Bill > S4910

Introduced Session

This bill requires a carrier authorized to operate in this State to accept into its provider network any health care facility or provider entity licensed or otherwise regulated by the State and in good standing upon application by the facility or provider entity. "Carrier" is defined in the bill to mean 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, and is to include the State Health Benefits Program, and the School Employees' Health Benefits Program. The health care facilities and provider entities captured in the bill include, but are not limited to: 1) adult medical day care centers; 2) ambulatory care centers; and 3) private practice offices of health care professionals authorized to open private practices. The bill establishes an application process by which a carrier is to follow to review the eligibility of a health care facility or provider entity. Additionally, under the bill, it is required that all health care facilities and provider entities in the network of a carrier be reimbursed at a rate no less than 200 percent of the applicable Medicare reimbursement rate for equivalent services rendered, unless the facility or entity agrees to a different rate. The reimbursement rates are to be disclosed in writing upon the issuance of a credential to participate in the network of a carrier and are to be updated annually. Moreover, the bill stipulates that an individual covered by a health benefits plan offered by a carrier authorized to provide insurance in New Jersey is to have the right to receive in-network benefits at any health care facility or provider entity licensed or otherwise regulated by the State that is willing to accept the reimbursement rate as offered by the carrier. A carrier is prohibited in the bill from excluding a health care facility or provider entity based on ownership structure, size, or affiliation status with a hospital system. The Department of Banking and Insurance is to oversee compliance with the provisions of the bill and is to be appropriated from the General Fund the sum of $2,000,000 to administer and enforce the provisions. A carrier found in violation of the bill is to be subject to a civil penalty of up to $25,000 per violation, and may be subject to additional sanctions, including suspension or revocation of any license or other credential issued by the State. A health care facility or provider entity is granted the right to appeal any exclusion decision or rate-setting through an expedited hearing process before an administrative law judge. In New Jersey, many health care facilities and provider entities face exclusion from health insurance carrier networks. The bill intends to broaden access to health care services for patients, widen streams of revenue available for providers, and prevent hospitalization as the only option for certain patients.

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Owen Henry (R)*, 

Introduced in the Senate, Referred to Senate Commerce Committee (on 12/01/2025)

Official Document