SENATE, No. 296

STATE OF NEW JERSEY

217th LEGISLATURE

 

PRE-FILED FOR INTRODUCTION IN THE 2016 SESSION

 


 

Sponsored by:

Senator  JOSEPH F. VITALE

District 19 (Middlesex)

Senator  NIA H. GILL

District 34 (Essex and Passaic)

 

 

 

 

SYNOPSIS

     Establishes certain standards for health benefits plans with tiered network.

 

CURRENT VERSION OF TEXT

     Introduced Pending Technical Review by Legislative Counsel.

  


An Act concerning certain health insurance networks 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:

     “Carrier” means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, the State Health Benefits Commission and the School Employees’ Health Benefits Commission.

     “Emergency or urgent basis” means all emergency and urgent care services including, but not limited to, those services defined pursuant to N.J.A.C.11:24-5.3.

     “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.    In the case of a health benefits plan with a tiered network, a carrier shall ensure that:

     a.     the actuarial value of the health benefits plan is reported on the carrier’s website and in plan documents supplied to the subscriber, in a form and manner to be prescribed by the Department of Banking and Insurance;

     b.    the cost sharing amount associated with the lowest or least preferred tiered of the plan is, at a minimum, actuarially equivalent to the cost sharing associated with a level of coverage for a silver health plan, as defined in 45 C.F.R. 156.140; and

     c.     University Hospital, and any other general or acute care hospital that is designated an instrumentality of the State, shall be included in the highest or preferred tier of the network.

 

     3.    This act shall take effect immediately.

 

 

STATEMENT

 

     This bill places certain requirements on carriers offering health benefits plans with a tiered network.  A tiered network is 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.  Carriers include an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, the State Health Benefits Commission and the School Employees’ Health Benefits Commission.

     The bill also specifies that a carrier must report on its website and in plan documents supplied to the subscriber the actuarial value of a health benefits plan with a tiered network.  Additionally, the cost sharing amount associated with the lowest or least preferred tier of the health benefits plan must be, at a minimum, actuarially equivalent to the cost sharing associated with a silver level of coverage for a silver health plan offered in the Health Insurance Marketplace created through the Affordable Care Act, as defined in 45 C.F.R. 156.140.

     Finally, the bill requires that any tiered network plan include University Hospital, and any other general or acute care hospital that is designated an instrumentality of the State, in the highest or preferred tier of the network.