Health Republic Insurance of New Jersey: Coverage Information

Coverage Information

    Balance Billing and Out-Of-Network Liabilities

  • Our plans provide affordable coverage for health services from providers within our network. Sometimes our members may need to seek care outside of our network. Selecting a provider that is out-of-network will increase your out-of-pocket expenses. Before you make an appointment, please make sure that your provider is within our network. You can find a complete list of our providers in our Provider Directory. 

  • Except in the case of an emergency, out-of-network services are not covered by HRINJ. You will be billed by the provider for out-of-network services and you will be responsible for the total cost. Out-of-network services can be defined as care from a non-network (non-participating) provider inside the service area, and as care from a non-network (non-participating) provider outside the service area.

    An exception can be made when there is not an in-network provider available who can provide the medically necessary service. In that event, the member is required to seek authorization from HRINJ prior to using the service. If the authorization is granted, you will only be responsible for the deductible, coinsurance, or copayment you would be responsible for in-network.

    IMPORTANT EXCEPTION: Emergency services do not require prior authorization. However, please notify HRINJ of these services within 48 hours, or as soon as is reasonably possible. In an emergency, you will only be responsible for the deductible, coinsurance, or copayment you would be responsible for in-network.

  • Member Claims Submission

  • Providers in our network submit claims to us on your behalf when you (or your enrolled dependents) receive services.

    If you are required to submit a claim directly for any reason, you can download a Member Claim Form, and follow the instructions. Should you need to submit a medical claim, please mail it to the following address:

    Health Republic Insurance of New Jersey 
    PO Box 1269
    Piscataway NJ 08855-1269

    Accurate and complete claim forms must be submitted to HRINJ within 365 days from the date of service.

  • Grace Periods

  • PAYMENT OF PREMIUMS - GRACE PERIOD

    On Exchange Members: No APTC or APTC members, who have not paid a full month’s premium during the plan year.

    The following paragraph only applies to Covered Persons who are NOT recipients of the advanced premium tax credit (APTC) and Covered Persons who are recipients of the premium tax credit but have not paid at least one full month’s premium during the Plan Year.

    Premiums are to be paid by you to Health Republic Insurance of New Jersey. They are due on each premium due date. You may pay each premium other than the first within 31 days of the premium due date. Those days are known as the grace period. You are liable to pay premiums to Health Republic Insurance of New Jersey from the first day the Policy is in force in order for the Policy to be considered in force on a premium-paying basis. You will be liable for the payment of the premium for the time the Policy stays in effect. If any premium is not paid by the end of the grace period, coverage will end as of the end of the period for which premium has been paid. You may be responsible for the payment of charges incurred for services or supplies received during the grace period.

    APTC members with at least one full month’s premium during the plan year. The following paragraph only applies to Covered Persons who ARE recipients of the advanced premium tax credit (APTC) who have paid at least one full month’s premium during the Plan Year.

    Premiums are to be paid by you to Health Republic Insurance of New Jersey. They are due on each premium due date. While each premium is due by the premium due date there is a grace period for each premium other than the first that runs for 3 consecutive months from the premium due date. We will pay all appropriate claims for services and supplies received during the first month of the grace period. We will pend the payment of claims for services beyond the first month through the end of the 3-month grace period. We will send you a notice if you do not make payment by the premium due date and if payment is not made, the Policy will end 30 days following the date of the notice. You will be liable for the payment of the premium for the time coverage stays in effect. We will notify the Federal Department of Health and Human Services that you have not paid the required premium by the premium due date. We will also notify the Providers for the pended claims that the claims may be denied.

    When a claim is ‘pended’, no payment is made. Instead, the claim is held until back premiums are paid, in which case the claim is processed and paid as appropriate. If back premiums are not paid during the grace period, the pended claims are denied at the end of the grace period.

  • PAYMENT OF PREMIUMS - GRACE PERIOD

    Premiums are to be paid by the Policyholder to the SHOP Marketplace for remittance to Health Republic Insurance of New Jersey. Each may be paid to the SHOP Marketplace by:

    1. Using your online account at HealthCare.gov/small-business/; or
    2. Calling the SHOP Call Center at 1-800-706-7893; or
    3. Mailing your premium check to: SHOP Marketplace, P.O. Box 2130, South Portland, ME 04116. A premium payment is due on each premium due date stated on the first page of the Policy. The Policyholder may pay each premium other than the first within 31 days of the premium due date without being charged interest. Those days are known as the grace period. If the premium is not paid by the end of the grace period, the Policy will terminate as of the paid-to-date.
  • Retroactive Denials

  • Health Republic Insurance of New Jersey will not retroactively terminate a Covered Person’s coverage after coverage takes effect unless the Covered Person performs an act, practice, or omission that constitutes fraud, or unless the Covered Person makes an intentional misrepresentation of material fact.

    Under certain circumstances, claims may be paid after a Covered person is no longer covered. For example, an employer may be late in reporting the deletion of a former employee. Claims may be “retroactively denied” as a result of eligibility changes. When the error has been corrected, any impacted claims would be adjusted accordingly. With the exception of claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing, or claims that were subject to coordination of benefits, Health Republic will not seek reimbursement for overpayment of a claim previously paid later than 18 months after the date the first payment on the claim was made.

    Members are highly encouraged to pay their premiums on-time. Members who have changed plans should ensure that their providers have the most current insurance information.

  • Recoupment of Overpayments

  • No clerical error or programming or systems error by the Policyholder or by Health Republic Insurance of New Jersey in keeping any records pertaining to coverage under the Policy will reduce a Covered Person's coverage. Neither will delays in making entries on those records reduce it. However, if Health Republic Insurance of New Jersey discovers such an error or delay, a fair adjustment of premiums will be made.

    Premium adjustments involving return of unearned premium to the Policyholder will be limited to the period of 12 months preceding the date of our receipt of satisfactory evidence that such adjustments should be made.

    If any relevant facts, are found to have been misstated, and the premiums are thereby affected, an equitable adjustment of premiums will be made. If such misstatement involves whether or not the person's coverage would have been accepted by us, subject to the Policy’s Incontestability section, the true facts will be used in determining whether coverage is in force under the terms of the Policy.

    If you believe you are entitled to a premium refund, contact us at 888.990.5706.

  • Except as stated below, neither clerical error nor programming or systems error by the Policyholder, nor Health Republic Insurance of New Jersey in keeping any records pertaining to coverage under the Policy, nor delays in making entries thereon, will invalidate coverage which would otherwise be in force, or continue coverage which would otherwise be validly terminated. Upon discovery of such error or delay, an appropriate adjustment of premiums will be made, as permitted by law.

    Exception: If an employee contributed toward the premium payment and coverage continued in force beyond the date it should have been validly terminated as a result of such error or delay, the continued coverage will remain in effect through the end of the period for which the employee contributed toward the premium payment and no premium adjustment will be made.

    Premium adjustments involving return of unearned premium to the Policyholder for such errors or delays will be made only if the employee did not contribute toward the premium payment. Except as stated in the Premium Refunds section of the Premium Amounts provision of the Policy, such return of premium will be limited to the period of 12 months preceding the date of our receipt of satisfactory evidence that such adjustments should be made.

    If the age of an employee is found to have been misstated, and the premiums are thereby affected, an equitable adjustment of premiums will be made.

    If you believe you are entitled to a premium refund, contact us at 888.990.5706.

  • Medical Necessity and Prior Authorization

  • One of the ways you can work together with us to keep our plans affordable is by using pre-approval (also known as prior authorization). This is a process during which we review a service your provider has recommended and determine if it is medically necessary and appropriate for your care. The actual course of medical treatment that you ultimately choose remains strictly between you and your provider. When you receive treatment within our provider network, the pre-approval or prior-authorization process is managed for your convenience by the participating provider. Our members are responsible, however, for obtaining prior authorization when using a non-participating provider for nonemergency care. In this situation, you should call Member Services at 888.990.5706 to obtain prior-authorization.

    Pre-Approval or Prior Authorization is required for charges incurred in connection with:

    • Durable Medical Equipment
    • Extended Care and Rehabilitation
    • Home Health Care
    • Hospice Care
    • Infusion Therapy
    • Speech, Cognitive Rehabilitation, Occupational and Physical Therapies
    • Autologous Bone Marrow Transplant and Associated Dose Intensive Chemotherapy for treatment of breast cancer
    • Nutritional Counseling (Applies only to Small Groups)
    • Certain Prescription Drugs including Specialty Pharmaceuticals and certain injectable drugs
    • Services and/or prescription drugs to enhance fertility
    • Complex Imaging Services
    • V2500 – V2599 Contact Lenses

    Benefits will be reduced by 50% with respect to charges for treatment, services and supplies which are not Pre-Approved by HRINJ provided that benefits would otherwise be payable under the Policy.

  • If you bring a prescription for a Prescription Drug for which we require Pre-Approval to a Pharmacy and Pre-Approval has not yet been secured, you must contact us to request Pre-Approval. The Pharmacy will contact the practitioner to request that the practitioner contact us to secure Pre-Approval. The Pharmacy will dispense a 96-hour supply of the Prescription Drug. We will review the Pre-Approval request within the time period allowed by law. If we give Pre-Approval, we will notify the Pharmacy and the balance of the Prescription Drug will be dispensed with benefits for the Prescription Drug being paid subject to the terms of the Policy. If we do not give Pre-Approval, you may ask that the Pharmacy dispense the balance of the Prescription Drug, with you paying for the Prescription Drug. You may submit a claim for the Prescription Drug, subject to the terms of the Policy. You may appeal the decision by following the Appeals Procedure process set forth in the Policy.

    For additional information on services that may require pre-approval or prior-authorization, we welcome you to reach out to us at Member Services at 888.990.5706

  • Drug Exceptions Timeframes and Enrollee Responsibilities

  • If your medication is not on our Preferred Drug List, or if the medication is marked PA, your doctor must provide required information and documentation through a prior approval process for you to receive your medicine.

    You and your practitioner may request that a Non-Preferred Drug be covered subject to the applicable copayment for a Preferred Drug. We will consider a Non-Preferred Drug to be medically necessary and appropriate if:

    • It is approved under the Federal Food, Drug and Cosmetic Act; or its use is supported by one or more citations included or approved for inclusion in The American Hospital Formulary Service Drug Information or the United States Pharmacopoeia-Drug Information, or it is recommended by a clinical study or review article in a major peer-reviewed journal; and
    • The practitioner states that all Preferred Drugs used to treat the illness or injury have been ineffective in the treatment of the Covered Person's illness or injury, or that all drugs have caused or are reasonably expected to cause adverse or harmful reactions in the Covered Person.

    We shall respond to the request for approval of a Non-Preferred Drug within one business day and shall provide written confirmation within 5 business days. Denials shall include the clinical reason for the denial. You may follow the Appeals Procedure set forth in the Policy. In addition, you may appeal a denial to the Independent Health Care Appeals Program.

    Download the prescription drug prior approval form

    For additional information on prescription drugs that may require pre-approval or prior-authorization, we welcome you to reach out to us at Member Services at 888.990.5706

  • Explanation of Benefits (EOB)

  • A few weeks after your service is performed, you will receive an Explanation of Benefits (EOB) to help you understand how a claim was paid by our claims department. The EOB contains detailed information about what we paid and what portion of costs are your responsibility. The portion of costs assigned to you will depend on your plan’s annual out of pocket amount, deductible, co-insurance and co-payment schedule. The EOB is not a bill, but rather a breakdown of costs regarding the service you received.

    You may access all of your EOBs 24 hours a day, 7 days a week in the Member Portal.

    More information on how to understand the EOB

  • Coordination of Benefits

  • Do you have more than one health insurance plan? If so, those plans need to work together to make sure you’re getting the most out of your coverage. One plan becomes your primary plan. It pays your claims first. Then the second plan pays toward the remaining cost.

    That process is called coordination of benefits.

    Coordinating your benefits helps us process your claims faster and maximizes your benefits, which can lower your out-of-pocket costs.

    It’s important that we keep your information up-to-date. We’ll send you a letter from time to time asking if you have any additional coverage. Please respond to that letter.

    Have you recently added a second insurance plan? Fill out the coordination of benefits form

    For additional information, please review your policy.