As of December 31, 2021, MAXIMUS Federal¹ has received 8,238 c. 32 arbitration requests since the law was implemented in 2018. Of the 8,238 cases submitted since the law’s enactment, 8,010 cases have been resolved by issuance of decision, by withdrawal requested by the initiating party or by dismissal for ineligibility. Zero 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, 2021 and December 31, 2021 may be found here.

Of the 8,238 cases that have been resolved, decisions (including default decisions) were issued in 6,253 cases, 1,256 cases were dismissed as ineligible and 729 cases were withdrawn. With respect to awards issued, carriers prevailed in 2,174 cases or 36% of the total and providers prevailed in 3,921 cases or 64% of the total. Awards to carriers totaled $11,452,066.64 and awards to providers totaled $49,893,434.61.

Of the 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. 

Decisions and Awards By Year

Below is a chart which shows decisions and awards on a year-by-year basis since the inception of the program in 2018.

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 New Jersey carriers issuing health benefits plans in the commercial market.  Hospital participation in HMO and PPO plans ranges from 81% to 98%.  Ambulatory surgical center participation in HMO and PPO plans ranges from 51% to 91%.

Aggregate trends in health benefit plan premium rates in the IHC and SEH markets over the last several years.

The MLRs for the past several years are summarized 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 44% for the individual health coverage (IHC) market and 49% for the small employer health coverage (SEH) market. Within the large group market there was much more limited data, but that data showed a reduction of approximately 49% adjusted for membership changes.

Between January 1, 2021 and December 31, 2021, the Department received 27 complaints relating to out-of-network health care charges.

As of January 30, 2022, the following self-funded plans opted into the arbitration process under the law. In light of the enactment of the federal No Surprises Act, DOBI Bulletin 21-14 provides that a self-funded plan that previously opted into the New Jersey arbitration by filing an ID card with the Department may opt out of the NJ Act arbitration if it wishes to be subject to the federal IDR established under the federal act.  Plans that have opted out, and the date of such opt-out, are also noted below.  The list of Plan Sponsors that have filed ID cards indicating opt-into the OON arbitration and the date of the opt-in is below.

The number of and description of claims received by the State Health Benefits Program and the School Employees’ Health Benefits Program for emergency out-of-network health care and inadvertent out-of-network health care may be found here.

The number of in-network physician specialists practicing in the State in a particular specialty with respect to the carriers that administer the State Health Benefits Program and the School Employees’ Health Benefits Program may be found here.