Sponsored by:
Senator NIA H. GILL
District 34 (Essex and Passaic)
Senator JOSEPH F. VITALE
District 19 (Middlesex)
SYNOPSIS
Requires health insurance carriers to comply with certain network adequacy requirements.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health insurance carrier network adequacy 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. 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 the following requirements are met:
a. The carrier has demonstrated that the provider network or, in the case of a tiered network, the preferred tier of the tiered network, meets all requirements for network adequacy. The commissioner shall not approve any provider network or tiered network on a conditional or prospective basis.
b. In the case of a managed care plan that provides a tiered network, the preferred tier of the tiered network shall separately meet all requirements for network adequacy.
c. Each health care provider that is used to meet network adequacy requirements shall be in the carrier's network or, in the case of a tiered network, in the same tier of the tiered network, for all covered services provided by that provider.
d. As used in this section:
"Health care provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service defined by the health benefits plan. Health care provider includes, but is not limited to, a physician and other health care professionals licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes.
"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).
"Preferred tier" means the level or tier of a tiered network that provides the level of cost sharing that is most favorable to a covered person under that managed care plan.
"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. This act shall take effect immediately.
STATEMENT
This bill requires health insurance carriers to comply with certain network adequacy requirements.
The bill prohibits the Commissioner of Banking and Insurance from issuing conditional approval of provider network adequacy. The bill provides that in the case of a carrier seeking approval for a tiered network, the preferred tier of the network must separately meet all requirements for provider network adequacy.
The bill also provides that each health care provider that is used to meet provider network adequacy requirements shall be in the carrier's network or, in the case of a tiered network, in the same tier of the tiered network, for all covered services provided by that provider.
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).