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  • NJ A887
  • Requires carriers to disclose selection standards for placement of health care providers in tiered health benefits plan network; establishes oversight monitor to review compliance.
Introduced
(1/27/2016)
In Committee
(4/4/2016)
Crossed OverPassedSignedDead/Failed/Vetoed
2016-2017 Regular Session
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.
2nd Reading in the Assembly, Regulatory Oversight and Reform and Federal Relations
Reported from Assembly Comm. as a Substitute, 2nd Reading  (on 4/4/2016)
 
 
Date Chamber Action Description
4/4/2016 Assembly Regulatory Oversight and Reform and Federal Relations Hearing (14:00 4/4/2016 Committee Room 12, 4th Floor)
4/4/2016 A Reported from Assembly Comm. as a Substitute, 2nd Reading
4/4/2016 Assembly Regulatory Oversight and Reform and Federal Relations Hearing (14:00 4/4/2016 Committee Room 14, 4th Floor)
3/7/2016 Assembly Regulatory Oversight and Reform and Federal Relations Hearing (14:00 3/7/2016 Committee Room 14, 4th Floor)
1/27/2016 A Introduced, Referred to Assembly Regulatory Oversight and Reform and Federal Relations Committee
Date Motion Yea Nay Other
Detail 4/4/2016 Assembly Regulatory Oversight Committee: Reported with Substitution 3 2 0