Requires health insurance carriers to provide adequate network of physicians.

A1018

ASSEMBLY, No. 1018

STATE OF NEW JERSEY

222nd LEGISLATURE

�

PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION

Sponsored by:

Assemblyman BALVIR SINGH

District 7 (Burlington)

SYNOPSIS

���� Requires health insurance carriers to provide
adequate network of physicians.

CURRENT VERSION OF TEXT

���� Introduced Pending Technical Review by Legislative
Counsel.

��

An Act

concerning network adequacy and supplementing
P.L.1997, c.192 (C.26:2S-1 et al.).

����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:

���� 1.��� As used in this act:

���� "Carrier" means an
insurance company, health service corporation, hospital service corporation,
medical service corporation, or health maintenance organization authorized to
issue health benefits plans in this State, and shall include the State Health
Benefits Program, the School Employees� Health Benefits Program, the Medicaid
program, and a Medicaid managed care organization.

���� "Commissioner" means
the Commissioner of Banking and Insurance and the Commissioner of Health.

���� "Medicaid" means the
Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).

���� �Network� means those
physicians who participate as in-network providers within a health benefits
plan.

���� �Office based medical
specialist� means physicians practicing in specialty areas recognized by the
American Board of Medical Specialties, American Osteopathic Association or the
American Podiatric Medical Association that are usually located in office-based
practices other than those physicians included in the definition of �primary
care physician� pursuant to this section.

���� �Primary care physician� means
a physician who:

���� (1)� has successfully
completed a residency program accredited by the Accreditation Council for
Graduate Medical Education or approved by the American Osteopathic Association
in the specialty of general family medicine, general internal medicine,
obstetrics and gynecology or general pediatrics; or

���� (2)� has been evaluated by a
carrier�s committee charged with setting standards for and reviewing provider
credentialing under the direction of the carrier�s medical director, and who is
found by that committee to demonstrate through training, education and experience
or expertise in primary care.

���� 2.��� All networks shall have
a sufficient number of physicians to ensure that 100 percent of covered persons
reside no more than:

���� a.��� a 20 minute drive or 10
miles, whichever is less, from at least three primary care physicians within
each type of primary care specialty as defined pursuant to section 1 of P.L.���
, c.��� (C.������� ) (pending before the Legislature as this bill) and within
the geographic boundaries of the State; and

���� b.��� a 30 minute drive or 15
miles, whichever is less, from at least three office-based medical specialists
within each specialty as defined pursuant to section 1 of P.L.��� , c.���
(C.������� ) (pending before the Legislature as this bill) and within the geographic
boundaries of the State.

���� 3.��� a.� Pursuant to section
2 of P.L.��� , c.��� (C.������� ) (pending before the Legislature as this
bill), a network shall have a sufficient number of physicians to:

���� (1)� meet the health needs of
covered persons;

���� (2)� provide an appropriate
choice of physicians sufficient to render services covered by the health
benefits plan; and

���� (3)� reasonably ensure that
covered persons have timely access, as required pursuant to section 2 of
P.L.��� , c.��� (C.�������� ) (pending before the Legislature as this bill), to
in-network facilities.

���� b.��� For purposes of
determining whether a sufficient number of physicians are included in the
network, the commissioner shall ensure that a carrier providing benefits for
emergency services shall ensure that:

���� (1)� requests for emergency
care shall be triaged immediately or no later than one hour from the request
for emergency care;

���� (2)� requests for urgent care
be provided within 24 hours of notification of the carrier;

���� (3)� requests for a routine
appointment be scheduled within two weeks; and

���� (4)� requests for a routine
physical examination be scheduled within three months.

���� c.��� Nothing in P.L.��� ,
c.��� (C.������� ) (pending before the Legislature as this bill) shall preclude
a health benefits plan from offering services via telehealth or telemedicine,
but services offered via telehealth or telemedicine shall not be counted toward
compliance with network adequacy requirements of P.L.��� , c. (C. )
(pending before the Legislature as this bill).

���� d.��� Nothing in P.L.��� ,
c.��� (C.������� ) (pending before the Legislature as this bill) shall preclude
a health benefits plan from including providers other than physicians,
including but not limited to physician assistants, advanced practice nurses and
registered nurses, in a network, but inclusion of such non-physician providers
shall not be counted toward compliance with network adequacy requirements of
P.L.��� , c.��� (C.������� ) (pending before the Legislature as this bill).

���� 4.��� Upon seeking initial
approval of a network and pursuant to P.L.��� , c.��� (C.������� ) (pending
before the Legislature as this bill), a carrier shall submit a plain language
description of the network to the commissioner with information sufficient to allow
the commissioner to determine whether the network is in compliance with the
provisions of P.L.��� , c.��� (C.������� ) (pending before the Legislature as
this bill).� The commissioner shall investigate the information supplied in the
description to ensure compliance.� Annually thereafter, the carrier shall
submit an updated, plain language description of the network to the
commissioner and shall certify that the network described therein remains
compliant with the provisions of P.L.��� , c.��� (C.������� ) (pending before
the Legislature as this bill).� The commissioner may investigate the updated
description for compliance with the provisions of P.L.��� ,
c. (C.������� ) (pending before the Legislature as this
bill).

���� 5.��� The Commissioner of
Banking and Insurance and the Commissioner of Human Services shall establish a
system by which covered persons may file formal complaints concerning network
adequacy with the Department of Banking and Insurance or the Department of
Human Services.

���� 6.��� A carrier shall display
the plain language description of each network available to the public in a
conspicuous location on its internet website within 20 days of the submission
of the description to the commissioner.

���� 7.��� An entity providing or
administering a self-funded health benefits plan which is subject to the
"Employee Retirement Income Security Act of 1974," 29 U.S.C. s.1001
et seq., may elect to meet the requirements of P.L.��� , c.��� (C.�������� )
(pending before the Legislature as this bill).

���� 8.��� A carrier that violates
any provision of P.L.��� , c.��� (C.������� ) (pending before the Legislature
as this bill) shall be subject to the penalties provided pursuant to section 16
of P.L.1997, c.192 (C.26:2S-16).

���� 9.��� The commissioner shall
annually provide a report to the Legislature, in accordance with section 2 of
P.L.1991, c.164 (C.52:14-19.1), containing the descriptions of each network.

���� 10.� The Commissioner of
Banking and Insurance and the Commissioner of Human Services shall adopt rules
and regulations pursuant to the "Administrative Procedure Act,"
P.L.1968, c.410 (C.52:14B-1 et seq.) to effectuate the purposes of this act.

���� 11.� This act shall take
effect on the first day of the third month next following the date of
enactment, except that the Commissioner of Banking and Insurance and the
Commissioner of Human Services may take such anticipatory administrative action
in advance as shall be necessary for the implementation of this act.

STATEMENT

���� This bill requires health
insurance carriers to provide an adequate network of physicians.�

���� Under the bill, a carrier will
ensure that a network have a sufficient number of physicians to ensure that 100
percent of covered persons reside no more than:

���� (1)� a 20 minute drive or 10
miles, whichever is less, from at least three primary care physicians within
each type of primary care specialty as defined in the bill and within the
geographic boundaries of the State; and

���� (2)� a 30 minute drive or 15
miles, whichever is less, from at least three office-based medical specialists
within each specialty as defined in the bill and within the geographic
boundaries of the State.

���� Under the bill, a network will
be required to have a sufficient number of physicians to:

���� (1)� meet the health needs of
covered persons;

���� (2)� provide an appropriate
choice of physicians sufficient to render services covered by the health
benefits plan; and

���� (3)� reasonably ensure that
covered persons have timely access to in-network facilities.

���� The bill provides that a
carrier will be required to submit a plain language description of the network
to the commissioner with information sufficient to allow the commissioner to
determine whether the network is in compliance with the provisions of the
bill.� The commissioner will investigate the information supplied in the
description to ensure compliance.� Annually thereafter, the carrier will be
required to submit an updated, plain language description of the network to the
commissioner and must certify that the network described remains compliant with
the provisions of the bill.�

���� Additionally, the bill
requires the Commissioner of Banking and Insurance and the Commissioner of
Human Services to establish a system by which a covered person may file a
formal complaint concerning network adequacy with the Department of Banking and
Insurance or the Department of Human Services.� The bill also requires a
carrier to display the plain language description of each network available to
the public in a conspicuous location within its internet website within 20 days
of the submission of the description to the commissioner.