S4687

An Act concerning health care access for certain individuals and supplementing P.L.1992, c.161 (C.17B:27A-2 et seq.).

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. a. The commissioner shall apply to the United States Secretary of Health and Human Services and the United States Secretary of the Treasury, under 42 U.S.C. s.18051 for a waiver of applicable provisions of the “Patient Protection and Affordable Care Act” with respect to health insurance coverage in the State for a plan year beginning on or after January 1, 2027, to effectuate the provisions of this act. If the waiver is approved, the commissioner may accept the waiver so long as the commissioner determines that implementation of the plan:

(1) will be beneficial to policyholders; and

(2) is expected to stabilize or reduce premiums for individuals residing in this State with incomes at or below 200 percent of the federal poverty guidelines who do not qualify for the State Medicaid or NJ FamilyCare Program.

b. If the commissioner accepts the waiver pursuant to subsection a. of this section, the commissioner and the board shall implement the plan to meet the waiver requirements in a manner consistent with federal and State law, as approved by the United States Secretary of Health and Human Services, and consistent with the provisions of this act. The commissioner may contract for actuarial services as necessary to implement the waiver application required pursuant to this section.

2. a. The commissioner shall establish a Basic Health Program in accordance with section 1331 of the “Patient Protection and Affordable Care Act” (42 U.S.C. s.18051), contingent upon the approval from the United States Secretary of Health and Human Services and the United States Secretary of the Treasury of a State Innovation Waiver application pursuant to section 1331 of the “Patient Protection and Affordable Care Act” (42 U.S.C. s.18051) and the commissioner's acceptance of any approval as provided in section 1 of this act.

b. The Basic Health Program shall:

(1) prioritize health equity, reduce the rate of uninsurance in this State, and promote continuous health care coverage;

(2) ensure that the program is available to qualified individuals residing in this State with incomes at or below 200 percent of the federal poverty guidelines who do not qualify for the State Medicaid or NJ FamilyCare Program;

(3) maximize leveraging of federal funds and minimize costs for enrollees in the program and to the State;

(4) provide, at a minimum, all essential health benefits required for an individual health benefits plan pursuant to P.L.2019, c.354 (C.17B:27A-7.26 et al.) and, to the extent practicable, an option or options for dental coverage;

(5) to the extent practicable, include an option that has no cost-sharing, deductibles or other out-of-pocket costs and an option that provides lesser cost-sharing, deductibles or other out-of-pocket costs than qualified health plans on the health insurance exchange;

(6) establish a capitation rate to be paid to providers that is sufficient to provide coverage, but with reimbursement rates that are higher than the current Medicaid reimbursement rates, to the extent practicable;

(7) offer health care coverage through managed care organizations and align procurements for service providers on the same cycle as the procurements cycle for managed care organizations;

(8) provide a transition period for eligible individuals to enroll in the program;

(9) take into account the health insurance exchange as an option for potential program participants if the participants choose to opt out of the program; and

(10) in addition to using managed care organizations to deliver the services in the program, include an option for offering the Basic Health Program on the health insurance exchange if the plans meet criteria established by the department.

3. The New Jersey Health Insurance Premium Security Fund, created pursuant to section 10 of P.L.2018, c.24 (C.17B:27A-10.10), shall be the repository for monies collected pursuant to this act, which shall be contingent upon approval from the United States Secretary of Health and Human Services and the United States Secretary of the Treasury of a State Innovation Waiver application pursuant to section 1331 of the “Patient Protection and Affordable Care Act” (42 U.S.C. s.18051) and the commissioner's acceptance of any approval as provided in section 1 of this act.

4. This act shall take effect immediately, except that sections 2 and 3 shall remain inoperative until the Commissioner of Banking and Insurance is granted and accepts a waiver pursuant to section 1 of this act, and the commissioner and the board may take any anticipatory administrative action in advance as necessary for the implementation of this act.

STATEMENT

This bill directs the Commissioner of Banking and Insurance to apply for a federal waiver of certain provisions of the Patient Protection and Affordable Care Act to support a Basic Health Program to provide health insurance to low-income individuals who are ineligible for Medicaid coverage. A Basic Health Program is to provide at a minimum, among other items:

(1) all essential health benefits required for an individual health benefits plan pursuant to current New Jersey law and, to the extent practicable, an option or options for dental coverage; and

(2) to the extent practicable, an option that has no cost-sharing, deductibles or other out-of-pocket costs and an option that provides lesser cost-sharing, deductibles or other out-of-pocket costs than qualified health plans on the health insurance exchange.

If the waiver is granted and the commissioner accepts the waiver, the board and the commissioner are to implement the plan to meet the waiver requirements in a manner consistent with federal and State law, as approved by the United States Secretary of Health and Human Services and the United States Secretary of the Treasury, and consistent with the provisions of the bill. The bill stipulates that the New Jersey Health Insurance Premium Security Fund in the State Treasury is to be the repository for monies collected pursuant to the bill, contingent upon approval of a State Innovation Waiver application pursuant to section 1331 of the Affordable Care Act and the commissioner’s acceptance of that approval.