As of December 31, 2020, MAXIMUS Federal¹ has received 5,717 c. 32 arbitration requests. Of the 5,715 cases submitted as of December 31, 2020, 5,428 cases have been resolved by issuance of decision, by withdrawal requested by the initiating party or by dismissal for ineligibility.  55 cases are pending with MAXIMUS Federal for either completion of eligibility review, receipt of information from the Provider or Carrier, drafting of decision or issuance of dismissal or withdrawal.  See chart below. The full list of arbitrations filed between January 1 and December 31 may be found here.

Of the 5,715 cases that have been resolved, decisions (including default decisions) were issued in 4,173 cases, 813 cases were dismissed as ineligible and 729 cases were withdrawn.  With respect to awards issued, carriers prevailed in 1489 cases or 36% of the total and providers prevailed in 2,683 cases or 64% of the total.  Awards to carriers totaled $5,222,355.84 and awards to providers totaled $31,434,987.84.

Of the 813 cases that were dismissed as ineligible, the primary reasons for dismissal are that the health benefits plan was issued in a state other than New Jersey or the health benefits plan is a self-funded plan that did not opt into c. 32 arbitration. 

The charts below show the percentage of hospitals and ambulatory surgical centers that participate in the Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) networks of the carriers issuing health benefits plans in the commercial market.  Hospital participation in HMO and PPO plans ranges from 67% to 98%.  Ambulatory surgical center participation in HMO and PPO plans ranges from 57% to 94%.

The aggregate Medical Loss Ratios for the last four available years are as follows:

As part of the Department’s rate review process, carriers were asked to provide data on out-of-network claims spending. All carriers from which the Department obtained data have experienced a reduction in involuntary out-of-network claim costs since the Act has taken effect. The change in the law likely contributed to reduced costs associated with claims for involuntary (i.e. emergency and inadvertent) out-of-network services paid by carriers. The extent to which costs were reduced varied by market and carrier. The size of the reduction may also vary. The total carrier spending on involuntary out-of-network services (as defined by each carrier) was reduced by 56% for the individual health coverage (IHC) market and 38% for the small employer health coverage (SEH) market. In the IHC market, the reduction in involuntary out-of-network service claim costs for carriers, adjusted for membership changes, ranged from approximately 30% to approximately 70%. Within the SEH market, the reduction on spending on claims for involuntary out-of-network services, adjusted for membership changes, ranged from approximately 20% to approximately 70%. Within the large group market there was much more limited data, but that data showed a reduction of approximately 48% adjusted for membership changes.

Between January 1, 2020 and December 31, 2020, the Department received 76 complaints relating to out-of-network health care charges.

As of January 28, 2021, 137 self-funded plans opted in to the arbitration process under the law. The list of Plan Sponsors that have filed ID cards indicating opt-in to the OON arbitration and the date of the opt-in is below.

The following multiple employer welfare arrangements (MEWAs) are subject to the provisions of P.L. 2018, c. 32 but have filed ID cards indicating participation in the OON arbitration. The list of MEWAs is below.