Jersey? ›

Full coverage car insurance includes a minimum of $15,000/$30,000 liability limits (most consumers purchase $100,000/$300,000), $5,000 in property damage liability and the ability to buy PIP coverage limits from $15,000 to $250,000.

How much insurance do I need in NJ? ›

In New Jersey, car insurance laws mandate drivers to carry minimum liability insurance coverage of 15/30/5. In addition, drivers need a minimum of $15,000 coverage for personal injury protection (PIP). Drivers who fail to meet these state minimum car insurance requirements can face fines, penalties and even jail time.

How many Americans have no health insurance? ›

Roughly 26 million people remain without health insurance in the U.S. Just under 2 percent of children are now uninsured.

Is health insurance mandatory in USA? ›

Health insurance coverage is no longer mandatory at the federal level, as of Jan. 1, 2019. Some states still require you to have health insurance coverage to avoid a tax penalty.

Are public hospitals free in USA? ›

Are public hospitals free in the USA? St. Jude's Children's Hospital provides free care & operates on donations. No public or private hospital provides free care, although taxpayers may be stuck with bills from people who can't pay.

What is the monthly income limit for Medicaid in NJ? ›

(By contrast, 138% FPL in 2019 was $1,437 per month, or $17,237 per year.) The only other eligibility criteria are ineligibility for Medicare and certain immigration-related restrictions.
Household SizeAnnualMonthly
1$17,609$ 1,468
2$23,792$ 1,983
3$29,974$ 2,498
4$36,156$ 3,013
5 more rows

What is the highest income to qualify for Medicaid? ›

Federal Poverty Level thresholds to qualify for Medicaid

The Federal Poverty Level is determined by the size of a family for the lower 48 states and the District of Columbia. For example, in 2022 it is $13,590 for a single adult person, $27,750 for a family of four and $46,630 for a family of eight.

Do you have to pay back Medicaid in NJ? ›

A. Here's how it works. Under both federal and New Jersey law, Medicaid is required to recover funds from the estate of an individual receiving — or who has received — Medicaid benefits on or after age 55.

Does medical look at savings account? ›

After January 2024, the ownership of a home, more than one vehicle, or the amount of money and savings in a banking account, will not be taken into account for Medi-Cal benefts. Q: Will Medi-Cal income limits change? No, this change applies only to the Medi-Cal asset limit.

What is the federal poverty level for 2022? ›

Federal Poverty Level (FPL)
Family size2021 income number2022 income numbers
For individuals$12,880$13,590
For a family of 2$17,420$18,310
For a family of 3$21,960$23,030
For a family of 4$26,500$27,750
5 more rows

Will inheritance affect my Medicare benefits? ›

Inheriting money or receiving any other windfall, such as a lottery payout, does not bar you in any way from receiving Medicare benefits. An inheritance won't prevent you from receiving Social Security retirement benefits or Social Security disability benefits either.

Does NJ Medicaid check your bank account? ›

While Medicaid agencies do not have independent access to a Medicaid recipient's financial statements, Medicaid does an annual update to make sure a Medicaid recipient still meets the financial eligibility requirements. Furthermore, a Medicaid agency can ask for bank statements at any time, not just on an annual basis.

How do I protect my assets from nursing home in NJ? ›

How to Protect Your Assets from Nursing Home Costs
  1. Purchase Long-Term Care Insurance. ...
  2. Purchase a Medicaid-Compliant Annuity. ...
  3. Form a Life Estate. ...
  4. Put Your Assets in an Irrevocable Trust. ...
  5. Start Saving Statements and Receipts.
27 Jul 2022

How do I protect my assets from Medicaid in NJ? ›

Many individuals have too many assets to qualify for these Medicaid benefits and can be left at the last minute paying for long-term care out of pocket instead of leaving it to the ones they love. Fortunately, placing assets in an irrevocable trust can shelter them, so they are no longer countable by Medicaid.

› medicaid › eligibility ›

Medicaid Eligibility › medicaid › eligibility › medicaid › eligibility
Medicaid is a joint federal and state program that, together with the Children's Health Insurance Program (CHIP), provides health coverage to over 72.5 mill...
Read New Jersey Medicaid eligibility requirements for long term care for seniors including the income, assets and level of care requirements.
Medicaid is the federal-and-state-funded health insurance program for low-income, needy Americans and their families. States jointly fund and run their programs...

What is hardship exemption NJ? ›

Hardship exemptions

You can qualify for this exemption if you had a financial hardship or other circumstances that prevented you from getting health insurance.

What is a hardship exemption? ›

An exemption that's needed when applying for Catastrophic coverage for people 30 and older who faced a "hardship" that prevented them from getting insurance. Hardship exemptions are one type of exemption that someone can claim to qualify for Catastrophic coverage, along with affordability exemptions.

Do I have to file 3853? ›

If you, or any member of your applicable household, did not have qualifying health care for the entire year, but had MEC and/or an exemption(s) for any month use form FTB 3853.

Is health insurance tax deductible in NJ? ›

If you are considered self-employed for federal tax purposes, or you received wages in 2021 from an S corporation in which you were a more-than-2% shareholder, you can deduct the amount you paid during the year for health insurance for yourself, your spouse/civil union partner or domestic partner, and your dependents.

How do I get a exemption certificate? ›

How you can apply. If you're entitled to a certificate because of your medical condition, speak to your GP or doctor. They'll give you an application form. You'll get a paper certificate in the post within 10 working days of us receiving your application.

What is exemption form? ›

A certificate of exemption is issued on application to prospective students who have obtained a Senior Certificate without endorsement or equivalent foreign school-leaving qualification, which meets the requirements of the published regulations and wishes to pursue first degree studies at a South African university.

Does NJ tax gap insurance? ›

Gap Insurance provided by a third-party insurance carrier is not taxable. (Please note that Gap Waivers are taxable). The sale of an extended warranty as an agreement to provide taxable services to tangible personal property is also subject to Sales Tax.

Does the IRS know if you had health insurance? ›

Each year, employers, insurance companies and others who provide health insurance will tell the IRS who they've covered. And they'll give you a Health Coverage Information Statement Form 1095-B or Form 1095-C) as proof you had coverage.

What is a medical hardship? ›

(fy-NAN-shul HARD-ship) In medicine, a term used to describe problems a patient has related to the cost of medical care. Not having health insurance or having a lot of costs for medical care not covered by health insurance can cause financial problems and may lead to debt and bankruptcy.

What is coverage considered unaffordable? ›

Affordability is calculated on the lowest-cost coverage available to you through an employer or Covered California. This coverage is considered unaffordable if your costs are more than 8.17 percent of your projected annual household income in 2023.

Will the IRS penalize for no health insurance? ›

Individuals who go without qualifying health coverage for a full year and don't file for an exemption may owe a tax penalty. The penalty amount is either 2.5% of the gross family household income or $695 per individual and $347.50 per child; you'll pay whichever amount is greater.

How do you avoid individual shared responsibility penalty? ›

You avoid the penalty if you have health insurance that provides what the law calls "minimum essential coverage." This includes nearly all employer-provided health plans, as well as coverage provided through government programs such as Medicare, Medicaid, veterans' health benefits and military Tricare plans.

Do I have to pay IRS for not having health insurance? ›

If you had no health coverage

Unlike in past tax years, if you didn't have coverage during 2021, the fee no longer applies. This means you don't need an exemption in order to avoid the penalty.

Does NJ tax health insurance premiums? ›

NJ Taxation

With a few exceptions, the tax rate is 2% of the premiums collected on insurance risks in this State. The tax is prepaid based on the previous year's premiums, with payments due March 1 and June 1. Exceptions: Group accident and health insurance premiums (1%);

Can I claim my health insurance premiums on my taxes? ›

You can usually deduct the premiums for short-term health insurance as a medical expense. Short-term health insurance premiums are paid out-of-pocket using pre-tax dollars, so if you take the itemized deduction and your total annual medical expenses are greater than 7.5% of your AGI, you can claim the deduction.

Are health insurance premiums tax-deductible in 2022? ›

Health insurance premiums can count as a tax-deductible medical expense (along with other out-of-pocket medical expenses) if you itemize your deductions. You can only deduct medical expenses after they exceed 7.5% of your adjusted gross income.


1. New Jersey Brokerage Regulations
(New Direction School)
2. Life insurance Practice Test Exam Prep 2 (Simulator exam With Commentary) -YBLA
(YBLA- YourBestLifeAcademy)
3. New Jersey Medicaid and New Health Care Laws
(Levine, Furman & Rubin, LLC)
4. Maintaining New Jersey's Reproductive Health Laws
(Steve Adubato)
5. Life and Health Insurance License Exam Free Practice Questions Past Paper Part 1
6. US Healthcare System Explained
(The Infographics Show)
Top Articles
Latest Posts
Article information

Author: Tyson Zemlak

Last Updated: 02/18/2023

Views: 6326

Rating: 4.2 / 5 (43 voted)

Reviews: 90% of readers found this page helpful

Author information

Name: Tyson Zemlak

Birthday: 1992-03-17

Address: Apt. 662 96191 Quigley Dam, Kubview, MA 42013

Phone: +441678032891

Job: Community-Services Orchestrator

Hobby: Coffee roasting, Calligraphy, Metalworking, Fashion, Vehicle restoration, Shopping, Photography

Introduction: My name is Tyson Zemlak, I am a excited, light, sparkling, super, open, fair, magnificent person who loves writing and wants to share my knowledge and understanding with you.