Bill > A4244

Introduced Session

This bill would require the Division of Medical Assistance and Health Services in the Department of Human Services to establish a Medicaid Managed Care Organization (MCO) Oversight Program to ensure the availability of accessible health care for individuals who are enrolled in the NJ FamilyCare and Medicaid programs. The Office of the State Auditor conducted an audit of the Department of Human Services, Division of Medical Assistance and Health Services, Medicaid Provider Networks for the period July 1, 2013 to May 31, 2016. Information from the audit indicated that managed care organizations (MCOs) which are contracted with the State to provide health benefits to Medicaid and NJ FamilyCare beneficiaries did not provide adequate access to: general acute care hospital service networks; dental providers; and accurate online provider directories. Additionally, the MCOs were not adequately reporting claims inactivity for providers and had provider panel sizes which exceeded the eligible limits. Furthermore, the audit recommended that the department take certain actions to ensure that the MCOs are meeting the contractual obligations regarding access to quality care and provider availability. This bill requires each MCO contractor to submit updated provider data and beneficiary data on a quarterly basis to the Medicaid MCO Oversight Program in a format designated by the Medicaid MCO Oversight Program. The submitted data will allow the Medicaid MCO Oversight Program to accurately determine if the MCOs are providing adequate network adequacy to the enrolled beneficiaries. Additionally, the audit disclosed that the MCOs are collecting updated beneficiary information but there is no currently implemented mechanism to share this data with the department. Without updated beneficiary information, the department is not able to ensure network adequacy. The updated beneficiary information collected by the MCOs could also streamline the work of entities, such as county welfare offices, which enroll individuals in Medicaid and NJ FamilyCare. To ensure the sharing of information, this bill requires the Medicaid MCO Oversight Program to share any updated beneficiary information with county welfare offices, or any other entity which is responsible for the enrollment or re-enrollment of beneficiaries in the Medicaid or NJ FamilyCare program. The audit also determined that the information in the MCOs' on-line directories containing eligible providers, and these providers' locations, was not always accurate. Therefore, this bill requires the Medicaid MCO Oversight Program to establish an independent verification system to annually verify that at least 20 percent of the information provided to the program from the MCO contractors is accurate and that 100 percent of the providers listed are eligible Medicaid providers. The audit also revealed that there was a need for the MCOs to identify inactive providers. To rectify this situation, the bill requires the MCO contractors to submit claims inactivity reports for all providers that meet the claims inactivity criteria established by the Medicaid MCO Oversight Program for that MCO contractor. Additionally, the audit disclosed that a small number of MCO contractors were listing providers as "eligible" who had patient panel sizes that exceeded acceptable numbers. This bill would require MCO contractors to verify that all of the participating providers' panel sizes do not exceed criteria established by the Medicaid MCO Oversight program for that MCO contractor. The bill also requires the panel size criteria for each provider specialty to include all patients of the provider, notwithstanding the patient's health insurance carrier. It is unclear what sanctions are currently being brought against MCO contractors that do not comply with the current contracts. Consequences for not meeting the requirements of this bill will be a minimum $50,000 fine for each failure to submit information as required pursuant to the bill. If, after an administrative hearing, the MCO fails to pay the fine, the MCO may be barred from contracting with the department for five years. Lastly, the bill requires an annual report containing the information provided to the program from the MCOs no later than 90 days from the first day of the calendar year. To evaluate longer term changes, the bill requires the Office of State Auditor to conduct a follow up audit on MCO provider networks three years after enactment.

AI Summary

Committee Categories

Shanique Speight (D)*, 

Introduced, Referred to Assembly Aging and Human Services Committee (on 02/19/2026)

Official Document