As of December 31, 2024, MAXIMUS Federal¹ has received 20,421 c. 32 arbitration requests since the law was implemented in 2018. Of the 20,421 cases submitted since the law’s enactment, 20,018 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 decided between January 1, 2024, and December 31, 2024, may be found here.

Of the 20,018 cases that have been resolved, decisions (including default decisions) were issued in 12,129 cases, 4,701 cases were dismissed as ineligible, and 3,188 cases were withdrawn. With respect to awards issued, carriers prevailed in 3,837 cases or 32% of the total and providers prevailed in 8,292 cases or 68% of the total. Awards to carriers totaled $25,189,170.41 and awards to providers totaled $109,002,236.19.

Of the 4,701 cases that were dismissed as ineligible, the primary reasons for dismissal are that the health benefits plan is a self-funded plan that did not opt into c. 32 arbitration, that the parties failed to negotiate or that the negotiation or arbitration was untimely, or that the health benefits plan was issued in a state other than New Jersey. 

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 83% to 100%. Ambulatory surgical center participation in HMO and PPO plans ranges from 70% to 96%.

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. The majority of 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 55% for the individual health coverage (IHC) market, 64% for the small employer health coverage (SEH) market, and 57% for the large group market adjusted for membership changes.

Between January 1, 2024, and December 31, 2024, the Department received 12 complaints relating to out-of-network health care charges.

As of January 31, 2025, 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-in to 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.

*Entity terminated self-funded coverage, meaning it did not change its opt-in status, but instead was no longer covered under a plan eligible to opt into OON Arbitration.

**Entity transitioned from self-funded coverage to the State Health Benefits Program, which is currently opted into OON Arbitration.