New Jersey § 52:14-17

§ 52:14-17.

As used in the School Employees' Health Benefits Program Act, sections 31 through

41 of P.L.2007, c. 103 ( C.52:14-17.46.1 through C.52:14-17.46.11 ): a. The term “ State ” means the State of New Jersey. b. The term “ commission ” means the School Employees' Health Benefits Commission, created by section 33 of P.L.2007, c. 103 ( C.52:14-17.46.3 ). c. The term “ employer ” means 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 which 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. d. (1) The term “ employee ” means a person employed in any full time capacity by an employer, and shall include

persons defined as a school employee by the regulations of the State Health Benefits

Commission in effect on the effective date of the School Employees' Health Benefits

Program Act. “Full-time” shall have the same meaning as in the regulation of the State Health Benefits

Commission regarding local coverage in effect on the effective date of the School

Employees' Health Benefits Program Act. (2) After the effective date of P.L.2010, c. 2 , the term “ employee ” means (a) a person employed in any full-time capacity by an employer who appears

on a regular payroll and receives a salary or wages for an average of the number of

hours per week as prescribed by the governing body of the participating employer which

number of hours worked shall be considered full-time, determined by resolution, and

not less than 25, and shall include persons defined as a school employee by the regulations

of the State Health Benefits Commission in effect on the effective date of the School

Employees' Health Benefits Program Act, or (b) a person employed in any full-time

capacity by an employer who has or is eligible for health benefits coverage provided

under P.L.1961, c. 49 ( C.52:14-17.25 et seq. ) or sections 31 through 41 of P.L.2007, c. 103 ( C.52:14-17.46.1 et seq. ) on that effective date and continuously thereafter provided the person is covered

by the definition in paragraph (1) of this subsection. 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. 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 School Employees' 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 School Employees' Health Benefits Program shall be final and binding

on all parties. e. The term “ dependents ” means an employee's spouse, domestic partner, or partner in a civil union couple,

and unmarried children under the age of 23 years who live in a regular parent/child

relationship. “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, domestic partners, or partners

in a civil union couple, of retired persons who are otherwise eligible for the benefits

under the School Employees' 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. f. The term “ 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 ( C.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. g. The term “ hospital ” means: (1) an institution operated pursuant to law which is primarily engaged in providing

on its own premises, for compensation from its patients, medical diagnostic and major

surgical facilities for the care and treatment of sick and injured persons on an inpatient

basis, and which provides such facilities under the supervision of a staff of physicians

and with 24 hour a day nursing service by registered graduate nurses, or (2) an institution not meeting all of the requirements of paragraph (1) but which

is accredited as a hospital by the Joint Commission on Accreditation of Hospitals.

In no event shall the term “hospital” include a convalescent nursing home or any institution

or part thereof which is used principally as a convalescent facility, residential

center for the treatment and education of children with mental disorders, rest facility,

nursing facility or facility for the aged or for the care of persons with substance use disorder . h. The term “ 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. s.1395 et seq. ), as amended, or its successor plan or plans. i. The term “ 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. j. The term “ successor plan ” means a managed care plan that shall replace the “traditional plan,” as defined

in section 2 of P.L.1961, c. 49 ( C.52:14-17.26 ), and that shall provide benefits as set forth in section 36 of P.L.2007, c. 103 ( C.52:14-17.46.6 ), and provide out-of-network benefits to participants with a payment by the plan

of 80 percent of reasonable and customary charges as set forth in section 37 of P.L.2007, c. 103 ( C.52:14-17.46.7 ) and as may be adjusted in accordance with section 40 of P.L.2007, c. 103 ( C.52:14-17.46.10 ).