New Jersey

SUMMARY

In 2013, New Jersey legislators declined to create an APCD in the state, citing the annual cost as the primary deterrent. New Jersey is increasing its regulatory oversight of hospital’s financial condition by requiring them to disclose unaudited quarter financial statements and contracts with related entities in an effort to control healthcare costs and promote greater transparency. New Jersey has also recently addressed the bargaining power disparity between providers and insurance carriers by prohibiting most-favored nation clauses in provider contracts.

 

LEGISLATION/REGULATION

New Jersey’s current regular legislative session runs from 1/10/2017 – 1/9/2018.

 

Recent Legislative Developments

Healthcare Transparency

2015-2016 S20/A4444 THE OUT-OF-NETWORK CONSUMER PROTECTION, TRANSPARENCY, COST CONTAINMENT AND ACCOUNTABILITY ACT: would require health care facilities to, at least 30 days prior to a patient’s elective, non-emergency procedure or upon scheduling it: inform a patient as to whether the provider is in or out-of-network; descriptions of the procedure; a reasonable estimate of the costs for the services; and information on all other costs related to the procedure.

S20 would require health plan carriers to disclose in writing to a covered person, at the time of enrollment, on the website, and upon request thereafter, a list of all in-network providers (updated every 20 days).

S20 would create an all-payers claims database (APCD) called the Healthcare Price Index. The index will (i) identify and electronically publish, annually, the list of median in-network paid commercial claims for the payment range of 75-250% and (ii) make median in-network commercial paid claims data available to the state and to researchers. Health carriers would be required to report records of all claims, including amounts billed and amounts paid for all providers, to the Commissioner of Banking and Insurance—at intervals to be established by the Commissioner.

Health care facilities and carriers that violate any provision of this Act would be subject to penalties between $1,000-25,000 per violation. In addition, any person or entity that receives data under the Act and intentionally or knowingly uses, sells, or transfers the data fro commercial advantage, pecuniary gain, personal gain, or malicious harm would be liable for a penalty of up to $500,000 per violation.

Inactive — Died.

 

Healthcare Cost

2015-2016 S20/A4444 NO SURPRISE BILLS: if an insured person receives medically necessary services at any health care facility on an emergency basis, the facility shall not bill the covered person in excess of any deductible, copayment, or coinsurance applicable to an in-network service provider. Active—Reviewed by the Pension and Health Benefits Commission on 7/31/15.

 

Healthcare Markets

  • None identified.

 

Key Statutes

We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.

 

Transparency in Healthcare

  • J. Admin. Code § 8:31B-4.1 requires that every hospital submit a uniform report on costs, revenue and statistical information. Annual acute care hospital cost reports, containing revenue data for all payers for each acute care hospital, are available to the public.

 

  • J. Stat. Ann. § 26:2H-5 authorizes the commissioner of health to conduct inspections of healthcare facilities. The commissioner is directed to establish a uniform statewide reporting system for health care facility utilization and costs.

 

  • J. Stat. Ann. § 26:2H-18.55 in setting out the duties of the commissioner of health, the commissioner is directed to “[s]tudy and, if feasible, establish hospital cost and outcome reports to provide assistance to consumers of health care in this State in making prudent health care choices.”

 

Healthcare Contracting

  • J. Admin. Code. § 11:24C-4.3 prohibits most favored nation clauses, or clauses having a similar effect, in an agreement between an insurance carrier and a participating provider. A most favored nations clause is an agreement between a payer (such as an insurance company) and a provider that typically requires a provider to give the payer the lowest rate that it gave to any other comparable payer, which can be anticompetitive by encouraging oligopolistic pricing by large payers and increasing barriers for new entrants. Agreements between a participating provider and a carrier are not subject to the prior approval of the Commissioner.

 

Healthcare Markets

 

  • J. Stat. Ann. § 30:4D-8.1 establishes a Medicaid ACO Demonstration Project with the goal of increasing access to care and increasing efficiency and cost reductions through improved coordination and information sharing. Such activities will be exempt from state antitrust laws to the extent necessary to facilitate the project.

 

  • J. Admin. Code. § 8:33:4-9 prohibits health care providers from acquiring, replacing, or adding to their facilities and equipment, except in specified circumstances, without the prior approval of the Department of Health through the state’s Certificate of Need process. A Certificate of Need regime aims to reduce healthcare overheard by reducing unnecessary or duplicative services, but can be anticompetitive by increasing regulatory barriers for new entrants.

 

 

LITIAGATION/ENFORCEMENT

  • None identified.

 

KEY RESOURCES 

New Jersey Legislature

New Jersey Office of the Attorney General

New Jersey Department of Banking & Insurance

NJ Hospital Price Compare