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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, 2019, MAXIMUS Federal1 has received 3,230 c. 32 arbitration requests. Of the 3,230 cases submitted as of December 31, 2019, 2,731 cases have been resolved by issuance of decision, by withdrawal requested by the initiating party or by dismissal for ineligibility.  499 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 14 Application received; eligibility to be determined
Preliminary Review 99 Awaiting info/documentation from Provider and/or Carrier
Review 386 Complete case files received; case needs to be arbitrated
Decision Pending 62 To be dismissed or withdrawn
Letter Sent 2669 Case closed (decision issued, case withdrawn or dismissed)
Grand Total 3230  

Of the 2,731 cases that have been resolved, decisions (including default decisions) were issued in 2,107 cases, 309 cases were dismissed as ineligible and 211 cases were withdrawn.  With respect to awards issued, carriers prevailed in 860 cases or 41% of the total and providers prevailed in 1247 cases or 59% of the total.  Awards to carriers totaled $2,236,526 and awards to providers totaled $14,940,576.

Decision Count of Case Number Sum of Total Award
Carrier Awarded 860 $2,236,526.61
Provider Awarded 1215 $14,590,262.46
Provider Awarded (Default) 32 $350,313.39
Grand Total 2107 $17,177,102.46

Of the 309 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, the health benefits plan is a self-funded plan that did not opt in to c. 32 arbitration and the amount in dispute is under $1,000. 

Dismissal Category Number
Not issued in NJ 142
Self-funded plan did not opt-in 76
Disputed amount is <$1k 34
Did not negotiate or negotiation untimely 28
Incomplete application 12
Duplicate case 5
Federal Plan 3
Medical necessity dispute 2
Pre-mature filing 1
DOS before 8/30/18 1
Workers Compensation 1
Not emergency or inadvertent 3
Medicare 1
Grand Total 309
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 81% to 98%.  Ambulatory surgical center (ASC) participation in HMO and PPO plans ranges from 49% to 92%. 

HMO Hospitals Percentage
Aetna 66 94%
AmeriHealth 64 91%
Cigna 61 87%
Horizon 69 98%
Oxford 63 90%
70 total General Hospitals in NJ
HMO ASCs Percentage
Aetna 192 65%
AmeriHealth 157 53%
Cigna 257 87%
Horizon 273 92%
Oxford 145 49%
296 total Ambulatory Surgical Centers in NJ
PPO Hospitals Percentage
Cigna PPO 60 85%
Horizon PPO 69 95%
Oxford Navigate 57 81%
Oxford Garden State 57 81%
UnitedHealthcare Core Network 57 81%
70 total General Hospitals in NJ
PPO ASCs Percentage
Cigna PPO 258 87%
Horizon PPO 273 92%
Oxford Navigate 235 79%
Oxford Garden State 164 55%
UnitedHealthcare Core Network 230 78%
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.

2020 8.7% 1.1%
2019 -9.3% 5.3%
2018 23.3% 8.5%
2017 8.7% 10.8%
Medical Loss Ratios

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

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 22% for the individual health coverage (IHC) market and 56% 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 10% 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 25% to approximately 70%. Within the large group market there was much more limited data, but that data showed a reduction of approximately 15% adjusted for membership changes.

Down Coded and Denied Claims Data

For the period of September 1, 2018 through June 30, 2019 the total number of claims received across all health insurance carriers was 36,248,712. The total number of claims includes claims paid timely, claims paid late, and claims denied. The total number of denied claims is 6,544,471 or 18% percent of total claims. (See the chart below) However, note that the same claim can be denied more than once if it is not resolved. Of these denied claims, the reasons provided for the denials include: (1) the claim was for an ineligible service or submitted by an unauthorized provider (69% of the denials);  (2) the documentation submitted with the claim did not include all the necessary information (10% of the denials); (3) the code submitted by the provider was incorrect or did not match the service or treatment provided (20% of the denials); (4) the amount charged on the claims did not appear to be in the range of the cost for such services or treatment (1.2% of the denials). This summary does not include claims for dental, vision or Medicare supplement coverage.

Claim Category Total
Denied Ineligible Denied Document Denied
Physician 15,616,999 1,511,656 311,540 445,904 11,480
Hospital 3,413,531 534,046 99,728 118,669 2,149
Other Health Care Professional 11,687,049 1,792,094 171,007 531,206 64,537
Other Health Care Facility 5,531,133 676,558 94,882 176,283 2,732
Total 36,248,712 4,514,354 677,157 1,272,062 80,898
Complaints Related to Out-of-network Health Care Charges

Between August 30, 2018 and December 31, 2019, the Department has received 64 complaints relating to out-of-network health care charges. 

Self-Funded Plans

As of January 20, 2020, 67 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.
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

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 2019
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 934 1199 1109 1184 1109 1241
Dermatologist 351 392 318 408 381 310
Endocrinologist 284 364 132 262 257 226
ENT 267 335 284 334 292 253
General Surgeon 631 790 565 695 586 676
Neurologist 396 674 444 477 456 410
OB/GYN 1350 1316 1100 1336 1206 1167
Oncologist/Hematologist 488 653 289 470 324 502
Ophthalmologist 588 716 638 707 676 610
Orthopedist 584 641 611 681 653 794
Psychiatrist 1128 772 521 599 643 542
Urologist 333 343 298 328 309 293
1MAXIMUS Federal is contracted with the Department to conduct c. 32 arbitrations.
*Source: AAMC New Jersey Physician Workforce Profile (2017). NJDOBI cannot verify the accuracy of the data.
As of January 31, 2020
OPRA is a state law that was enacted to give the public greater access to government records maintained by public agencies in New Jersey.
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