The IHC Program has been fully operational, as a standardized, open-enrolled, community rated market, since August 1, 1993. Individual coverage is available to anyone who is a resident of New Jersey and does not have access to employer-based group insurance or Medicare. The SEH Program went into effect on January 1, 1994, with the sale of standardized, open-enrolled, modified community rated plans. Small employers (those with 2-50 full-time employees) may choose to purchase standardized health benefits plans, offered by all carriers, or, under certain conditions, they may purchase or renew pre-reform ("non-standard") plans. The small employer market is a "modified community rated" market, which permits carriers to consider the age and gender of the employees and the location of the business in determining rates.

The IHC and SEH Programs are each run by a Board of Directors responsible for implementing health insurance reform and regulating the market. The IHC Board consists of nine people (some appointed by the Governor and others elected by insurance companies and HMOs doing business in New Jersey) representing insurers, HMOs, consumers, the AFL-CIO, and the Commissioner of Insurance. The SEH Board is similar in makeup, and consists of 18 members, including insurance agents, a doctor, representatives of small business, and others. Members of the boards meet monthly and serve without compensation. The Boards are State agencies with rulemaking authority and are funded entirely by assessments of health insurers and HMOs.

Standard Plans:
The standard health benefits plans (called B, C, D, and E) and an HMO plan, designed by the Boards, are the only plans carriers may offer to individual New Jersey residents. Small employers may purchase standard plans and may renew or purchase pre-reform plans under certain conditions. Carriers must offer all plans on a guaranteed issue/guaranteed renewal basis, which means that an eligible person or small employer can never be denied coverage or renewal.

Community Rating:
The standard plans for individuals are community rated, which means that a carrier must offer a standard plan to everyone at the same rate, regardless of the applicants' age, gender, profession, health status or geographical location in the State. In the small employer market, the plans may be rated only on the basis of age, gender, family status of the employees in the group, and the location of the business in the State - not on health status.

Portability and Pre-existing Conditions:
Generally, all conditions are covered by a standard plan as of the effective date, if an applicant's prior health coverage has not lapsed. An individual applicant without prior coverage may have to wait for up to one year for coverage of a pre-existing condition. In the small employer market, a pre-existing condition waiting period of up to six months may be imposed only on groups of two to five that have no prior coverage. None may be imposed on groups of six to 50.

Minimum Loss Ratio:
Rates carriers charge for coverage are not regulated. However, a carrier participating in the IHC or SEH Program is required to pay out 75 cents in benefits for every dollar received in premiums. If this minimum loss ratio of 75% is not met, the carrier must refund some portion of the premium to the policyholder.

SEH Program Results:
The small employer market has been highly successful. Based on enrollment figures provided to the SEH Board by carriers, 847,000 persons were covered under small employer plans as of the end of 1997, up from 694,000 as of the end of 1994, an increase of nearly 150,000 persons in three years. Approximately 15% of small employers purchasing coverage in the 4th Quarter of 1997 were previously uninsured.
A free Buyer's Guide may be obtained by calling 1-800-263-5912.