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The Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act (P.L. 2018, c. 32) Data Reporting
Arbitrations Filed Under P.L. 2018, c. 32

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.

Initiated 22 Application received; eligibility to be determined
Preliminary Review 116 Awaiting info/documentation from Provider and/or Carrier
Review 149 Complete case files received; case needs to be arbitrated
Decision Pending 55 To be dismissed or withdrawn
Letter Sent 5373 Case closed (decision issued, case withdrawn or dismissed)
Grand Total 5715  

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(including default decisions) were issued in 4,173 cases, 813 cases were dismissed as ineligible and 729 cases were withdrawn.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.

Decision Count of Case Number Sum of Total Award
Carrier Awarded 1489 $5,222,355.84
Provider Awarded 2650 $31,434,987.84
Member Awarded 1 $2,384.55
Provider Awarded (Default) 33 $355,113.39
Grand Total 4173 $37,014,841.62

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. 

Dismissal Category Count of Dismissal Reason
Plan not issued in NJ 236
Self-funded plan did not opt in 295
Did not negotiate/ untimely negotiation / untimely arbitration 85
Disputed amount is <$1k 43
Incomplete application 75
Federal Plan 3
Member was not covered during DOS 2
Medical necessity dispute 3
Not emergency or inadvertant 62
Provider has contract with Carrier 1
Service before 08/30/18 1
Workers Compensation dispute 1
Medicare and/or Medicaid Plan 6
Grand Total 813
 
Provider Network Status

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%.

HMO Hospitals Percentage
Aetna 67 95%
AmeriHealth 67 95%
Cigna 60 85%
Horizon 66 94%
Oxford 69 98%
 
70 total General Hospitals in NJ
 
HMO ASCs Percentage
Aetna 199 68%
AmeriHealth 168 57%
Cigna 272 93%
Horizon 272 93%
Oxford 197 67%
 
290 total Ambulatory Surgical Centers in NJ
PPO Hospitals Percentage
Cigna PPO 60 85%
Horizon PPO 66 94%
Oxford Navigate 47 67%
Oxford Metro 47 67%
UnitedHealthcare Core Network 47 67%
 
70 total General Hospitals in NJ
 
PPO ASCs Percentage
Cigna PPO 273 94%
Horizon PPO 272 93%
Oxford Navigate 215 74%
Oxford Metro 197 67%
UnitedHealthcare Core Network 211 72%
 
296 total Ambulatory Surgical Centers in NJ
 
Health Benefit Annual Rate Trends
The chart below shows aggregate trends in health benefit plan premium rates in the individual health coverage (IHC) and small employer health coverage (SEH) markets over the last several years.
Year IHC SEH
2021 3.3% 2.5%
2020 8.7% 1.1%
2019 -9.3% 5.3%
2018 23.3% 8.5%
2017 8.7% 10.8%
 
Medical Loss Ratios (MLR)

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

Year IHC SEH
2019 78.9% 78.6%
2018 78.72% 80.54%
2017 89.38% 81.27%
2016 95.29% 83.38%
New Jersey Medical Loss Ratio reports can be found here.
 
Total Spending on Inadvertent and Emergency Out-of-network Costs

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.

 
Complaints Related to Out-of-network Health Care Charges

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

 
Self-Funded Plans

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.

Opt In Date Plan Sponsor
07/01/2019 Affiliated Physicians and Employers Master Trust
07/01/2019 Employers Association of NJ
07/01/2019 Employers Association of NJ (RX Express Scripts)
09/01/2019 Princeton University
01/01/2019 Association Master Trust
01/01/2019 Mack-Cali Realty Corp.
01/01/2019 NJ Manufacturers
01/01/2019 NJ Turnpike Authority
01/01/2019 South Jersey Industries
01/01/2019 VNA of Central NJ
01/01/2019 Romark Logistics
01/01/2019 ICIMS
01/01/2019 Community Surgical Supply
01/01/2019 Academy Bus
01/01/2019 Township of Freehold
01/01/2019 Town of West New York
01/01/2019 Hoagland Longo Moran Dunst and Doukas, LLP-PPO
01/01/2019 Motors Management, Inc.
04/01/2019 Aurobindo Pharma
04/01/2019 AMSPEC Services LLC
04/01/2019 Atalanta Corporation
05/01/2019 Yang Ming
05/01/2019 Passaic Valley Water
05/01/2019 Warren County
01/06/2019 Mycone Dental Supply Inc.
07/01/2019 Flemington Raritan BOE
07/01/2019 Jackson Township BOE
07/01/2019 Brick Township BOE
07/01/2019 Egg Harbor Township
07/01/2019 Ray Catena Motor Car
07/01/2019 Freehold Township BOE
07/01/2019 East Brunswick Public Schools
07/01/2019 Union County
08/20/2019 G & S Motor Equipment Co, Inc.
08/20/2019 Hopewell Valley Regional School
08/01/2019 Evonik Corporation Medical Plan
09/01/2019 Education Services Commission NJ
10/01/2019 Felician University
01/01/2020 Atlantic Health System
01/20/2020 Capital Health System
01/20/2020 Tris Pharma, Inc.
01/20/2020 Humanscale Corporation
01/20/2020 CentraState Healthcare System
01/20/2020 St. Joseph's Healthcare System Inc. Opt Out 01/01/2021
01/20/2020 New York Presbyterian Hospital
01/20/2020 Virtua Health Inc.
01/20/2020 American Music Supply Inc.
01/20/2020 Atlantic Medical Imaging
01/01/2020 1-800-FLOWERS.COM
01/01/2020 Acrisure, LLC
01/01/2020 American Roll-On Roll-Off Carrier Group Inc.
01/01/2020 Delta Galil USA Inc.
01/01/2020 Elwyn Inc.
01/01/2020 Gracie Square Hospital
01/01/2020 Kings Physician Services, PC
01/01/2020 New York Presbyterian Brooklyn Methodist
01/01/2020 New York Presbyterian Hudson Valley
01/01/2020 New York Presbyterian Medical Group Westchester
01/01/2020 New York Presbyterian Queens
01/01/2020 RCG Global Services, Inc.
01/01/2020 Redfin Corporation
01/01/2020 Rockefeller Group International Inc.
01/01/2020 Roosevelt Paper Company
01/01/2020 Silvercrest Center for Nursing and Rehabilitation
01/01/2020 Westchester Medical Practice, PC, dba New York Presbyterian Medical Group Hudson Valley
01/01/2020 Vinson & Elkins LLP
01/01/2020 WWL Holdings Americas LLC
01/01/2020 WWL Vehicle Services Americas Inc.
01/01/2020 Kearny Bank
01/01/2019 Members Health Plan of New Jersey
03/01/2021 The Kuiken Brothers Company
01/01/2021 Wework Management LLC
01/01/2020 Christian Health Care Center
01/01/2020 Borough of Florham Park
01/01/2020 Hard Rock Hotel & Casino Atlantic City
01/01/2020 The Knights of Columbus
01/01/2020 DeSimone Consulting Engineers
02/01/2020 Union City Board of Education
01/01/2020 The Fresh Market
03/01/2020 Rotor Clip
03/01/2020 Rancocas Anesthesiology, P.A.
03/01/2020 Montgomery Board of Education
03/01/2020 Holtec International
03/01/2020 Springpoint Senior Living Inc.
04/01/2020 Shore Point Distributing Company, Inc.
04/01/2020 Autolenders Liquidation Center, Inc.
05/01/2020 Ettain Group Holdings LLC
06/01/2020 Air Group, LLC
07/01/2020 Bridgewater Raritan Board of Education
07/01/2020 Carteret Board of Education
07/01/2020 Nutley Board of Education
07/01/2020 The ARC Ocean County Chapter
07/01/2020 Welfare Fund of Local No. One I.A.T.S.E.
07/01/2020 Mason Tenders' District Council Welfare Fund
08/01/2020 Ralph Clayton & Sons, LLC
08/01/2020 Sheet Metal Workers Local 25 New Jersey Welfare Fund
09/01/2020 Bihler of America
09/01/2020 Lululemon USA Inc.
10/01/2020 IPC Systems Inc.
11/01/2020 Specified Technologies Incorporated
11/01/2020 Custom Bandag Inc.
01/01/2021 Clarke Environmental Mosquito Management Inc.
01/01/2021 Astellas US LLC
01/01/2021 Guggenheim Capital LLC
01/01/2021 Millennium American Holdings Inc.
01/01/2021 Equistar Chemicals LP
01/01/2021 Houston Refining LP
01/01/2021 Engineered Composites
01/01/2021 A. Schulman Inc.
01/01/2021 Lyondell Chemical Company
01/01/2021 Sartorius Group North America
01/01/2021 Chemtrade Holdco US Inc.
01/01/2021 Collabera Inc.
01/01/2021 CB Neptune Holdings LLC
01/01/2021 Society for Worldwide Interbank Financial Telecommunication Inc.
01/01/2021 The Nature Conservancy
01/01/2021 South Brunswick Board of Education
01/01/2021 Institute for Defense Analyses (IDA)
01/01/2021 Dealer Tire LLC
01/01/2021 Merlin Entertainments Group US Holdings Inc.
01/01/2021 IBA USA Inc.
01/01/2021 PTC Therapeutics Inc.
01/01/2021 Planned Systems International Inc.
01/01/2021 CMC Materials Inc.
01/01/2021 Regeneron Pharmaceuticals Inc.
01/01/2021 West Windsor - Plainsboro Regional School District
01/01/2021 GS1 US Inc.
01/01/2021 Nomura Securities International Inc.
01/01/2021 Essence Global LLC
01/01/2021 McCollister's Transportation Group Inc.
01/01/2021 Instinet Holdings Incorporated
01/01/2021 ADG LLC dba Great Expressions Dental Centers
01/01/2021 MSG Entertainment Group LLC
01/01/2021 MSG Sports LLC
01/01/2021 MSGN Holdings LP
01/01/2021 Teamsters Local 817 Welfare fund
01/01/2021 Xylem Inc.
01/01/2021 Takeda Pharmaceuticals USA Inc.

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.

Plan Sponsor
Affiliated Physicians and Employers Master Trust/Member's Health Plan NJ
Association Master Trust
 
Network and ONET Physician Specialists as of December 2020
Specialty Statewide Aetna AmeriHealth CIGNA Horizon Oxford
Specialty Total # in State* Total in-network Total in-network Total in-network Total in-network Total in-network
Cardiologist 943 1429 1119 1150 1110 1241
Dermatologist 363 394 321 404 375 349
Endocrinologist 294 408 142 266 258 281
ENT 256 323 289 330 92 293
General Surgeon 674 860 612 710 722 787
Neurologist 405 799 469 486 481 494
OB/GYN 1363 1623 1158 1383 1229 1394
Oncologist/Hematologist 498 808 290 488 352 575
Ophthalmologist 578 719 662 692 674 681
Orthopedist 556 711 642 696 648 860
Psychiatrist 1133 748 538 655 741 622
Urologist 346 353 306 329 298 321
 
1MAXIMUS Federal is contracted with the Department to conduct c. 32 arbitrations.
*Source: AAMC New Jersey Physician Workforce Profile (2019). NJDOBI cannot verify the accuracy of the data.
 
As of January 31, 2021
 
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