The State of New Jersey
NJ Department of Banking and Insurance
search  

Home > Insurance Division > Mandated Health Benefits Advisory Commission > Frequently Asked Questions
Questions and Answers on the Mandated Health Benefits Advisory Commission Act
1. What does the Act require with respect to mandated health insurance coverage? Answer
2. Do New Jersey mandated health benefits only apply to health insurance coverage issued in New Jersey? Answer
3. Which plans must provide mandated health benefits? Answer
4. Who serves on the Commission? Answer
5. What are the duties of the Commission relative to the review of bills? Answer
6. Are all proposed mandated health benefit bills referred to the Commission for review? Answer
7. What information relative to the proposed mandated health benefit is included in the Commission's review? Answer
8. What mandated health benefits does New Jersey have? Answer
9. Where can I find information about proposed mandated health benefit bills? Answer
10. Can I submit information regarding a proposed mandated health benefit to the Commission? Answer
11. What happens after the Commission issues a report recommending for or against a particular mandate? Answer
12. How can I obtain a copy of the Commission's report? Answer
 
1. What does the Act require with respect to mandated health insurance coverage?
The Act requires a review of proposed mandated health benefits by an expert body to provide the Legislature with adequate and independent documentation defining the social and financial impact and medical efficacy of the proposed mandate.
2. Do New Jersey mandated health benefits only apply to health insurance coverage issued in New Jersey?
Yes. Mandated health benefits are defined as a benefit or coverage that is required by New Jersey law to be provided by any company authorized to transact health insurance in New Jersey in health policies and contracts issued in New Jersey, regardless of the state of domicile of the company. Mandated Health Benefits include coverage for specific health care services, treatments or practices, or direct reimbursement to specific health care providers. Mandated benefits do not apply to self-funded plans where the employer is responsible for the claims but uses an insurer or third party administrator to process claims. Very large employers typically have self-funded plans.
3. Which plans must provide mandated health benefits?
Any benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in New Jersey by or through a carrier must provide a mandated health benefit. Health benefits plans do not include the following plans, policies or contracts: accident only, credit, disability, long-term care, coverage arising out of workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P. L. 1972, c.70 (C.39:6A-1 et seq.) or hospital confinement indemnity coverage.
top of page

4. Who serves on the Commission?
The Act provides for a commission of 17 voting members as follows:

Organization Representative
Commissioner of Health or designee Martin Zanna, MD
Office of Planning and Development
Commissioner of Human Services or designee Pamela R. Orton, RN, Health Care Administrator
Division of Medical Assistance and Health Services
Commissioner of Banking and Insurance or designee Gale Simon, Assistant Commissioner
A representative of a commercial health insurance company Vacancy
A New Jersey licensed physician who is a member of the Medical Society of New Jersey Mary F. Campagnolo, MD, MBA, Virtua-Lumberton Family Physicians
A representative of the New Jersey Business and Industry Association Melanie L. Willoughby, Senior Vice President, Vice Chair
A representative of a health service corporation Sandi Kelly, Director, Actuarial Affairs, Horizon BCBSNJ
A New Jersey licensed physician Ronald J. Librizzi, DO, Chief, Maternal Fetal Medicine, Virtua Health System, Chair
A representative of organized labor Susan Michielli, UFCW
A medical educator from the University of Medicine and Dentistry of New Jersey whose major field of expertise is the study and evaluation of the cost of health care and health insurance
William E. Halperin, MD, MPH, Dr. P.H., Department of Preventative Medicine & Community Health, UMDNJ
A representative of the New Jersey Association of Health Plans Wardell Sanders, Esq., President, New Jersey Association of Health Plans
A representative of the New Jersey Hospital Association Vacant
A representative of the New Jersey State Nurses Association Carolyn T. Torre, RN, MA, APN, C
A representative of the New Jersey Dental Association Maria Ambrosio, DMD
A representative of a consumer advocacy organization Vacant
Two representatives of the general public who are knowledgeable about health benefit plans

Richard McClellan

Julia A. Oliver, CPA, CFO, American Bible Society

The Act also provides for 4 nonvoting members:

Two members of the Senate, not from the same political party
Senator Samuel D. Thompson
Senator Joseph F. Vitale
Two members of the Assembly, not from the same political party
Assemblywoman Angelica M. Jimenez
Vacant
top of page
5. What are the duties of the Commission relative to the review of bills?
The commission is to review any bill introduced in either House of the Legislature that would require a carrier to provide a mandated health benefit within 60 days after the date the review is requested, and provide its comments and recommendations in writing to the prime sponsor, committee chair and presiding officer of the House in which the bill is pending.
6. Are all proposed mandated health benefit bills referred to the Commission for review?
No. If the presiding officer of the House in which the bill is pending determines that the bill is an urgent matter, the presiding officer will notify in writing the Commission and the chair of the standing reference committee to which the bill is referred, and the House or committee may consider and vote upon the bill as soon as practicable; or, if the chair of the standing reference committee to which the bill is referred, in consultation with the Commissioner of Health, determines that the bill is of such an urgent matter that it would seriously impair the public health to wait for the Commission to issue its report, the chair will notify in writing the presiding officer of the House in which the bill is pending, and the Commission, of that determination, and the standing reference committee, with the agreement of the presiding officer of the House, may consider and vote upon the bill as soon as practicable.

7. What information relative to the proposed mandated health benefit is included in the Commission's review?
The Act limits the Commission's review of a particular mandated health benefit bill to include the social and financial impact as well as the medical efficacy of the mandated benefit. The specific factors are listed below.

Social Impact

  • the extent to which the proposed mandated health benefit and the services it would provide are needed by, available to and utilized by the population of New Jersey;
  • the extent to which insurance coverage for the proposed mandated health benefit already exists or, if no coverage exists, the extent to which the lack of coverage results in inadequate health care or financial hardship for the affected population of New Jersey;
  • the demand for the proposed mandated health benefit from the public and the source and extent of opposition to mandating the health benefit;
  • relevant findings bearing on the social impact of the lack of the proposed mandated health benefit; and such other information with respect to the social impact as the Commission deems appropriate.
Financial Impact
  • the extent to which the proposed mandated health benefit would increase or decrease the cost for treatment or service;
  • the extent to which similar mandated health benefits in other states have affected charges, costs and payments for services;
  • the extent to which the proposed mandated health benefit would increase the appropriate use of the treatment or service;
  • the impact of the proposed mandated health benefit on total costs to carriers and on administrative costs;
  • the impact of the proposed mandated health benefit on total costs to purchasers and benefit costs;
  • the impact of the proposed mandated health benefit on the total cost of health care within New Jersey; and such other information with respect to the financial impact as the Commission deems appropriate.
Medical Efficacy
  • if the proposed health benefit mandates coverage of a particular treatment or therapy, the recommendation of a clinical study or review article in a major peer-reviewed professional journal;
  • if the proposed health benefit mandates coverage of the services provided by an additional class of practitioners, the results of at least one professionally accepted, controlled trial comparing the medical results achieved by the additional class of practitioners and the practitioners already covered by benefits;
  • the results of other research;
  • the impact of the proposed benefit on the general availability of health benefits coverage in New Jersey; and such other information with respect to the medical efficacy as the Commission deems appropriate.
Balancing the Social, Economic and Medical Efficacy
  • the extent to which the need for coverage outweighs the costs of mandating the health benefit; and the extent to which the problem of coverage may be solved by mandating the availability of the coverage as an option under a health benefits plan.
Analysis of information collected from various sources, such as:
  • a State data collection system;
  • the Departments of Health and Banking and Insurance;
  • health planning organizations;
  • proponents and opponents of the proposed health benefit mandate, who shall be encouraged to provide appropriate documentation supporting their positions.

The Commission shall examine such documentation to determine whether:

    • the documentation is complete;
    • the assumptions upon which the research is based are valid;
    • the research cited in the documentation meets professional standards;
    • all relevant research respecting the proposed benefit has been cited in the documentation;
    • the conclusions and interpretations in the documentation are consistent with the data submitted; and such other data sources as the Commission deems appropriate. In analyzing information from the various sources, the Commission shall give substantial weight to the documentation provided by the proponents and opponents of the mandate to the extent that such documentation is made available to them.
top of page

8. What mandated health benefits does New Jersey have?
New Jersey has enacted the following mandated health benefits, coverage or reimbursement to providers since 1972:

Large Group Mandate Statutory Site Effective Date Description of Mandate
NJS 17B:27-46.1. 1977 Alcoholism Treatment
NJS 17B:27-46.1i. 1994 Any Willing Pharmacy
NJS 17B:27-46.1ii 2009 Autism or Other Developmental Disability
NJS 17B:27-46.1v. 1995 Biologically Based Mental Illness
NJS 17B:27-46.1j. 1995 Bone Marrow Transplants
NJS 17B:27-46.1l. 1996 Childhood Immunization, Lead Poisoning, Hearing Loss
NJS 17B:27-46.1y. 2002 Colorectal Screening
NJS 17B:27-46.1c. 1987 Congential Bleeding Disorders
NJS 17B:27-46.1u. 1999 Dental Anesthesia and Dental Benefits
NJS 17B:27-46.1m. 1996 Diabetes
NJS 17B:27-46.1t. 1998 Domestic Violence Injuries
NJS 17B:27-46.1r. 1998 Food and Food Products
NJS 17B:27-46.1gg 2008 Hearing Aids for Certain Persons Aged 15 or Younger
NJS 17B:27-51.4. 1977 Home Health Care
NJS 17B:27-46.1x. 2001 Infertility Treatment
NJS 17B:27-46.1f. 1991 Mammograms
NJS 17B:27-46.1b. 1985 Maternity Without Regard to Marital Status
NJS 17B:27-46.1p. 1997 Minimum Mastectomy Stay
NJS 17B:27-46.1b. 1985 Minimum Maternity Stay
NJS 17B:27-46.1z. 2002 Nonstandard Infant Formula
NJS 17B:27-51.4. 1977 Nursing Home Care
NJS 17B:27-46.1g. 1994 Off-Label Drug Use
NJS 17B:27-46.1jj. 2012 Oral Anticancer Medications
NJS 17B:27-46.1ff. 2007 Orthotic and Prosthetic Appliance
NJS 17B:27-46.1aa. 2002 Out-of-Network Services
NJS 17B:27-46.1n. 1996 Pap Smears
NJS 17B:27-55. 1997 Pre-existing Conditions Under Certain Circumstances
NJS 17B:27-46.1ll. 2013 Prescription Eye Drop Refills
NJS 17B:27-46.1ee. 2005 Prescription Female Contraceptive
NJS 17B:27-46.1o. 1996 Prostate Cancer Screening
NJS 17B:27-46.1a. 1983 Reconstructive Breast Surgery
NJS 17B:27-46.3. 1980 Second Medical/Surgical Opinions
NJS 17B:27-46.1kk. 2012 Sickle Cell Anemia
NJS 17B:27-46.1h. 1994 Wellness Examinations
NJS 17B:27-46.1e. 1990 Treatment of Wilm's tumor
top of page
9. Where can I find information about proposed mandated health benefit bills?
The New Jersey legislature's Web site provides a list of all proposed bills by subject.

10. Can I submit information regarding a proposed mandated health benefit to the Commission?
Yes. Submissions of materials and documentation can be made, in writing to the Commission using this form (HTM) or download a MS Word document. Your submission should be mailed to:

New Jersey Department of Banking and Insurance
Mandated Health Benefits Advisory Commission
P.O. Box 325
Trenton, NJ 08625

11. What happens after the Commission issues a report recommending for or against a particular mandate?
The Legislature may consider the mandated health benefits bill in its normal course of business. It is not required to accept the recommendation of the Commission.

12. How can I obtain a copy of the Commission's report?
Copies of the Commission's completed analyses are available online. You can receive printed copies by making a request through the Open Public Records Act.

top of page
For More Information
Contact:
NJ Mandated Health Benefits Commission
P.O. Box 325, Trenton, NJ 08625
Telephone: 609-292-3100, ext. 50377 and 50390
E-mail: MHBAC@dobi.state.nj.us
 
OPRA
OPRA is a state law that was enacted to give the public greater access to government records maintained by public agencies in New Jersey.
line
Adobe Acrobat
You will need to download the latest version of Adobe Acrobat Reader in order to correctly view and print PDF (Portable Document Format) files from this web site.
state seal
Copyright © 2011, State of New Jersey
New Jersey Department of Banking and Insurance