Sponsored by:
Senator SHIRLEY K. TURNER
District 15 (Hunterdon and Mercer)
SYNOPSIS
Establishes certain network adequacy and standard application requirements for health insurance carriers; requires determination of hospital diversity for tiered networks.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning network adequacy of health insurance carriers and supplementing P.L.1997, c.192 (C.26:2S-1 et al.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. As used in this act:
“Network adequacy” means the adequacy of the provider network with respect to the scope and type of health care benefits provided by the carrier, the geographic service area covered by the provider network, and access to medical specialists pursuant to the regulations promulgated pursuant to section 19 of P.L.1997, c.192 (C.26:2S-18).
“Tiered network” means a managed care plan provider network with more than one level or tier of in-network benefits, based on different levels of reimbursement and cost sharing accepted by the health care providers in that network.
2. Pursuant to section 19 of P.L.1997, c.192 (C.26:2S-18), the commissioner shall only approve the network adequacy of a managed care plan if:
a. The carrier has demonstrated that the provider network or, in the case of a tiered network, each tier of the tiered network, meets all requirements for network adequacy at the time of approval, including having the necessary contracts in place with providers to meet network adequacy. The commissioner shall not approve any provider network or any tier of a tiered network on a conditional or prospective basis.
b. In the case of a tiered network, the commissioner determines that each tier of the network includes a diversity of hospitals located throughout the State, including hospitals which provide significant levels of care to low-income, uninsured, and vulnerable populations, to assure that the tiered network does not discriminate against underserved or high-risk populations.
c. The carrier annually submits all information required by the standard network adequacy application to the commissioner, as provided in section 3 of this act.
3. The commissioner shall formulate a standard network adequacy application to be completed by any carrier offering a managed care plan. The form shall include all information relating to network adequacy or tiered network adequacy required by P.L.1997, c.192 (C.26:2S-1 et al.) and any regulations promulgated pursuant thereto, as well as any additional information the commissioner deems relevant.
4. The commissioner shall base any determination of the network adequacy of a managed care plan on the current number of covered persons under that plan, if the plan is in effect, as well as the number of projected covered persons anticipated to be enrolled the following year. The projections for covered persons shall be based on the persons to whom the plan is intended to be marketed.
5. This act shall take effect immediately.
STATEMENT
This bill requires health insurance carriers to meet certain network adequacy standards and requires the Commissioner of Banking and Insurance to make a determination of hospital diversity for tiered networks.
The bill prohibits the commissioner from issuing conditional approvals of provider network adequacy. Carriers must demonstrate that the provider network or, in the case of a tiered network, each tier of the tiered network, meets all requirements for network adequacy before network adequacy is approved, including having the necessary contracts in place at the time of approval. In the case of a tiered network, the commissioner must make a determination that each tier of the network includes a diversity of hospitals located throughout the State, including hospitals which provide significant levels of care to low-income, uninsured, and vulnerable populations, to assure that the tiered network does not discriminate against underserved or high-risk populations.
The bill requires the commissioner to formulate a standard network adequacy application to be completed by any carrier offering a managed care plan. The form must include all information relating to network adequacy or tiered network adequacy. The carrier must annually submit all information required by the standard network adequacy application to the commissioner.
This bill also provides that the commissioner must base any determination of the network adequacy of a managed care plan on the current number of covered persons under that plan, if the plan is currently in effect, as well as the number of projected covered persons anticipated to be enrolled the following year. The projections for covered persons must be based on the persons to whom the plan is intended to be marketed.
Under the bill, “tiered network” means a managed care plan provider network with more than one level or tier of in-network benefits, based on different levels of reimbursement and cost sharing accepted by the health care providers in that network. “Network adequacy” means the adequacy of the provider network with respect to the scope and type of health care benefits provided by the carrier, the geographic service area covered by the provider network, and access to medical specialists pursuant to the standards in the regulations promulgated pursuant to section 19 of P.L.1997, c.192 (C.26:2S-18).