Bill Text: NJ A1871 | 2018-2019 | Regular Session | Introduced
Bill Title: Requires carriers to disclose selection standards for, and establishes certain requirements regarding, placement of health care providers in tiered health benefits plan network.
Spectrum: Partisan Bill (Democrat 8-0)
Status: (Introduced - Dead) 2018-01-09 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A1871 Detail]
Download: New_Jersey-2018-A1871-Introduced.html
STATE OF NEW JERSEY
218th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2018 SESSION
Sponsored by:
Assemblywoman ELIZABETH MAHER MUOIO
District 15 (Hunterdon and Mercer)
Assemblyman REED GUSCIORA
District 15 (Hunterdon and Mercer)
Assemblywoman VALERIE VAINIERI HUTTLE
District 37 (Bergen)
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington)
Assemblyman WAYNE P. DEANGELO
District 14 (Mercer and Middlesex)
Co-Sponsored by:
Assemblyman Danielsen, Assemblywomen Quijano and Pinkin
SYNOPSIS
Requires carriers to disclose selection standards for, and establishes certain requirements regarding, placement of health care providers in tiered health benefits plan network.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel.
An Act concerning tiered 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:
"Commissioner" means the Commissioner of Banking and Insurance.
"Hospital" means a general acute care hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.)
"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).
"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. The commissioner shall evaluate a tiered network annually for network adequacy. That evaluation shall be certified by the Commissioner of Health.
3. A carrier that offers a managed care plan that provides for in-network benefits and for a tiered network, shall:
a. as selection standards to determine the placement of health care providers in a tier, use at least quality of performance and cost-efficiency measurements that are endorsed by the National Quality Forum, the AQA, Leapfrog, or that are based on other bona fide nationally-recognized guidelines; and may use other performance measurement standards, provided that they are approved by the commissioner.
b. make written disclosures regarding the selection standards used to determine the placement of health care providers in a tier in accordance with the provisions of this act.
4. A carrier shall disclose to a health care provider at least 120 days prior to the beginning of a plan's open enrollment period in a manner to be determined by the commissioner, and on at least an annual basis and otherwise as frequently as the commissioner deems necessary, as to each plan that provides for a tiered network:
a. a description of the quality of performance and cost-efficiency measurements or other performance measurement standards used as selection standards to determine the placement of health care providers in a tier, including the data and methodology used to establish the performance measurements and the formulas or methods used to determine the weight given to any factors used to establish the performance measurements;
b. a notice that a health care provider has a right to seek review from, and provide additional information to, the carrier with respect to any selection standards used to determine the placement of the health care provider in a tier, and the data, methodology, formulas or methods used to establish the performance measurements, and to request the carrier to correct errors and to consider additional information; and
c. a notice that a health care provider has a right to appeal the carrier's placement of the health care provider in a tier, through an appeal process that shall be developed by the department pursuant to section 5 of this act.
5. a. A carrier shall submit a network for each plan that it offers, to the department for review, at least 120 days prior to the beginning of a plan's open enrollment period.
b. The department shall develop a process for a health care provider to appeal a decision by a carrier to place, or not to place, a provider in a tier and that process shall include all of the following components:
(1) The carrier shall notify the provider of the provider's placement in a tier at least 120 days prior to the beginning of a plan's open enrollment period;
(2) The provider shall have the right to appeal the provider's tier placement to the department within 20 days of receiving notification of the provider's tier placement; and
(3) The department shall issue a decision regarding the provider's tier placement within 30 days of receiving the provider's appeal.
c. The carrier shall submit its network to the department, including any revisions made pursuant to the appeal process set forth in subsection b. of this section, for final approval at least 60 days prior to the beginning of the plan's open enrollment period.
d. The provider shall have the right to elect to not participate in the carrier's network, within 10 days of receiving final notification of the provider's tier placement.
e. A carrier, for the purpose of placing hospitals in a tier, shall evaluate each hospital individually, and shall not use any system that aggregates the performance measurement standards or evaluations of multiple hospitals for determinations of placement of multiple hospitals in one tier.
6. The carrier shall submit to the commissioner, at least 120 days prior to the beginning of a plan's open enrollment period in a manner to be determined by the commissioner and on at least an annual basis and otherwise as frequently as the commissioner deems necessary, as to each plan that provides for a tiered network, a description of the quality of performance and cost-efficiency measurements, or other performance measurements standards, used as selection standards to determine the placement of health care providers in a tier, including the data and methodology used to establish the performance measurements and the formulas or methods used to determine the weight given to any factors used to establish the performance measurements.
7. a. At the time that the commissioner approves a carrier's network, the carrier shall disclose to consumers, as to each plan that provides for a tiered network:
(1) the names of each health care provider in the network and the tier in which the provider is placed;
(2) a description of the selection standards to determine the placement of health care providers in a tier, including the data and methodology used to establish the performance measurements and the formulas or methods used to determine the weight given to any factors used to establish the performance measurements; and
(3) any limitations of the data, methodology, or performance measurements used by the carrier, and that the performance measurements may have a risk of error and should not be used as the sole basis for selecting another health care provider.
b. The carrier shall disclose this information on its website and in accordance with any other requirements to be determined by the commissioner. The carriers shall also, clearly and conspicuously disclose, in all promotional and agreement materials, the cost-sharing differentials in various tiers.
8. A carrier shall not reclassify provider tiers or determine provider placement in tiered plans more than once per year, except that carriers may, at any time:
a. add providers to a network; and
b. change a provider's tier placement to the tier of a tiered network that provides the level of cost sharing that is most favorable to a covered person.
9. Nothing in this act shall be construed to require a carrier in any way to disclose to consumers, providers, or other carriers, any information concerning its negotiated fees between the carrier and providers.
10. If any person violates
any provision of this act, the Commissioner of Banking and Insurance shall have
the authority to assess penalties and take any other action provided for in
section 16 of P.L.1997, c.192 (C.26:2S-16).
11. This act shall take effect on the 90th day next following enactment.
STATEMENT
This bill supplements the "Health Care Quality Act" to require health insurance carriers to disclose selection standards for placement of health care providers in tiered health benefits plan networks and provides for the appointment of an oversight monitor to review compliance with the bill's requirements. With respect to those various selection standards and other data, the bill provides guidelines and details as to how those standards and data shall be calculated. For the purposes of 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.
The bill requires the carrier to disclose to the oversight monitor, as to each plan that provides for a tiered network, a description of:
(1) any quality of performance and cost-efficiency measurements used as selection standards to determine the placement of health care providers in a tier;
(2) the data and methodology used to establish the performance measurements;
(3) the formulas or methods used to determine the weight given to any factors used to establish the performance measurements;
(4) the extent to which nationally recognized evidence-based or consensus-based clinical recommendations or guidelines are used to establish the performance measurements;
(5) the extent to which data concerning patient episodes of care is used to establish the performance measurements;
(6) the extent to which patient treatment outcomes or patient satisfaction surveys are used to establish the performance measurements; and
(7) any limitations of the data, methodology, formulas or methods used to establish the performance measurements.
The carrier shall disclose this information in a manner to be determined by the oversight monitor and on at least an annual basis and otherwise as frequently as the oversight monitor deems necessary.
The bill further requires a carrier to disclose to consumers, as to each plan that provides for a tiered network:
(1) the names of each health care provider in the network and the tier in which the provider is placed;
(2) a summary of the information regarding performance measurements required to be disclosed to the oversight monitor pursuant to section 2 of this bill, which shall include information on and how performance measurements are used as selection standards to determine the placement of health care providers in a tier;
(3) a notice that the health care provider performance measurements are only a guide to choosing a health care provider and that consumers should confer with their primary care physician before selecting other health care providers;
(4) any limitations of the data, methodology, or performance measurements used by the carrier, and that the performance measurements may have a risk of error and should not be used as the sole basis for selecting another health care provider; and
(5) information on how a consumer can register a complaint with the carrier and the oversight monitor with respect to any aspect of a health care provider's placement in a tier or any disclosure required pursuant to this section.
The carrier shall disclose this information on its website and in accordance with any other requirements to be determined by the oversight monitor.
The bill also requires a carrier to disclose to a health care provider, as to each plan that provides for a tiered network:
(1) the information provided to the oversight monitor concerning quality of performance and cost-efficiency measurements used as selection standards to determine the placement of health care providers in a tier, as required pursuant to section 3 of this bill;
(2) a notice that a health care provider has a right to seek review from, and provide additional information to, the carrier with respect to any quality of performance and cost-efficiency measurements used as selection standards to determine the placement of the health care provider in a tier, and the data, methodology, formulas or methods used to establish the performance measurements, and to request the carrier to correct errors and to consider additional information;
(3) a notice that a health care provider has a right to appeal the carrier's placement of the health care provider in a tier, through an appeal process that shall be developed by the Commissioner of Banking and Insurance.
The carrier shall disclose this information in a manner to be determined by the oversight monitor on at least an annual basis and otherwise as frequently as the oversight monitor deems necessary.
The bill further requires the Commissioner of Banking and Insurance to appoint, and contract with, an independent, nationally recognized standard-setting organization as an oversight monitor to review and evaluate the disclosure processes required to be maintained by carriers pursuant to the bill. The commissioner shall select a non-profit organization that is tax exempt pursuant to 29 U.S.C. s.501(3) of the Internal Revenue Code of 1986 and that has experience in the processes and methodologies used in health care provider performance measurement systems and in monitoring those systems.
The bill requires that the contract specify the responsibilities of the oversight monitor, including the monitoring of each carrier's disclosures, the developing of an appeals process for health care providers as to their placement in a tier, and the developing of a process to evaluate consumer complaints.
Finally, the bill also provides the Commissioner of Banking and Insurance with the authority to apply an annual surcharge to health benefits plans to pay for the expenses incurred for the oversight monitor and other expenses, and with the authority to assess penalties and take other actions for violations of the bill's provisions.
