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.

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(including default decisions) were issued in 2,107 cases, 309 cases were dismissed as ineligible and 211 cases were withdrawn.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.

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. 

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%. 

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.

The aggregate Medical Loss Ratios for the last three available years are 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 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.

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.

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

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.

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.