Here are some things to expect after you apply for health coverage through GetCoveredNJ:
When you apply, GetCoveredNJ will confirm your information automatically. If it cannot, you will be asked to submit documents to confirm information on your application.
The type of document you have to send depends on what GetCoveredNJ could not confirm. Listed below are the documents you may be asked to send. The most common data matching issues are income, citizenship, and immigration information. You will have 90 days to send your documents.
If you apply for coverage outside of Open Enrollment, you may need to send documents to learn if you qualify for a Special Enrollment Period.
You will know if you need to send documents when you get your eligibility letter. You can also look in your GetCoveredNJ account. When you apply, you will get an eligibility letter. If it says you have to send documents to confirm information, send them as soon as you can.
You can upload documents and check on your status in your GetCoveredNJ account. If you need help, you can call the Customer Call Center. Or you can work with a free certified assister or health insurance agent (broker).
Why do I have to confirm my information?
GetCoveredNJ will ask you to confirm information if there is a data matching issue on your application. A data matching issue happens when information on an application cannot be matched with the data in trusted resources such as Social Security records and IRS databases.
- Verify Income
- Verify Identity
- Verify United States Citizenship
- Verify Eligible Immigration Status
- Verify Social Security Number
Not sure what to expect now that you are enrolled in coverage? Find answers below
Your health plan will send you a membership package. It will have enrollment materials and a health insurance card. The card is your proof of insurance. It may take a few days after you apply through GetCoveredNJ for your health plan to send your card, especially in busy times like Open Enrollment.
If you don’t get your card, call your health plan. Ask if they sent your card. Ask if your coverage is active. Health plan member services numbers are listed on their websites. Or go to this list of insurance companies and their customer service phone numbers.
If you enroll by December 31, your coverage will start on January 1. If you enroll in January, your coverage will start on February 1.
If you do not have a health insurance card, contact your health plan. They may be able to tell you your member number or send you a temporary card to give your doctor or pharmacy. Here is a list of insurance companies and their customer service phone numbers.
If you get care after your coverage starts but before you get your card, you may have to pay for your care at the time of service. If you pay for covered services, you can file a claim with your health plan to get it paid back.
You pay your premium directly to your health plan. Follow their instructions for how and when to pay your premium. You may be able to pay online. It is important to pay your total monthly premium to your health plan by the due date. Your coverage could end if you do not pay your monthly premiums. Here is a list of insurance companies and their customer service phone numbers.
If you don’t agree with a Marketplace decision, you may be able to file an appeal. You generally have 90 days from the date of your Eligibility Determination Notice to ask for an appeal.
Marketplace decisions you can appeal:
- Not eligible for advance payments of the premium tax credit (APTC)
- Eligible for APTC, but the amount is wrong
- Not eligible for a Special Enrollment Period
- Not eligible to buy a Marketplace plan
- Not eligible to choose a Catastrophic plan
You cannot file an appeal until you get the Eligibility Determination Notice. It is a letter that says your eligibility for coverage has ended or your savings have changed. The letter will also explain your appeal rights.
You may challenge coverage denials by a health insurance company. Coverage required on an emergency or urgent basis require a decision within 48 hours.
Other types of denials may also be challenged. These include utilization management (UM) denials. UM denials are refusals to pay a claim or authorize a service or supply because the insurance company determined it is:
- not medically necessary to treat the covered person’s illness or injury,
- experimental or investigational,
- cosmetic, or
- dental rather than medical.
Two other types of UM decisions that may also be challenged:
- Denial of an “in-plan exception” (a request to get services from an out-of-network provider when the insurance company’s network does not have any providers who are qualified, accessible, and available to perform the specific medically necessary service), and services are required on an emergency or urgent basis.
- Administrative denials, such as refusal to pay a claim or authorize a service or supply based on contract provisions or other grounds not involving the exercise of medical judgment.
To learn more, go to: https://www.nj.gov/dobi/division_insurance/managedcare/ihcap.htm.
Health care providers are not allowed to “balance bill” for certain surprise services, such as in an emergency, or when an in-network provider was not available in an in-network hospital. Under state law, doctors and hospitals may not bill you above the amount of your in-network cost-sharing, including your deductible, co-pays, or co-insurance.
Report to your health plan any attempts by the out-of-network health care provider to bill you for these types of services above what you would pay for in-network care. You may also file a complaint with the New Jersey Department of Banking and Insurance online. Or call the consumer hotline at Consumer Hotline 1-800-446-7467, from 8:30 am to 5:00 pm EST Monday through Friday.
To learn more about consumer protections from out-of-network billing, go to: https://www.state.nj.us/dobi/division_consumers/insurance/outofnetwork.html
If anyone in your household had a Marketplace plan in 2020 through Healthcare.gov, you should get Form 1095-A, Health Insurance Marketplace Statement, in the mail in early 2021. This form is needed to file your 2020 taxes and to show that you had health coverage. New Jersey requires individuals to maintain minimum essential coverage.
- Your 1095-A has information about Marketplace plans anyone in your household had in 2020.
- The form comes from the Healthcare.gov, not the IRS.
- Keep your 1095-As with your important tax information, W-2 forms, and other records.
To learn more about the 1095-A form and contacting Healthcare.gov, go to: https://www.healthcare.gov/tax-form-1095/#find-1095-a.
Starting in early 2022, your 1095-A forms for your 2021 coverage will come from Get Covered New Jersey.